This is a topic that I want to be really thorough about. I wanted to write “emergencies” ever since I started training in the emergency room of PGH. Me and my fellow doctors talk about it all the time. It is the primary duty of a doctor to know what is and is not an emergency, and what incident is more emergent than the other. First let’s start off by defining what EMERGENCY is.
According to Merriam-Webster Online Dictionary:
Main Entry: emer·gen·cy 
Pronunciation: i-'m&r-j&nt-sE
Function: noun
Inflected Form(s): plural -cies
Usage: often attributive
1 : an unforeseen combination of circumstances or the resulting state that calls for immediate action
2 : an urgent need for assistance or relief <the governor declared a state of emergency after the flood>
I prefer to use the first definition because it is more complete. There are 2 important keywords: unforeseen and immediate. Unforeseen circumstances include gunshot wounds, vehicular accidents, seizures, and strokes. Emergency rooms usually do not let these cases transfer to other hospitals UNLESS the ER is very full. In cases that they have to transfer patients, we make sure that the patient is STABLE enough to make the travel, while explaining to the relatives that there is still a risk that the patient MAY die on the road. That is why in ideal situations, a doctor must either accompany the patient to the next hospital, or at least call the next hospital to check if they have vacancy. We hardly see doctors accompany patients to other hospitals anymore. PGH has too many patients and it would be too much of a loss to send a doctor out. Sometimes when a patient has to go out for a diagnostic procedure, the residents send an intern to facilitate it. A lot of other hospitals send patients straight to PGH because patients could not afford the prices in private hospitals. And a lot of patients are turned down because of improper conduction (or improper transfer).
Mistake #1: The resident of the hospital where the patient is coming from did not coordinate with the ER officer of PGH that they are sending over a patient. They send in people when in truth there is no more room for the patients. Sometimes they send the patient to PGH because they could not afford the CT scan there, when they do not know the the PGH CT scan is BROKEN. UP-PGH is the most popular and biggest charity hospital in the Philippines, and so we get a LOT of cases, that are sometimes too much for us to handle.
Solution: Coordinate well with the other doctor. It’s all about communicaton.
The next keyword in the definition of emergency is IMMEDIATE.
Mistake #2: Going to the emergency room but is not really an emergency.
Here comes a patient looking weak (acting weak?).
I ask politely: “Sir what is the reason for coming to the hospital at 2 in the morning?”
He answers: “My stomach hurts.”
Me: “Did somebody punch it?”
Patient: “No.”
Me: “Since when has it been like this?”
Patient: “Since 2 weeks ago.”
And my face melts. A stomachache of 2 weeks duration is NOT AN EMERGENCY. If it were a stomachache of 2 hours that is focused on the right lower quadrant, then maybe I would entertain appendicitis which requires emergency surgery.
Solution: A 2 week duration stomachache is best handled on an out patient basis! You should have come during office hours.
Mistake #3: A not-so-life-threatening case.
Triage: “Why are you coming into the emergency room?”
Patient: “My eyes are red and itchy.”
Sore eyes can be handled in an outpatient basis. It does not pose an immediate threat to the patient. Cases like this which we cannot fully ignore are sent to “Ambulatory Care”. The clinic in PGH which caters to not-so-emergency cases but are cases which cause the patient discomfort so we cannot send them home immediately.
Solution: Do not immediately send these patients away. Assess the patient well, and then make sure that the reason for coming is really emergent. Are you sure it is just Sore eyes? Maybe it is acid burn. A good history and PE is worth more than 1 diagnostic exam.
Mistake #4: Not being able to detect a TRUE emergency. Sometimes I want to bump my head into a wall when I hear about cases when a burn victim is brought to the ER 2 WEEKS AFTER the incident. The wound looks contaminated, and the patient cannot feel the affected limb. The time for saving that body part has come and gone. Time for amputation.
I really wish that people would learn to understand one thing:
FIRST COME, FIRST SERVED does NOT apply to the ER!
In the ER, the patients who get full attention first are the ones in the brink of dying, or in Tagalog, “Agaw buhay”. I remember one time as a clerk in UMC, that I was ambu-bagging (pumping oxygen for the patient to breathe) a small infant whose heart suddenly stops beating. All the nurses were busy fixing the patients IV line and administering emergency medicine. My resident was barking orders all of the place in order to save this poor baby’s life. Then with no sensitivity at all, this woman, a mother of a child with cough, comes up to me while I was ambu-bagging and says:
“Are the labs of my child done yet? We’ve been waiting for hours.”
I really wanted to strangle her but of course I couldn’t do that while I was ambu-bagging hehehe. Please, be patient. One of the consultants in UMC who is very particular about doctor-patient relationships insisted that once in a while, we should tell the not-so-emergent patients that we apologize for the inconvinience that they are experiencing. True, it would make them understand and be a little more patient. But honestly, is it even necessary for me to tell you to WAIT while we try to keep this other patient from leaving the face of the earth?
Ahh… Emergency room DRAMA. That’s why I admire those Americans who make TV shows out of hospital happenings. Why don’t we do that here? We get a lot of them in PGH alone.
Before I forget, I also want to emphasize this one detail about the ER:
ER is not = Ward
When a patient is stable but is in need of daily medical management, it is best that they are placed in the wards right after being stabilized by the ER staff. Once they are not having airway or breathing problems, and all of their vital signs are stable, they should either be sent home, or admitted. The ER is like a gateway. It is not for long term care. It is all about saving people enough to live another day. Because of PGH’s large yet full wards, people end up staying in the ER for a long time which ideally, should not be the case. That is why the ER has a room called the OU, which stands for Observation Unit. In my opinion it stands for Overstaying unit. It’s risky to keep a stable patient in the ER. They could get infected by another patient or what. They are lucky that there is a place like this in the ER. Otherwise, they might have to be sent to another hospital with enough beds. When I am in the ER, I like to get the job done quickly so that I could either send the patient home or admit the patient. Because overstaying patients are the ones causing the crowds, not to mention that they also have watchers or relatives making the ER crowded. How can we manage the real emergencies when so many people are getting in the way? They make the ER more toxic than it really should.
