Transcript

[00:00:00] Susan Russell, MD: Let's get stronger.

[00:00:03] Khalilah Gates, MD: Healthier.

[00:00:03] Michelle Prickett, MD: Calmer.

[00:00:04] Russell: Smarter.

[00:00:05] Gates: Better.

[00:00:06] Russell: Living a healthier life is a journey, not a destination.

[00:00:09] Gates: You can always get better.

[00:00:11] Prickett: Let's get better together.

[00:00:20] Prickett: Alright ladies, we've got a fun one today. So, we've got patients that are calling us, we've got family that are calling us and saying, I'm not feeling well I need to go get seen. Do I need to go to the ER?

[00:00:30] Russell: That's right. A certain season is upon us, and that is the time when the emergency room gets really busy. So, I think it's only fair that we talk about when to go to the emergency room, when you should not go to the emergency room, and where you go somewhere in between, specifically immediate care.

[00:00:48] Gates: What are the options? What can they do for you? I think are important things for our listeners to understand so that, when we're sending them to these various places or when they're trying to decide where to go, they have some sense of, oh, this, I can probably go to the emergency room or this I can go to the immediate care for.

[00:01:06] Prickett: Yeah, I think there's many options, why can't it be seen in the clinic? And then when are real true emergencies and when do we need to send someone to the emergency room? Today, we're talking to Northwestern Medicine Emergency Medicine Resident Physician Dr. Evelyn Huang about how to get the right care at the right time. Welcome Dr. Huang.

[00:01:24] Evelyn Huang, MD: Thanks for having me.

[00:01:25] Prickett: Tell us a little bit about what the emergency room is best served for, what are some of the services you can provide, no one wants to go, but we want to know when to go.

[00:01:34] Huang: The emergency room is for medical emergencies, and that can look very different for a lot of people. So, of course, you watch TV and you think about people who are getting CPR, or they're getting shocked. Those are the people that come through our doors. People who are getting in severe car accidents or having any sorts of trauma, they are coming to us as well. But what I don't think people realize is that we are seeing everyone and anyone, right? So, there are people who come to us if they need a warm place to stay or if they have housing instability and are looking for a warm meal or any resources, and that's the great part of our job and also a really difficult part of our job because we are seeing anyone who wants to be seen. And I think a lot of people call us the safety net of the hospital. I would consider us the safety net of the community in the neighborhood we're serving because if somebody is in trouble, they show up and we're there to serve them.

[00:02:29] Gates: So, can you define what an emergency is? Outside of like CPR and shocking, what do you define as an emergency?

[00:02:37] Huang: I think that looks different for a lot of people. So, what I typically think of as a medical emergency are things like, well, we've already talked about CPR, trauma, heart attacks, strokes, those are all big medical emergencies. But oftentimes, if people are worried, you know, and we are the only option. I want them to be seen because it might be something scary. If somebody is having chest pain, there are a million reasons why somebody could be having that, and it's our job to figure that out. So, if somebody feels like they're having an emergency, they should go to the emergency department. I never wanted to discourage that.

[00:03:15] Russell: Yeah, I think for us as specialists, when I see people in clinic that don't look that great, it's always very clear if somebody is medically unstable, where their vital signs are disarranged in a way where we think they're not in a great place just looking at them in front of me, like that's always a you do not pass go, go straight to the ER. But also, if I'm thinking about a diagnosis in my head that I think could lead to major physical impairment or even death within the next 24 hours, that's another reason I might think about the emergency department. Even if the patient looks stable from the standpoint of their blood pressure or their heart rate or their oxygen levels So as a specialist in clinic, that's kind of what I think.

[00:03:59] Prickett: Yeah, I think when you know exactly what's going on and you know how to get it, it's always good. It's those questions in between where it's not 100%, and I think a lot of our patients will come like, "Oh, I want to see my doctor." And I'm kind of hampered. I don't have a CT scanner in my office. We have some things, but we don't have EKGs in our office necessarily. Like, to get everything at once to see it in one viewpoint really is helpful, especially when we're talking about these things that, if left untreated, could lead to lifetime impairments.

