Welcome to Charting with Doctor McNeil. Welcome again to Charting with Doctor McNeil. I am Doctor Patsy McNeil, emergency medicine physician by training, second in command of Adventist HealthCare, and we're gonna have a great conversation today. Shortly, I'm gonna have some good friends of mine introduce themselves and their roles, as well so that they can tell you the exciting, roles that they have. We're gonna talk about emergency medicine, the emergency department particularly, and what you see in Hollywood or on television versus what the reality is. There are lot of popular shows out there, everything from going back in the day to ER to the current show, The Pit, and there's Grey's Anatomy.

There's always these medical shows like the house, as well. But what is reality and what is actually not? Few places in health care are as familiar to the public and as misunderstood as the emergency department. Television often portrays the emergency department as this place of dramatic patient entrances and lay lives says, and that actually does happen.

But sometimes on television, they portray it in ways that aren't really reality based, and we're gonna have a little bit of a conversation to help you help us take care of you best.

All right. We're gonna go around the room here and have everybody introduce themselves. I'm gonna start with Doctor Neil Roy.

Hi, Patsy. Thanks for having me. I'm the Chief Medical Officer of the Shady Grove Medical Center. But before that and continue, I'm a practicing emergency medicine physician. I work in our ER every week and truly love doing that more than anything else. I've been a hospital administrator for a few years now and I've been an emergency department chairman for several years before that. And before that, I grew up training and being an emergency medicine physician.

Fantastic. Doctor.

Andrew Yes, thanks for having me, Patsy.

My name is Andrew Baum. I am the chairman and medical director for Shady Grove's emergency department. Before that, I was a bit of a regional traveler throughout Maryland. I worked at many different sites across our region and started out as a nocturnist doing nights only and now transitioned to the bright side.

Thanks for having me.

Did nights many years ago. It was fun. All right, we're going to go on to Doctor Jonathan Wenk.

Thanks, Patsy. It's good to be here. I am currently the Medical Director of the Emergency Department at White Oak Medical Center. And I'm also the President of the medical staff there. I have been a practicing emergency physician for twenty six years.

Twenty six years.

That's a Time flies when you're having fun.

Yes, it does. Yes, it does. We're gonna start this conversation about television versus reality. Alright? So I'm gonna start with this question and and anyone can take it. But do you believe are the biggest misconceptions people have about emergency medicine, and how much of that comes from television and movies?

I'll start. When I see medical dramas on television, whenever there's an unfortunate victim who has a cardiac arrest, they are resuscitated and revived one hundred percent of the time.

And I think that creates a false expectation in people. The sad reality is a lot of our cardiac arrest victims don't survive, but the expectation is now there because what they see on television is everybody lives happily ever after.

That's true. There are times when people leave in ambulances and chest compressions are being done, and they get to the hospital and they come in like, so what's what's the plan? And and it's a very hard conversation to have. Very, very difficult because it's not, often the case. So that that is true. What else? Anybody else have anything else, that they wanna bring forward?

Sure. Yeah. I think I think that, you know, TV depictions oftentimes portray the ER as a constant rodeo of traumas and gunshots and CPR. And while we do experience a fair number of those things, you know, most most of what we do is is more critical thinking. Right? It's trying to weed out the scary things. It's trying to determine if, you know, the chest pain that you have is heartburn versus a heart attack or if the headache that you're experiencing is a migraine versus a a bleeding, you know, in the brain.

And, you know, while while we do see exciting things, know, I I think it may be a bit exaggerated on television more than what we see in in real life.

Can you imagine what a shift would be like if they were like that all the time? You'd be exhausted. The week would be miserable if every third second there was a patient trying to die.

And while watching the pit, they experience all of those exciting things within the scope of one episode, which is supposed to be one hour. And while all of us probably have seen everything that that is experienced on that show, we never would see all of that in one single shift.

Yeah. I tell my family it's several years worth of exciting cases packed into an hour or two. Yeah.

You see it all, but not immediately.

Yeah, think for me, I'm going veer left a little bit. I think one of the misconceptions is that emergency medicine physicians are miserable. And I see on a lot of shows that emergency medicine physicians are all suicidal and unshaven and unkempt.

And while yes, burnout is real and is high amongst all physicians, including emergency medicine, we chose to go into emergency medicine. So all medical students decide what specialty they want to go into. And all of us chose to be emergency medicine physicians. And we really enjoy the job.

We're fairly compensated. It's work that's really rewarding and meaningful. And we have schedules that are envious to any other profession. And it's something that we're really lucky to be able to do.

And I think a lot of times that privilege doesn't come across on TV shows.

Also, it's just plain cool. It's Yes, 100 just one of the specialties that is just plain cool. Get to see all the things. You do the diagnosis when other doctors don't get to do them.

Yeah. I tell my family, you know, we get the coolest procedures, we get the greatest toys. We've got, you know, bedside ultrasound machines that do all kinds of fancy things.

The one we have now, when you're putting an IV in, it puts a little red stop sign on all the arteries and a little green go sign on all the veins. It just shows you how to hold the probe against the patient's chest to get an echo and it computes the ejection fraction for you. We gadgets and we're like the James Bond of medicine.

And sometimes a little bit of the hero as well. When there's a really truly sick patient, you get to do all the things, right? You get to use your expertise, talk to the family, talk to the patient, do the things that save life. It's a really amazing job and a way to spend your life. I'm gonna go on my next question here, talking about television a bit.

Dude, the shows make patients expect certainty faster than medicine can honestly provide it. You know, television, they come in, they see the doctor, there's a little bit of drama, the doctor lays hands on him and ****, here's the diagnosis that comes forward like magic. But what are your thoughts about that?

Yeah.

