Recently, my wife, Lisa, had been referred to an Emergency Room (E.R.) setting by a doctor due to swelling and a black and blue leg from a surgical operation involving a hip replacement. My wife had been told by a tele-health doctor that she needed to go to the E.R. because of possible arterial involvement via a vascular etiology of swelling. In layman’s terms, Lisa had unusual swelling post-surgery. The referral was based on photos she had sent to the doctor that was seeing her online as there were no doctors available to see her in person.
Upon arrival at the E.R. a little after 1 p.m., we were told to stand in a line to register as a new patient. Because Lisa could not stand and was in a wheelchair, it was left to me to endure the slow process of waiting my turn. We wondered why people had to stand in line. We thought a way of making the process more patient friendly and helpful would be for an intake person to direct patients to take a number and be served when their number came up. As a close friend, who works in an E.R. setting told me, some patients may have to be seen immediately if they are suffering from acute chest pains, a sign of a possible heart attack. Because Lisa with the other patients had to stand in a line before meeting the nurse who inquired about their symptoms, the hospital appeared to lack an immediate screening procedure to monitor the gravity of a patient’s visit.
When Lisa was finally seen about an hour later by the intake team, she was not informed as to what they had decided. From here, we both sat for another three hours until she was called, and as they started wheeling her into a room, they told her she was going to have an ultrasound to rule out a blood clot. Here is where things became chaotic. The technician doing the ultrasounds reported that E.R. does not handle what she had been sent to the E.R. for, a vascular etiology of swelling. A week earlier she had been referred for an ultrasound for swelling of the leg that turned out negative. Now the swelling and black and blue marks were more extensive in covering her leg and toes. Not clear as to why she was having the same procedure again and, because she thought it was unnecessary, she refused it.
By now I had pretty much lost track of time, so I had no idea how much time had elapsed. Lisa later told me the ultrasound tech had talked to the charge nurse who found a room for her per order of her surgeon, Dr. Park, who was at the hospital at that time.
After some more time had gone by, she was finally seen by a staff doctor, who told her she had a pulse that indicated that her circulation was normal. Insofar as we were already at the hospital, although not essential, he said it would not hurt to have another ultrasound done. When Lisa and I both asked when she would be receiving it, the doctor did not know. He also pointed out the obvious: There are not enough of us to handle the influx of patients. He let Lisa know that her surgeon, Dr. Park, had been consulted and had ordered an X-ray of the hip and would see her that night. We both asked the charge nurse how long we would have to wait for the ultrasound but she also could not give us an answer.
It was now well into the evening and neither of us had eaten anything, so I ordered dinner for the two of us and picked it up while Lisa waited to be called for the ultrasound. When I returned with our dinner, Lisa still had not been called in for the ultrasound. It was after 9 p.m! However, her surgeon was in the room, checked her feet for a pulse, and told her the X-ray of her leg revealed no abnormalities. Finally, some good news. He confirmed what the staff doctor had said that it could not hurt to have the ultrasound done insofar as she was already at the hospital.
Upon once more asking the charge nurse how much longer Lisa needed to wait for the ultrasound, none of the staff present knew. It was now about midnight, and a new shift of workers had arrived. When the nurse came in to check on Lisa, he had no idea how much longer we needed to wait at which point, Lisa, extremely angry, lashed out at him. The charge nurse then came in visibly upset at Lisa’s reaction denying any sort of culpability. Although it was not their fault, I told them we were both frustrated after having waited over 6 hours without receiving any knowledge as to when the procedure would occur. Upon checking the records, the nurse said Lisa had been put at the back of the line when she had canceled the ultrasound much earlier. We both insisted that she find out how much longer we needed to wait.
After leaving the room, the charge nurse returned in about five minutes and told us that Lisa was 11th on line confirming that there were 10 people in front of her. She asked if we wanted to wait; we told her we had had enough and were ready to leave. After gathering all of Lisa’s belongings, the nurse returned to the room and informed us that a patient had rejected the ultrasound and, that we could have his turn right now. We thanked her, and at last, Lisa had the ultrasound. It was a little after 1 a.m.in the morning when we departed from the hospital after a 12–hour siege.
During Lisa’s E.R. visit, ironically and apropos to the situation, I read a piece in the New York Times with the heading: Can E.R.s Handle Hardest Cases? The article detailed how on September 23rd a 20-year-old Columbia undergraduate, named Sam, had gone to the E.R. at Mount Sinai Morningside in New York City with symptoms of a headache and chills. Physical exam ruled out meningitis and tests for Covid, flu and respiratory syncytial virus (R.S.V.) were all negative, so he was discharged and given Tylenol and Zohran (prevents nausea and vomiting). However, the next day his condition worsened: He had thrown up all day with uncontrollable shivering and painful leg cramps. He returned to Mount Sinai Morningside the next day; a patient returning to E.R. within a short time is considered a red flag.
Although he told his doctors he felt better, Sam’s lab results were off on several parameters. Once more he was discharged and, two days later he was found in his dorm room dead. Sam’s girlfriend believed a contributing factor to his death might have been that he was not a good advocate for himself. His parents were in another country at the time of his illness and could not be his advocates. Unlike my wife, Lisa, who expressed her frustration directly to the attending staff, Sam was young lacking the experience of us elders. This, in conjunction with the fact that E.R. staff are under mounting pressure to discharge patients as fast as they can perhaps led to a premature release of this young man. The observation by the staff doctor that treated my wife, Lisa, that there are too many patients compared to doctors only will worsen If Trump successfully cuts Medicaid.
The Times article cited a saying in medicine: “When you hear hoofbeats, think of horses, not zebras.” The point made here is that a patient’s symptoms usually support the most obvious diagnosis, not the rare possibility. Even an autopsy was unclear as to the etiology of Sam’s death. The need to make decisions quickly in an ever-increasing patient population admitted to E.R. settings, in conjunction with Sam’s symptoms that did not support a simply explained diagnosis, very likely contributed to his death.
One outcome of AI employed with beneficial intentions is that someday soon it will alleviate the pressure doctors face in decision making. But until that time, any patient entering an E.R. need hope that he or she’s symptoms fit the diagnostic category of a horse rather than that of a zebra.
Dr. Bernard F. Natelson 