[00:04:25] Gates: And I think of the emergency room, as Russell pointed out, what's going to cause you significant harm in the acute setting? But that then leads in, and particularly I struggle with this in clinics sometimes: What can go to the emergency room and then what can I refer to the immediate care center? And so how do we see that? Like, where's the line? Emergency room versus immediate care center.

[00:04:46] Huang: Yeah, I think it's kind of in the name: emergency medicine, medical emergencies, right, and then immediate care, it's somebody that should be seen that day, but in my mind, the acuity or the severity is a little bit less. So theoretically, they could be seen at that immediate care and then go right back home. So, I think there can be a lot of gray zone, and very oftentimes somebody will go to immediate care and get sent to our emergency department and that's OK. That happens. There are a lot of different symptoms that somebody can be seen for in an immediate care that could also be seen at an emergency department. For example, I tell most people, hey, if it's a sore throat, if you think you have the flu or a cold or COVID, you could go to immediate care, get tested there, maybe even get some treatments there. But then I say stuff like that. And if somebody has a sore throat, sometimes that can be even a little more complex. And that could be something like an abscess or something a little bit scarier and that should be seen in the emergency department. So, there's no good rule, but part of our job is kind of teasing that out. I will say that immediate care usually does not have the same resources that we do, so they don't have testing, oftentimes, or imaging. Some of them do. And we just get results really, really fast. And that's part of why we're able to do our jobs because we're able to find out a lot of information in a short amount of time. Sometimes immediate care isn't always open as well. A lot of them are not 24 hours. So even things that could be seen in immediate care do end up at our doors for that reason as well.

[00:06:17] Prickett: I think immediate care is also nice because many of them are open to both adults and children and the hours are a little bit later. That's one of the questions we'll have. Well, should I wait till tomorrow or should I try to come later at night? And you don't necessarily want to send to the emergency room because they're stable. Their breathing is OK. They may be having a little bit of an issue, but they're not struggling to breathe. They're not having any red flags that might say emergency room. But I do think that it's important to know that immediate is available if you're not super severe, but you have an issue and you want to get it diagnosed and resolved. And many of them do take adults and pediatrics.

[00:06:50] Gates: And so, when we talk about where people should go, oftentimes we'll get phone calls and, we'll tell patients, Go to the emergency room. They're like, no, I'm not going to the emergency room. I'm going to wait for forever. Can you talk to us about why are the waits the way they are right now across the country? And, how do you decide if I'm sitting in a waiting room, who goes right away and who gets to sit out there?

[00:07:13] Huang: Great question. My parents asked me the same question as well. I think we should start with what the process is when you arrive at the emergency department. So, when you arrive, you're either coming in through the ambulance or you're going in through the main doors and kind of showing up on your own or somebody's bringing you in. Usually if somebody's coming in via ambulance the paramedics will call ahead and we'll know about that patient. And based on the story, we can sometimes tell whether or not they're going to need immediate care. The example that keeps coming up is if somebody's getting CPR actively, they're going to be going straight to our main room and we're going to be seeing that patient immediately. If the story seems like we have a little bit of time to figure things out, then they'll go to our triage area, and that's exactly where somebody would go when they show up at our doors as well. The triage area is usually a healthcare provider, most oftentimes a nurse, at least in our emergency department. And they are taking your story, they're getting your vitals as well, and may start grabbing some blood tests from you as well. They'll get an EKG if you're coming in with something like chest pain or shortness of breath. Based on that information, that can tell us a lot about the acuity or severity of things. For example, if somebody's vitals are unstable, meaning their blood pressure is abnormal, their heart rate is abnormal, or if their EKG is showing something scary, they may immediately get roomed. After all of that, then somebody may either go straight to the room or they may go to the waiting room and then based on how many people are there, that's how long you wait. Our waits can be so long and it's frustrating, and it's frustrating for us too. The reasons I think are pretty complex.

[00:08:47] Russell: Could you talk a little bit about the role the emergency room plays in mental health and when it would be appropriate to go to the emergency room for something related to mental health?