Think going back to the first question, know, some of the misconceptions is that, you know, by the end of every episode, everyone has an answer, everyone has a diagnosis. And I think when a patient comes into my emergency department as one of my patients, I set an expectation and say, listen, I'm going to do my best. But my goal is not necessarily to find an answer as an emergency physician, but it is to rule out the scary things, the things that can be life threatening, the things that can make you really sick or require a hospitalization or a surgery. And at the end of this encounter, I'll tell a patient, you know, my my goal is to hopefully rule out those life threatening scary things.

And if I can do that, I can reassure you that we're not missing something. But I I often or sometimes will not come up with an answer for you. And I think that's you know, across emergency medicine, we don't always have an answer at the end of it. If we don't have an answer, our job is to help connect you with those next steps, get you to a specialist, get you to the right people, to help you run tests that we don't have access to from the ER and sort of get you closer to that answer.

Yeah, I think a lot of TV series set up some unrealistic expectations that we're going to nail the diagnosis 100% of the time. And the reality is very different. There was a study published years ago that only twenty percent of people who present with abdominal pain will have a specific diagnosis made at the end of their visit. And that's despite all the testing we do with scans and blood tests and everything else.

You know, and patients get very disappointed when, you know, I can't come up with an exact answer for them. And I think a lot of these TV series set an unrealistic expectation because everybody always gets an answer and it's cured in the end.

Especially, this is not on the ER show, but House, like you're making diagnoses that you see once in several lifetimes, you know?

Yeah. Have to Google most of the house Exactly. Is it? Is speaking?

Yeah. And don't get me wrong.

I, I, is, it is frustrating for the physicians as much as, as for patients.

Absolutely.

We'd like to have an answer.

We'd like to be able to close the loop and wrap it up nicely We don't like uncertainty any more than the patient does.

I used to say sometimes when I was practicing, which I am no longer doing, you know, I can tell you right now that there are no diagnoses that make me concerned about you going home and spending the rest of this week out looking for further answers. So you're gonna be safe. I would never send you home if you were going to have some bad outcome within the next week. That's not gonna happen.

However, I can't tell you what this is. And so the obligation on but back on you a bit is to take the information I gave you, go to your doctor, and then follow-up the rest of the work. But you can sleep well tonight. That that's what the closed loop, bit is at the end of a end of a vision.

So let's let's talk about what really happens even more. What happens behind the scenes that patients rarely see or understand? Now you think about a patient in the waiting room, they it's it seems quiet, the keyword. Right?

Or they're in their room in the emergency department if they're gifted enough not to have curtains, but they have an actual door. Right? What what's going on during a shift that they have no idea is going on?

Yeah, I think the biggest thing is in a single patient's mind, they are the only patient in the emergency department. And I think the reality of it is, is that we are constantly juggling 30 or 40 patients to make sure that we're able to get the best care to the sickest people right away.

And what's life threatening to a patient may not necessarily be life threatening in reality, and it's definitely not something that may be concerning from a life threatening standpoint to your physician. So I'll give you an example. Like, we all hear that chest pain is terrifying. If you're 20 years old and have chest pain, yeah, there's a likelihood that that could be something bad.

But it is much more concerning if you're 80 and have chest pain than if you're 20. So, a 20 year old walking into the ER is like, Look, I've got chest pain. I should be seen yesterday.

The rest of the ER is not as concerned about that patient. Doctor.

The big one, which actually is difficult though, when patients come in for the first time with some severe vertigo, for instance, the majority of the time, that's not something that is life threatening, the vast majority of the time. A few times might be, but that feels like you're dying, but the doc knows that you have some time just to figure that out. And so they don't they don't quite understand that. Anything else you guys have to add?

Well, think another thing is that when we are not directly at the bedside, we are still doing a lot of work on that individual patient's case. So I may not be directly at the bedside with the patient, but I'll be looking at their imaging studies, looking at their labs, looking at their EKGs, reviewing their old records and old notes. I'll be talking to consultants on the phone. So there could be a lot of work that goes into the case that they're not seeing, because it's not done right at the bedside.

Also, Doctor Roy, you mentioned something that I think patients don't understand.

You see them and they see you and it might be no noise. It's not the drama like they have on television of screaming and people, it's not that happening. But you may have twenty, thirty patients. And so they're like, what's going on? It's taking too long. You're one person and you're trying to make decisions that are critical life saving or life extending or life affirming decisions on 20 people at the same time. And so you may not see your doctor for an hour because it takes some time to do those things.

Or a couple hours.

Or more. So, that's just the that's just the way that that it occurs. Is the sickest patient in the emergency department always the person who looks the sickest?

I was going to say to your earlier question, the sickest patient is often not the loudest patient in the Yes, in fact, it's often the quietest.

Right, it's the elderly gentleman who is sitting there with sepsis in the chair next to you, or somebody who is quietly suffering a heart attack, to Doctor Roy's point. Behind the scenes also, we are constantly having to re triage the patients that we have. So when new information or new results come back, that may be different than what we were originally expecting, we're having to reprioritize certain patients at any given time. And so it sometimes can feel like a patient is waiting longer or being ignored, But that is never our intention. But also, sometimes it's like a constant revolving change of priorities in the department for us 100%.

Behind the Talk a little bit about triage and what that is for people.

I think they probably know from watching these shows, but there's a triage that's done by the nursing staff when they first present, and there's that retriaging that you're talking about. Talk about what that word means and what that looks like.

