A Challenging Day in the Emergency Department

They wait outside their ED room’s doorway, with their arms crossed.  A simple visit over, all but the discharge medication faxed, patient instructions added, discharge button clicked.  The visit started well with a pleasant conversation during the examination.  Evaluation efficient and appropriate.  But now they are waiting to go home, and their eyes are throwing daggers.   I could tell them I was interrupted on my way to the desk to complete their discharge. I could tell them I was interrupted by an elderly man who could not breath in Room 2, or chest pain in Room 3 or the clinic calling with a transfer and the radiologist calling with a new malignancy on CT.   But I simply apologize and repeat this cycle over and over again today.  Some days are like this.

One of the aspects of the emergency department that I find most challenging is patient flow in the midst of interruptions.  Critical patient arrivals, patient surges from triage, phone calls, asynchronous result review, documenting, RN questions and pharmacy clarifications.  In busy ED’s, this can amount to more than 10 interruptions per hour in some studies.  My interruptions do not come close to this, but I still at times feel overwhelmed.  

There were times when working clinic, I could fall an hour behind with work-ins and complex patients.  But my patients knew me and they would still be cordial to me despite the delay.   This is not always true in the ED.   I try to move fast, practice the best quality I know how, provide the best service I can and disposition as quickly as possible.  Despite this, they stand in their room’s doorway with their arms crossed angry that they are still waiting for discharge.  

In clinic, there was an overflow escape known as a schedule that would limit the flow of patients in.  On the worst days, there was still time for a sandwich and bathroom break.  There was still the appreciation for care from most of my patients.  

But today the emergency department surge continues.  It is on these days, that histories and exams are clipped and compressed and sign-outs to hospitalists are mediocre at best.   No time to open a reference or  consider a quality differential.  Hungry, fatigued and operating on clinical reflexes and base knowledge.  Small conflicts with sparks of dissatisfaction by patients and hospitalists.  I could explain the attempts at maximizing patient status over hours in the ED.  How I tried to stave off an admission, but this failed.  Now the family is frustrated with the long ED course, and the hospitalist sees this as a dump.   

So I continue to optimize my emergency department task juggling and patient flow.  But today as I leave the department, my shift over, I can still see a patient standing in their room’s doorway with their arms crossed and angry.   This was a challenging day.

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