[00:08:57] Huang: Yes, that is a large bulk of the patients that we see, and it can be very, very difficult, and it looks a little different in every emergency department. We are lucky enough at Northwestern that we actually have psychiatry in the emergency department with us 24/7, so that is incredible for us and that helps a lot of our patients. But in general, I tell people that they should be seen if they have concerns about their safety or the safety of others. That's a blanket rule. The people that we see often are going through mental health crises, and either they will be brought in because a bystander saw them outside, they are concerned about that person, so emergency medical services brings them in, or people bring themselves in if they're concerned about their own safety, that they feel that they are having a mental health crisis or oftentimes we see people who are brought in by their friends or family who are worried. So, for us, we typically will see this patient. We'll kind of try to figure out what's going on, the different parts of it. We will often evaluate them medically, meaning we'll look at their labs and make sure there's nothing strange going on, such as, like, their electrolytes look OK, and see if there could be another reason why they're feeling this way. If we kind of medically clear them, then we'll have Psychiatry see them. And Psychiatry helps us decide, hey, is this person safe to go home, follow up with a psychiatrist? Or do they need more care? Meaning, do they need to be admitted psychiatrically? It's a team effort, and it's a really important job of the emergency department. Other emergency departments may not have psychiatry, so oftentimes they may be calling in a social worker or some kind of mental health worker to come in and kind of help make that decision.

[00:10:38] Prickett: One of the questions I always get from patients is, if you're talking to them and they're worried about it, they're saying, should I drive to the emergency room or should I call an ambulance? When would you advise either a loved one, family member, community member, when to call 911 and get an ambulance and when do you think it may be OK, if they are struggling, to have someone physically drive them to the ER?

[00:10:57] Huang: You know, in medical school, I had a shift in the call center, so I was able to hear what everyone calls 911 for and it's very interesting, and I think, in general, if you're worried, call 911. It's OK, it will get filtered to the right person. In terms of when to call them medically, if you are unable to get to the emergency department in a safe way, in a timely way, then I would call. Basically, what happens is it goes to the call center, they will call the closest ambulance or paramedics, they'll arrive at your home. If you're having issues getting out of your home, they have a lot of tools to help carry you or get you down the stairs, and then you'll go in the back of the ambulance. The paramedics and EMTs are all great about knowing which hospital or which healthcare center you should be going to. So oftentimes, a lot of different hospitals have different resources, and they may not have exactly what you need so they may direct you to a hospital that's a little bit further away, but they have the procedures or the specialists that you may need and they will take you to that place. So, if there's any concern that you can't make it there on your own, you should absolutely call.

[00:12:04] Prickett: I think the other thing to build on is oxygen. So, we don't necessarily always have oxygen in the car, so people that we're really worried about someone not breathing, they have oxygen in ambulances. And so that's another reason I think that we may say, hey, call 911, get them an ambulance because that will ensure that their oxygen is high.

[00:12:21] Russell: And even beyond that, there are certain diagnoses where now providers in ambulances can start providing care even before you hit the emergency room. So, stroke, which is one of the certain areas, but also for sepsis. If there's concern that you have a serious infection, a lot of times the handoff between EMS and the emergency room can lead to people getting things like antibiotics sooner than they would have before, which often is the thing that really makes a difference when those of us in the ICU are thinking about outcomes. So, another reason why, you know, if in doubt, just call and the person on the line can always advise you if needed.

[00:13:02] Prickett: So, you brought up that it's the safety net of our communities, but the other members of our communities are everyone in our healthcare system. We are specialists, the three of us are specialists, and many times within our specialty, we act as primary care doctors. How do you all feel when your patient calls saying I'm sick?