Triaging is ordering or sort of placing it mentally or in practice in order of severity, in our minds. Right? So, you know, it's easy to say, well, yes, somebody having a heart attack is is sicker than somebody who stubbed their toe. But when you're sort of in this gray area in the middle ground, when somebody has an undifferentiated abdominal pain, meaning an abdominal pain that we don't know what's causing it, it could be that they ate something bad, or it could be that they have a bowel obstruction or that they've perforated or something they're septic or very sick. And so when we start to work up those patients and as we get information back, we're having to readjust our interpretation of how sick they are at any given time and what resources they're going to need from our department.

Right. And we're trying to assign priorities, right? Who do we need to attend to first? And we have to constantly reshuffle those priorities because there's new information that becomes available or because there's a sudden change in a patient's condition, or the EMS entrance is always open, always offloading new ambulance people who might be a much higher priority.

And so as you work through your shift, you are constantly assigning priorities and then reassigning priorities.

I'm gonna turn to you, Doctor Roy, because you have a little bit more of a unique lens here because you're a clinician who works still in the emergency department as an active doctor, but you're also the chief medical officer. And so you see finance, you see stewardship as far as how we overuse or underuse the facilities that we have to make sure we take care of these patients properly.

So thinking through test ordering, because the more tests that order, the longer you're gonna be in the emergency department, and that's just the truth. Do physicians sometimes order tests because of fear, fear of missing, something or litigation being sued or patient dissatisfaction? Just talk a little bit about that and others may wanna add in as well.

Yeah. I may be going against the grain. Well, I don't really think we overutilize as much as people would perceive the emergency departments overutilize. I think by and large, our ER, and this is as an administrator, and most ERs try to be as judicious with the resources as possible and make safe decisions.

And I tell people that, yeah, the ER might get you three CAT scans, but then you're going home at the end of the day. Whereas ten years ago, you may not get those CAT scans, but you'll be kept in the hospital overnight. As a hospital administrator or hospital leader, I would much rather you get those scans and go home than stay in the hospital. And as a loved one, my parents have been to the hospital more than I would like, and my wife had her appendix out. I would much rather remake the diagnosis, treat the patient and have them home over staying in the hospital for days on end.

I a 100% agree. And that's generally my attitude as well. But we have several generations of training here and the way that I was trained, probably Doctor Wenk's trained almost exactly at the same time.

And then the evolution of what I've seen, we weren't allowed to order as much. And so you had to use a lot more clinical kind of hands on discussions. And that doesn't mean we didn't miss things. I wanna be exceptionally clear there about that.

Now there is a sense of order, order, order. Jonathan, I mean, we you were taking over a shift for me one time, and you said, you know, the radiation damage that can occur from CAT scans is not from doctors. It's from lawyers. And so there's a lot there's a lot of ordering of of CAT scans and tests and so forth.

You know that CAT scan is going to be normal, but We definitely order more CT scans than we used to, especially when I trained and early in my career.

We definitely do a lot, you know, more scanning now.

But the reality is the image quality is better than it's ever been. The diagnostic yield is as good as it's ever been.

Do we overdo it? Yeah, probably we do overdo it a little bit. But, you know, back in the day before we CAT scanned everybody, they used to teach surgeons that they should have a negative twenty five percent appendectomy rate, meaning twenty five percent of the appendices that they took out should be normal. And that was to make sure that they got all of the diseased ones, right? So you had to kind of overdo it or on the side of overdoing it to make sure you were capturing everybody. And I kind of use that same logic towards CAT scans. I think a certain percentage should be normal to make sure I'm doing enough on the right people to get all the ones that I need to be getting.

That's a true clinician answer. I love that. And that's very true. What I do see from our imaging, administrators, why are the doctors ordering so many CAT scans? We're getting there more and more. I'm like, yeah, people are living longer and getting sued and there's a balance there.

Have I ordered a CT scan knowing full well it's going to be normal? Yeah, I've done that. I think we've all done that. I think, you know, there's patient expectations and family expectations. Are you going to do a scan? And, you know, obviously in the back of your mind, yeah, if I miss something or overlook something, you know, I'm gonna get in trouble.

You know? So, yeah.

It's a balancing act. It is. That's the bottom line. And for those who don't sit in the seat of looking in the patient's face and looking at their child's face, if it's a CAT scan of the head on a on a on a very small child, for instance, for a fall, versus some of the people who sit next to me now as second in command of the company, they just that's a disconnect.

That's really hard to fully explain. Yes. We're having more tests done. Yes. We will have the conversations to make sure that people balance and truly are expeditious and wise in how they choose them.

But we're gonna order tests when we need to order tests. That's just the one that's gonna be.

Also think it's easy to be shortsighted in terms of cost. And it's like, hey, this CAT scan costs $600 but no one's really thinking about the cost of a miss. And I think you touched on it about litigation. Think the reality of it is, is that is the world we live in.

We have poor outpatient support infrastructure to make sure that if someone doesn't get a scan today, they're gonna be able get a CAT scan tomorrow. Like my dad needed to get a CT scan of his abdomen. And he called to get one done. He was scheduled two weeks later.

Well, this is for abdominal aortic aneurysm, which is something that's, if not diagnosed, will kill you right away.

So, the fact that it takes so long to do things on the outpatient world really puts more onus on the ED to make that diagnosis to order that test.

Yeah, it's really a juggling to do. I mean, all of medicine is, but in the emergency department, it's difficult to balance what you've talked about, patient expectations, the costs involved in healthcare in America, as we all know, we're leading the pack. We're number one, as far as how much we're spending. And some of these things we've discussed are the reasons why.

But if you come to the emergency department, the good news is as a patient that our expertise and the physician's expertise, the nurse expertise, the likelihood that you're gonna go home and have a bad outcome is almost zero. We really, really work towards making sure that you are safe and well taken care of and have enough information to go to your next step safely. It doesn't happen a 100% of the time, but it happens the majority of the time. That's something I can say with with the certainty.