The ER is a dynamic and action-packed place to be. But not everyone should be there. Now you know why in the hospital, we don’t just lump patients in one room. There is the Out Patient Department (OPD), the Emergency Room (ER), the Operating Room (OR), the Pay ward, and the Charity ward. Maybe one day I can discuss how things go in those are rooms. But for now…
Know your place.
Interesting insights. Definitely systems thinking (Peter Senge). As a previous intern myself (in same hospital), I would like to put some of the mistakes and solutions under a different perspective — that from poverty and the lack of accessible healthcare for many poor Filipinos.
Mistake #1: The resident of the hospital where the patient is coming from did not coordinate with the ER officer of PGH that they are sending over a patient.
Solution: Coordinate well with the other doctor. It’s all about communicaton.
Seems to be obvious until you become a resident in one of those hospitals outside PGH. Trauma patient, no attending surgeon (or at least none if the patient is charity). You then have to refer to PGH or another govt hospital. But if you do call, what are the chances that any of these govt hospitals will actually say “yes, we have a vacancy”? Probably nil. So you send the patient out with a referral letter “To Hospital of Choice”, and then instruct them verbally to go to PGH knowing it has the necessary complement (albeit strained) to manage the case.
Challenge question: There is really no lack of surgeons (around Metro Manila, there’s actually a surplus). Why do they say “no” to charity patients? Because they think it’s not worth their time. How do we solve that?
Mistake #2: Going to the emergency room but is not really an emergency.
Mistake #3: A not-so-life-threatening case.
As an intern, this has plagued me so much. Imagine yourselves winded at 4am after a long night and then they come in to complain about their 2-week old abdominal pain.
But why do they come at that time? Refer back to our lessons in primary health care — health care must be accessible. The poor do not have access. The PGH ER is the place where they know they will be seen within an acceptable period of time (at least to their perspective). OPD is too crowded. Private hospitals (na nilalangaw sa gabi, are abundant around PGH but will not take them in.)
Bottomline: universal health insurance — where every Filipino gets the quality care he deserves regardless of his ability to pay. And of course, a complete redesign of the practice system of Filipino doctors from the good ol’ reliable fee-for-service scheme (which works for pay patients only — but the hospitals need to push for their expensive hi-tech equipment to obtain maximum profit from the patient’s visit) to a social health insurance scheme (which works for all but may not be hi-tech at all and therefore less profit for hospitals and less expense for the insurer (which is the Filipino people)— here, going low-tech saves costs and doctors rely mainly on clinical skills rather than technology).
I take pride in PGH’s goal to make good clinicians out of its graduates. And I see the reason why: good ethical clinicians are more effective and less expensive for patients and for the health system.
Thank you so much Dr. Love for your comment for my blog article! It is an honor to be able to discuss such matters with a fellow doctor like yourself. I also agree with a lot of what you said, and i am very thankful to hear the side of another person. It goes to show that there are other doctors out there that are as concerned as I am with what goes on with our hospitals and our patients.
I am actually not from UP, I studied in a different school of medicine (DLS-HSC). So I also know what it is like to be a clerk in a pay hospital. I know what kind of experience they got when they were still in the pay hospital and the what kind of turmoil they had to endure being sent to a far-off hospital with which they are not even sure they will get in. It’s really a good thing that I decided to transfer schools for my internship. I used to think that if we just send them off to PGH or to a Hospital of choice, then they would have a good chance of getting in. It is a government hospital after all, and there is no expensive OR fees like in my previous hospital. I used to wanna bang my head on the wall (figuratively speaking of course)when a patient who we sent off to go to PGH ends up going back to DLS in Dasmarinas saying they were turned down. They are probably the ones who were told to go to some other government hospital like National Children’s hospital. But because their ambulance just dropped them off and now they are stranded in manila, they opted to just go back to their province.
It is definitely untrue that all calls to PGH are turned down saying that we have no room. I always encounter times when my resident tells me “Hey we have a patient coming from (name your province) and they are going to transfer here.” And we take them in with open arms. The ER resident will really tell the referring resident from the other hospital if there is a vacancy. The problem is there isn’t always going to be a vacancy. But at least, if the resident referring will be told at that point that PGH has no room, then they would just have to call some other government hospital to take their patients in. The patient would not have to go hopping from one hospital to another, further wasting their time and money. Then of course, this is what IDEALLY should be done. It’s pretty draining to have to coordinate all of your hospitals when it is easier to just give them a slip that says “to hospital of choice”. I think the only compromise that we can give about that is to explain to the patient that there is NO GUARANTEE that they will get in to PGH and they should not just send their rides may it be an ambulance or a jeepney away when they step foot on PGH so that they would have an easier time transferring from hospital to hospital.
It’s really a pity being the clerk who has to write an abstract for a patient to transfer instead of helping them right then and there. It rips my heart out to be the intern at the receiving end, listening to my resident (or to myself), that there is no room for them in PGH. That their transfer letter has no power to let them in.
Primary health care – health care must be accessible.
There can never be enough doctors, nurses, medical staff, hospitals, and medical equipment… If this is the state that we are living in then we are really in big trouble. Nurses and doctors are leaving for another country. What will be left?
Doc, we got a lot of work to do… Let’s get started ^_^