[00:13:17] Russell: Well, I think after hours or on the weekend, if you're somebody who's looking to get diagnosed and treated, I'm not going to do that for you over the phone. And if somebody has a real concern, then I'm going to refer them to an immediate care center or the emergency department, depending on what the issue is. However, this is a diagnosis that I know you for, and we've talked about treating this in the past. Often, as a specialist, I'll triage and diagnose and treat my patients over the phone. I think the perfect example is in the case of asthma or COPD, where often we can prescribe things over the phone for patients that are known to us and even order some diagnostic testing, like testing for the flu or for COVID infection that can be done without you being seen in the emergency room, safely where you get this stuff done. And then diagnostically, we're able to talk back to you about what the results are and so forth going forward. But a lot of that depends on me knowing who you are and what your history is. So, the time when you develop an acute problem is probably not the best time to be calling me cold for the first time and I don't know who you are, what your background is. You probably have to come see me in clinic and be known to me first before I would do that kind of stuff for you without seeing you face to face. I see you guys nodding, so I'm thinking you're agreeing with me here.

[00:14:37] Prickett: Yeah, I think that's exactly right. Having a primary care doctor is really key, so someone who kind of covers all the bases and can be a first response. Many of the questions we get is, can I get a refill? I need this medicine, I'm out. And I hate if I hear a patient has to go to the emergency room for something along that line. I also think thinking about exacerbation plans or if this happens in something I know that I'm currently treating, here's the plan of how we can attack it so you don't need to seek emergency care unless there's an emergency. So, we can say, OK, this is the toolbox of things we can do and how I want you to approach it. And asthma is another good example. People will have an asthma action plan or something to say, OK , this is how I will self-monitor and how I will self-treat, and if I go beyond that, that's when I need to really seek outside resources.

[00:15:18] Russell: So, Dr. Huang, now that you're almost done with training, how do we put you out of business? How do we prevent people from coming to the emergency room? How do we help decrease all of the volumes that we often see, especially in the winter months?

[00:15:32] Huang: People ask me all the time what's the number one way to stay out of the ER. Because I understand most people don't want to see us. My answer is always to have a primary care provider. You guys kind of touched on this. Primary care providers know you. They follow you once a year, maybe multiple times a year. They know your history, they know your medicines, they know your story. And that's something that I oftentimes will never be able to know because I only see you for your visit in the ER. And I think that a lot of times, when you have this rapport with a primary care provider, if you know that person, you trust them. They can help guide you medically, but also, you trust them enough to tell them things that you might be worried about. I have seen many patients who come to us, and it's because the symptoms that they've been feeling for years, that they were scared to talk about, that they didn't see anybody about has worsened so much that they need to be seen by us. And if they had mentioned it in the past or if they had a provider that they could talk to, then maybe it would have been caught earlier and maybe it could have been solved or treated earlier.

[00:16:36] Russell: And then I'm guessing preventative things like vaccinations might be helpful as well.

[00:16:41] Huang: Absolutely. Yes. Vaccinations, obviously we're coming up on the winter season, so things like the flu or COVID, all those respiratory symptoms that you guys see in the ICU, in your clinics, we see them too. And getting vaccinated will absolutely help if you can. And then obviously making that appointment with your primary care doctor. Maybe I won't have to see you then.

[00:17:03] Gates: Throwing in RSV if you're over 60.

[00:17:06] Huang: Great one as well for the kids, I do see kids sometimes as well.

[00:17:08] Prickett: Well, this has really been wonderful as we wrap up here. Dr. Huang, were there any last thoughts or any additional things that we didn't touch on that will be important for our listeners to really understand how best to utilize emergency treatments and emergency services?

[00:17:23] Huang: Anytime I discharge a patient from the ER, I always tell them, "Hey, you are always welcome back here." And I tell anyone that asks me, too, "You are always welcome. If you're worried, we want to see you." And it may take a little while because that waiting room is really long. But truly, if you are feeling something, we want to hear about it. We want to help fix it. And you should never be scared to come see us because we have so many tools and, if anything, we can help you feel better. And we may not get to the answer, but you should always be seen. And I want you to be seen by somebody.

[00:17:55] Prickett: We learned so much about what's behind those curtains of the emergency room. So, thank you for your time and for sharing with us today, Dr. Huang.

[00:18:02] Huang: Thank you for having me.

[00:18:07] Russell: Thanks for listening to Get Better.

[00:18:10] Gates: We hope you leave this podcast better than when you started.

[00:18:14] Prickett: For more information, visit nm.org/healthbeat.