I see the numbers just to be just to be clear. Let's move on. You know, let's talk about trust. And, I always say that as emergency medicine physician, one of the big first thirty second hurdles to make is you have to make this person you've never met before very secure with the fact that you're going to be able to save your life if the nightlife needs saving.

And they're gonna have to be vulnerable. They're gonna have to be naked sometimes. You're gonna have to touch them in places. They don't even let their spouse touch Okay?

But you're gonna need to do that and do it with an immediacy. So tell us about how you build trust and remain compassionate when caring for patients who may be angry, frightened, frustrated, intoxicated, hostile, mental health problems, abusive.

Talk it through. It's the hardest part of the job to me.

Well, first you need a thick skin. Right? You're you're, you know, you're gonna get called names. You know, there are gonna be patients who are confused or intoxicated or don't understand what's going on. I never take anything personally.

I always acknowledge, my patients' feelings. If they're frustrated, they're angry, they're sad, they're upset. I always introduce myself, talk about who I am, and, you know, I'm here to care for them. And then I acknowledge whatever's upfront on their mind first. And I think that's how you start to establish rapport.

Yeah. I think beyond that, I I think fear often is a manifestation of another emotion, of anger, of embarrassment, of feeling ignored, of being intoxicated. There's so many emotions that think that can present as anger in an emergency department and be misinterpreted. I also think it's important to remember that even though this might be one of one hundred patients you see in a given week for me as a clinician, this very well might feel like the worst day of their lives coming And sort of keeping that in perspective when you're interacting with the patient that they are scared.

Probably to be in the emergency department to begin, this might be the only time they've ever been in a hospital before. And the way that that presents will be different for different patients. But I think keeping in the back of your head and keeping in mind that this is probably one of the worst days of their lives will help you connect a little bit better with them.

Yeah, I would totally agree with the fear that patients face and their families face. And I think understanding that families are also your patients at the same time, it goes such a long way. Like my wife, she's an emergency room physician as well. One day she like had some shrimp and later on that day she's like, Hey, my stomach's kind of hurting. And then she's kind of pointing to her right lower quadrant. And that evening she's kind of struggling to lift our kid and we're both like, Hey, probably go to the ER.

She pulls her ultrasound.

We have an ultrasound at home because- Because do.

Yeah.

So we like look at ourselves and she's looking at her kidneys and looking at her appendix. I'm not really seeing anything. This is probably fine. All night, she's not sleeping. The next day, I'm like, All right, we really got to go now. We go to the ER, she has appendicitis.

One of our surgeons at Shady Grove took her to the OR. And I remember knowing that this is a cut and dry, straightforward appendicitis. And I was terrified. And I was like, What if this is the one time where something goes wrong with anesthesia, something goes wrong with the surgery itself?

Like the surgeon, he's one of our best surgeons. His name is Doctor Felscher. He's like spectacular.

Spectacular, Yeah.

And I had no logical fear for him not doing an excellent job on my like super healthy wife, but it was still there. And I went to the sushi place across the street and I couldn't finish my sushi, which is crazy for me. Like I could never Doctor.

Not do Royce. Yeah.

Shocking. But you know too much, right? And you know, as emergency physicians, we are trained to think in worst case scenarios, right?

Yeah. We've all seen the worst case scenario. Right. So it always just jumps right to the forefront of your mind.

But if I was terrified, imagine how someone that's been told in the news all the time that chest pain equals heart attack, now has a 20 year old son with chest pain in the ER, how terrified that mom must be despite the fact that we all here know that that's nothing wrong with that child. Right.

Most likely.

Right. Think one of the big things to really lean into though is hostility is fear. Hostility is not just hostility. Hostility is And it's really difficult though.

In television, sometimes gets this right, sometimes gets it wrong. It is very hard when you are in your third or four shifts, third or four night shift, let's say, and it's the ninth hour of your ten hour shift and somebody you walk to the room in at five hours in is like, who are you? It's, here we go. So it's very difficult.

So for the public and for us all, just give us as much grace as we are absolutely gonna give you would be amazing. Yeah. Because we're only human though, and we understand what we're working with, but it's important to understand. We understand that hostility is fear.

You must understand sometimes we're tired though, so help us out a little bit.

Yeah. And you know, we have to always be compassionate. Right? If you've worked four shifts in a row and you're getting to the end of that fourth shift and, you know, studies have shown you do run out of compassion. It's exhaustible and, you know, you can renew it, but it does have its limits.

Right. For the public, thinking through this and you see people on the pit and you see people on these shows and you know what the reality is as a doctor, let's talk a little bit about empowering the public to what they should do in the emergency department to understand how they come in and what they should do, know, ask, to really make their visit maximized and the most safe. So you have a person who's coming in, they get worked up, what should they be asking along the way? What should they expect as a baseline, bottom line for maximizing their care outcome?

Just give us a little bit of flavor there on things that, you know, just choose a thing or two that I think should think in my mind, my favorite thing is when patients tell me exactly why they're in the ER.

This sounds ridiculous, but why they're here and what their fear is.

Because more often than not, they'll say, Hey, my neck's hurting and my stomach's hurting and my ankle's hurting. And I'll say, What is the one thing that made you come today and not yesterday or tomorrow? And more often than not, it's not the neck, not the stomach, not the ankle, but they've been having chest pain for three days. And think, and they're scared that it's a heart attack.

So for me, and I believe most emergency room staff, not just physicians, is just to say, what are you afraid of and what brought you here today?

That's very true. I will say that patients sometimes really ramble because they're scared, basically. But I've had an older I remember when I was in training down south, an older woman start with the fact that the point of, well, I was at the Piggly Wiggly.

I had not gotten my eggs. I'll never forget this. I was like, why is this woman talking about So and she rambled on and on. At the end of the day, she was worried because she had some left sided weakness, and she was having a stroke. And it would took quite a while, especially in your early in training to figure that out. I was like, please, just a fax, man.

So that gets your The more specific and detailed information, the better, but also remaining focused.

And, Patsy, you're right. People come in, they're they're anxious and upset and afraid. And so they're just all over the place. They're scattered. I'm hearing about their toe. I'm hearing about their hair. I'm hearing about their shoulder.

It would be helpful to me and make me better able to diagnose you if you can be specific and stay focused on the main symptom that concerns you.

When you've had experiencing symptoms for a longer period of time, especially, redirecting and thinking about, Okay, what was the tipping point that made you come in today? What worried you today in this moment, to Doctor Roy's point? Why are you here today? What changed?

Also, a side note, if patients could come in with a list of their medical problems and medications and allergies would be tremendously And the medication has to be the name, not white pill, yellow pill, red pill.

Do you know how few colors there are in the rainbow and how many pills there are? Because a little blue pill could be literally 100 things. And so point well taken.

I to laugh when patients would come in with a piece of paper with all of their medical history. But now I find it so incredibly helpful in getting us a fast answer and getting us a fast way to narrow down our diagnoses and workups. And so I find that particularly helpful.

It's hard. Life is big. People have children and jobs and bosses and all these things. But the most important thing you can do really for all of those things is take responsibility for your healthcare.

Keep in your wallet, little folded up paper with your medication list. Know your diagnoses. All of us have had a million times when a patient would say, No, I don't have high blood pressure. And they're on three hypertensive medications or antihypertensive medications.

Like, what's up?

I think each of us here has seen the patient who has enormous old healed surgical scars, and can't tell us what surgery they had and what it was for. Like that's every day.

Like the person came to you cut you you open open don't know what they removed.

And to Very that point, medicine is very complex. It is. It's a different language to learn. And I do understand that sometimes it can be very difficult if you're not immersed in this medical mindset to really know everything that's going on or to the degree of detail sometimes that we like to see. But certainly having a familiarity with your medical history would be very, very helpful for us when you come into the emergency department because it's the first time we're meeting you. We don't know you like your primary care doctors do. And so giving us that boost will help tremendously throughout your care.

I think to echo that is not assume that we already know everything. So oftentimes people like, yeah, you've always spoken with my primary care doctor. I'm like, well, no, have not. But I'm happy to call him, but why don't you tell me from your point of view what's going on? And then also understanding that if you've had symptoms for a much longer period of time, we're actually less concerned than if it started today. I think it's important to start with the most recent symptoms and then go to the older, longer symptoms.

100%. We're gonna switch a little bit now and talk about the broader healthcare system and what that does in the emergency department and to the emergency department. I always say that for American HealthCare, community health care ops, and the emergency department is really the canary in the coal mine when things begin to go a little ripe. Jonathan Wink, I know you remember back in 2007, 2008 when the real estate, collapse occurred and all of a sudden we had a lot of people come in because they just lost their health insurance because their economics began to fail. And so we saw a lot of people. That was basically a landing symptom of economics in the community that we lived. It was amazing.

Absolutely. And you know, along those lines, what I'm seeing right now is a big increase in our overnight visits. And I'm starting to wonder why that is. And is it because people are afraid they're going to lose their job if they don't show up at work?

So they're going to force themselves to work during the day and then come in at night to get checked out. So I'm wondering if these, you know, enormous night visit volumes that we're seeing have something to do with what's happening with the economy, with the job market.

We're seeing volumes increase all across the region, actually all across our all of our hospitals right now. I'm not quite sure what's going on, but I think it has something to do with economics in some way. Is the emergency department then thinking about your answer there, your statement, sometimes the place people go because the rest of the health care system has failed them.

Absolutely.

Yeah. If you try to get an appointment with a specialist, you know, and they tell you, oh, our next appointment is three months. Right. You know, we're seeing that all the time now. You try to get an appointment with your regular primary doctor, they can tell you it's a week or two weeks.

And that's for people who have insurance. We haven't even touched on the people who have lost their insurance, who have nowhere else to go for care.

What does this do to your emergency departments, guys? What do?

Does All of a sudden you have X number of patients and now we're having X plus It number transforms them into the pit, right?

Mean, is the angry mob in the waiting room, right? And this is part of the reason for that.

Yeah. And it's unfortunate because then that leads to to boarding and a cascade of problems that I think political folks don't really completely understand. I'm hoping they understand versus not care about the fact that when they drop Medicaid coverage, for a popul you know, a population of people that's basically a size of Pennsylvania, which is actually what has happened, folks, those people still have to get health care. So they have to go someplace, which means they have to go for every little thing to the emergency department.

They can't go to urgent care because they have to pay for that. Exactly. Immediately. So they come to the emergency department, all of a sudden, the public I mean, when you have your chest pain, guess what the emergency department looks like?

And so it's a a big deal.

Big deal. Absolutely.

As you said, we're we're sort of the canary in the coal mine, right? When when, you know, our our volumes explode, when there's a downturn in the economy, when people have lost their jobs, lost their insurance, when they've eliminated Medicaid enrollment, you know, that blows up our waiting rooms. We see it all the time.

And I think on the bigger side, on a macro level, people often feel like the emergency department is separated from the hospital. And I try and like it to a restaurant where if everyone that goes to a restaurant stays ten hours as opposed to staying for three hours, your wait to get a table is gonna be way longer.

And the less outpatient resources you have, which include things like nursing homes and primary care visits, the longer people stay, not just in the emergency department, but in a hospital. And because of that, the people that normally could get in quickly, move through the system and go home, everyone waits longer.

Stay tuned, folks. We'll see what happens, going forward in the next several years. But I do believe that knowing my colleagues such as yourself, the nurses in the emergency department, the the culture of the emergency department is really bring it on, we write it done, we're gonna get this done. But there has to be a limit at some place to that stretch. And I haven't quite figured out where it is. We we did very well dependent in the pandemic. We did very well during that 2007, 2008 surge that occurred.

Disasters happened across the country now all the time. We just kind of absorb it, but I I do wonder where the end of that is, really. Alright. Let's let's talk about the human side of emergency medicine. You see it a lot on television. You experience it a lot, as well.

It's got a little bit dark, I'm gonna go lighter. I'm just gonna put it out there. What's the hardest case emotionally, not medically, but emotionally to deal with? And there are many. Yeah.

I thought about this. I have one that I still kind of grapple with. It's It actually wasn't the patient. So a 20 year old that had a history of drug abuse, went home and lay on the sofa. His mom came by, saw that he was sleeping, shook him a little bit, assumed he was sleeping and went back.

And then she came back a couple hours later and tried to wake him up and he didn't wake up. She called 911 and he came to the hospital and he died. And then I'm sitting in the room talking to mom and mom asked me, she's like, Hey, could I have done anything to prevent this?

And I said, no. And I was like, hey, there's nothing you could have done. This just would have happened. And I I still grapple with whether I said the right thing.

And I I think I did. I feel like I did because that lady looked like a weight was lifted off her chest when I told her that. And this was early in my career, maybe fifteen years ago. I still think about her and the way she interacts with healthcare now.

And remembering that when someone dies, their whole family becomes your patient. And, I still think about that.

Yeah, I mean, of the hardest parts of the job is delivering the worst news possible to people, right?

The worst.

And sometimes that news is expected.

And sometimes that news is completely unexpected.

And it is our job and probably one of the hardest parts of our job is to sit down, look somebody in the eye, and tell them that their loved one has died.

And what's even worse is if it's a child or it's a suicide. And those are the cases that sort of take their emotional toll.

Yes. They do.

It's less of the most memorable or hardest cases for probably most of us are not the big resuscitation or CPR, the gunshots. It really is those emotionally taxing encounters where you have to tell a parent that their child has died you tell somebody that their parent has died or vice versa. And even in those situations, it's not so much that the patients, the families rather, may not remember exactly the technicalities of what happened during that encounter, but they are going to remember how they felt how you interacted with them in that last encounter. And I really think that those are the cases that I maybe not in that moment that I take a step back because I have other patients. And we have to continue the shift and keep going.

But it's really those are the cases that when I go home and I sort of have a chance to breathe and take a deep breath and and and really reflect on my shift, those are the ones that that still really get to me that that I have a hard time with.

They land and they last forever. And you know that you what you say and what you do in that moment, it will impact this person for the rest of their life. This is not gonna be something I'm think about for a week and forget. It'll be for the rest of their life. When I worked in a more urban, very busy, very pit like actually, environment early when I was an attending, There was, a drop off of a 14 year old who had a gunshot wound to the chest who died, unfortunately, and I had to tell his mother.

Two months later, the same scenario happened with an 18 year old that was dropped off and we cracked the chest and did all the things that you do. It was his brother. So I had to tell that mother, that 14 year old in the 18 I had I I told her, I will never forget the look on her face.

I had all kinds of questions about what what's happening, and I had no ability at that stage in my career or now to have a conversation that's gonna help her at all. And that will stay with me forever. There are multiple cases that we're all gonna have and that we all have that will last with us as long as it lasted with that person. And that is just a part of the job, but it is very, very, very difficult part of the job that is the most unpalatable. But, it's an honor to do it, but it's.

Yeah.

And I think that for any of us, whenever we, whenever, if we ever get to a point where that doesn't affect us, you know, emotionally or as a physicist, that's time to hang it up.

Yeah.

That means you lost your empathy and it's time to retire.

It's time to retire. Because also when you make mistakes too. So it's it's a really unsafe, way to be. Last thing on this topic.

What is the most heroic thing that happens to the emergency department but would look very boring on television? I always say that we have the everything's exciting. That's not quite true. You know, you think about lawyer shows and being lawyers, nothing like those shows is quite boring.

I'm sorry to all the lawyers that's listening to me right now. But your job, not exciting. I'm just gonna put it out there.

Our job, however, is very exciting, but there are things that are really heroic that are like quiet.

Yeah. I think for me, and I know we talked about diagnostic uncertainty, but oftentimes when you trust your gut on something and you do the extra test or do something at the bedside or keep a patient longer, and then you make an outcome or a diagnosis that truly saves her life. And this is that third EKG on a patient with like vague chest pain that's young, and you're like, you know what, let me just do one extra test.

And then you clinch something that if you hadn't captured, they would have gone home and died. I think those are perhaps the most heroic things that no one talks about that we don't even talk about. We're just like, Oh, man, that worked out well. But it's something where someone came really close to dying. And because of something in decades of training, we were able to pick up and capture.

Doctor Yeah, you know, in emergency medicine, sometimes things can be incredibly subtle, right? So not every heart attack comes in clutching their chest in agonizing pain, right? And I tell people who are not in medicine, every single diagnosis comes in two flavors, obvious and subtle. And it may be boring, to some folks to think of us sitting at a computer looking at their blood test results, their lab data, their things, sifting through piles of data, right?

But, there could be a very subtle and important clue buried in there that it's our job to find. As Neil said, it can save a life.

The case that I always think through that, Doctor Baum, you mentioned a minute ago is sepsis, which is for the public, there's a cascade of that occur when you have a deep infection that gets into the bloodstream and makes people really sick. And that sounds very dramatic, truth of the matter is somebody could be sitting up in a chair on their phone looking at Instagram and all of a sudden like, why is their heart rate 125?

You know? And then you start to dig and dig and dig, and all of a sudden it's like the world reveals itself, for a horrible infection. Then you could have just looked at them, pat them on the head, letting them go home, and they would have died. And so that's one example I think of as well. It's really subtle and it's very academic and intellectual kind of thing to dig into and diagnose, but it's not a razzle dazzle case. It just isn't.

And we do a lot of detective work, so it's not all just scans and tests and blood work and things like that. I had a case once where somebody came in, a young, healthy person, they had an episode where they nearly passed out. They had a near fainting spell and they looked totally well and their vital signs were normal, EKG normal, everything was looking normal.

And I remember contacting the paramedic who drove the patient into the emergency department, and she said to me, You know what was weird is when I first got to the scene and put a pulse ox probe on the patient's finger, the oxygen saturation was only 88. I thought that was kind of weird, but it became up to 100 when we came into the hospital.

And so that tiny little detail, led to the diagnosis of huge blood clots in the lungs that could have been life ending for that patient. And so it was just a little bit of extra detective work in that particular case. And so, you know, it may not seem that exciting to folks making calls, talking to people, but the reality is we're detectives and you never know which tiny little subtle clue might break the case wide open.

I think to that point, Elsie, I think you're also getting to something else.

You know, it is a team sport, especially in the emergency department.

Percent.

And I think a lot of the, I'm going to give some shout out kudos to the other parts of our emergency department because, yes, the physicians do a lot and we can make diagnosis and run tests and all this stuff. But behind the scenes, in a part that might not be as visible to the patient, there's a lot of other heroes in the department It's too, the It's the nurses who find that subtle change in heart rate and alert somebody. Or the technician who gets that EKG done minutes within the patient's arrival. Or even the environmental services folks who come in and they can turn over and clean a room in a couple of minutes so that it's available for another patient to come in. I think those are some of sort of behind the scenes things also.

I have a case from early in my career that along those lines, I had a 26 year old man who came to the ED, for chest pain, and this was his third visit in three days.

So the first visit he gets standard battery of tests, EKGs, cardiac troponin levels, everything normal, goes home. He's 27, he's young and healthy.

And he returns the next day, he's got this peculiar chest pain going on and he gets even more testing. He gets high resolution CAT scan of his chest and looking for pulmonary emboli and aortic aneurysms and everything.

And once again, they find nothing and he's discharged. And now he's come back for the third time in three days. So this is already now kind of a red flag for us emergency physicians when somebody has come back now three times, for the same symptom complex. And now I'm his doctor on this third visit. I did not see him the first two visits.

And again, everything's normal under the sun. Ekgs, blood tests, he looks well. His pain doesn't sound consistent with anything dangerous or serious.

I find nothing and I don't really see any need to hospitalize him at this point. So I'm getting ready to discharge him yet again.

I've typed up his discharge and, his nurse comes over to me and says, Do you want to give him any medicine for fever before he goes?

And, this was a new development. So I said, excuse me. And she said, Oh, I just took a full set of vital signs on him, including a repeat temperature, and he now has a fever of 102.

So I go reassess him at the bedside, and I'm still having trouble making sense of all this. But now I've decided, well, armed with that new piece of information, I am not going to discharge him home. I will be admitting him to the hospital. So, gets admitted, and the following day he develops bilateral leg weakness.

Oh, no. And he is discovered to have a spinal epidural abscess in his thoracic spine. And he undergoes, immediate surgery with neurosurgery, and he, does well and, regains his neurologic functioning. And, I will never forget that nurse coming up to me with that detailed piece of information that totally changed the course of things.

And so, you know, that case sticks in my mind as this is a team sport and I am dependent on the people around me to do this job well.

Very much so. Doctor Wenk, you always bring these questions these cases, make my palms sweat. Yeah.

That that's no fun. That's that case, no fun. But it's very interesting though. I will say that.

We're gonna close out a little bit. We're gonna go back to television.

I'm assuming you all have seen the pit. You've all seen ER. You've all seen these other house shows. You've seen, you know, Grey's Anatomy and on and on and on it goes.

I'm just gonna ask for opinion here. Want you to think about these shows a little bit so we can bring the public back to to what's real and not real. Let's start with the easiest one to to to think through. How realistic is, Grey's Anatomy?

So, with the caveat that I've only seen one or two episodes Right.

I sized it up as a a silly soap opera that didn't appeal to me.

So There's far less intimacy in closets than as depicted in the show.

The quote that mainly makes me want to say out loud, ain't nobody got time for that. Who has time to do all that? People die and things happen and you have that time.

I honestly, the one episode I watched, I think the physician intentionally ended a patient's life so that the heart could be harvested for a transplant for her boyfriend who needed a heart transplant.

Never happens.

So I remember thinking, so that's homicide. And, we don't do that. We don't do that.

So I think we're ordering CAT scans because we're afraid of lawyers.

We certainly aren't doing that.

We're certainly not committing homicide.

I mean, come on now.

We're gonna go on to another show. Let's talk about House. What do you think about that show as far as real or not real? Entertaining. What are your thoughts?

I think the diagnoses are real and very interesting.

I think it is impractical one that there is one single doctor who spans the vast scope of every specialty, right? So, know, that does not happen.

Where did you go to medical school?

I saw an episode once where the doctors were running the MRI machine. I wouldn't even know where the on button is.

Me neither.

And, nobody ever wore gloves in that show ever, no matter what procedure or icky thing they were doing. Nobody ever wore gloves.

Yeah. That makes no sense at all. Let's talk about ER. Have you seen ER with the fantastic George Clooney at all? What do you think, Doctor.

Rooley?

I think I also think it's pretty unrealistic across the board.

Like I wanted to be an ER doc watching ER growing up as And a I was like, this is nothing like what I was watching.

Yeah. Just the cases are so big and so dramatic and so constant. It's that goes back to the comment that you would never survive a week if all your shifts were like that.

I thought the first season, the medical cases were pretty accurate.

I think the cases were accurate.

Sadly, as as that show went on, it got more soap opera. That's true.

Lastly, the most recent show, and I had avoided seeing it. I didn't want to seeing it. I'll just say that. And I'd watched it particularly for this podcast episode and that is The Pit.

Yeah. My gripe with The Pit, and this is unique to me, is the very first episode, a hospital administrator goes down and pulls the doc out of the room to talk about patient satisfaction scores. And I turned off the TV.

The misconception is that hospital leaders don't care about the ER. And I just think that's just not true. I think the rest of the diagnosis lab, that's the most accurate of a show I've seen, but that part really bothered me.

True. And I will say that here, administrators don't do that at Adventist HealthCare. There are variants of different shades of that across the country, depending on what health system you work for and what hospital you are in.

And there are some institutions that have, financial incentives for hitting patient experience scores and things like that.

They can weaponize that particular metric quite easily. And so, our experience here is not the universal experience, but by and large, you're quite correct. Any other commentary on the pit, the cases, the pace, the whole?

At least it's Yeah.

I mentioned earlier that, you know, that while while we have seen nearly all of the cases that are presented in that show, we we would never see them all in one shift. That would be that would be impossible. I I think that the the the inaccuracy of the timing of how we see patients is there. I think also it makes we are all very cool people. We all think of ourselves. But I think that show might embellish how cool we actually are.

Speak for yourself, Doctor. But it's a good show though.

Have to say it's more accurate than others by far.

Yes. Yeah. It's gory and graphic for people who are, squeamish. True. My parents watched it and were taken aback by the gore.

But think there's Isn't your dad a pathologist? Oh yeah. But if you're not expecting it and you turn around and you watch it, you're like, woah, this is not your garden variety show. Right?

I think they go out of their way to be a little graphic, a little gory. Right?

That said, I do think the one thing that pick gets right is sometimes is that feeling of like how intense it can be and how high stress an environment it can be.

Can be.

You know, not, not a 100% of the time, but I do think it captures some of that. You know, have a lot of colleagues who have watched The Pit and really have a hard time watching it because it makes them feel like they are at work.

That's And the reason why I didn't wanna watch it.

Right. And it does make you feel like you're work.

Yeah. We have a rule in my house that, we don't watch that after I've worked a shift. Yeah. Gotta watch that on my day off or something.

Yeah. It's too much. There was an episode that I watched, I see on a plane recently, where somebody was opening up a cast and there were a bunch of maggots in there. Did you guys see that show? Yeah.

Done that. Don't wanna do that again. I just wanna say that that that was really real. And so there are episodes or parts of that that really resonate as flashbacks Yeah. Basically.

There episode where I think there, there was a young girl who drowned in a swimming pool.

Yeah.

We've been And I had that case when I was a resident.

And, I remember talking to the parents. It was horrible. And I had to kind of relive it watching that episode.

There are this is not about the pit. There are cases though where you think something horrible is is wrong. You know, the cases that were my least favorite were having some child who's a toddler who's screaming, you don't know why, you don't know why, and then they burp and they start smiling. And it's like, oh, medical school doesn't teach you anything about diagnosing gas in a non speaking human.

You know, it's just very stressful as well as well. But there's goods, there's bads, they're often represented in that show. Closing questions. What is one thing everyone should know before coming to the emergency department?

Let's set some expectations here.

I think the first thing is the goal of the ER is to rule out things that are going to cause permanent or life changing or death within three to seven days. Not make a diagnosis, it's to rule out diagnosis.

Yeah, going to try to make an exact diagnosis every time, but the reality is, in most instances, what we're going to do is rule out the immediate life threat.

A 100%.

Yeah, I think we would always and also, you know, I would recommend to come in early when you feel or experience symptoms. We would rather reassure somebody who is well rather than having to treat somebody who has waited too long to come in and is in a much worse spot.

I also would say if you don't understand what's going on, workup you don't understand, you understand why things are happening, you're about to be discharged, and you don't understand the care you got, the diagnosis that has or has not been been made. You gotta own that and ask the questions. You gotta slow the doc down. They're running around the nurse, make them go back and just sit there and say, I I really am sorry for taking your time here, but I really am afraid of x, and I don't feel comfortable with y.

And these are the questions I still have. And I know you've just done thousands of dollars of tests. Please tell me why and what was there and what was not there. I don't understand.

Own it. You know, you have to really speak up and be empowered to do so.

That's what I would say.

I think, I'd like people to know that low back pain, most people don't need an MRI. That's the one thing I want people to know. Because everybody asks for one, everybody wants one. It is a great test. It is a great tool.

But the reality is it does not change management in ninety nine percent of people with low back pain.

Very true. So we're gonna close out now, and I thank you all for being so clear and so transparent about what it's like to really work in emergency department. You know, care is often practiced under extraordinary pressure with incomplete information and very little time. It's just a job.

Alright? And I do hope for the public and for our community here. Today's conversation has helped illuminate not only how emergency departments work, but also the judgment, teamwork, and humanity required to care for anyone who comes through those doors. It's been a great conversation, guys.

I fully appreciate you coming to the table.

Thanks, Thank you.

Alright. Charting with Doctor. McNeil.