Why Is It Taking SO Long?!

One of the biggest complaints I hear people express about visiting the ER is, “Why did it take so long?! I just had a ______________ (you can fill in the blank with: sprained ankle, little cut, sore throat, etc., etc.)!”

Without a doubt, care in the ER often takes longer than most of us would like – the patient, the patient’s family, the ER doctor, the nurse – everyone! Let me try to shed a bit of light on why this is.

First of all, every ER has a finite amount of resources. A finite number of treatment rooms, a finite number of doctors, a finite number of nurses, etc., etc., etc. Almost every ER Director would like to have more rooms in which to see patients coming to us for care, but our resources are constrained (though I am, on a daily basis, struggling and scrapping for more space!). Given that our resources are limited, we have to do the best we can for all of our patients. This generally involves a process of “triaging” patients. The term “triage” comes from a French word meaning “to sort.” So, when we triage patients, we are trying to get the best possible feeling of why a patient has come to the ER – what the symptoms are and what MIGHT be causing them. This allows us to prioritize patients and make the most of our limited resources. We try to ensure that patients with potentially life or limb threatening issues are seen first, and then those who have less pressing problems (these latter cases tend to be seen in the order that they arrive in the ER). This could mean that if you’re in the ER with a sprained ankle, you may have to wait a bit while patients with chest pain (possible heart attack), weakness (possible stroke), etc. go before you.

Once you are seen by the doctor (or another advanced provider such as a physician’s assistant or nurse practitioner), further time is needed for that person to get your history and do a physical examination. Remember, the details the ER doc needs will be a bit more extensive than your private physician might need, because the ER physician generally doesn’t know you or your medical history at all. Therefore, we need to get more info, so that we understand “where you’re coming from,” and can better decide how to approach your problem, both in terms of diagnosis and treatment.

After the doctor gets an idea of the possible things that could be going on, s/he develops a “differential diagnosis.” That’s a laundry list of all the possible things that could be causing your problem, generally ranked from most severe possibilities to least severe. Then the doctor must begin to rule out, as needed, the worst things that could be going on, and ultimately get down to a “short list” of what’s most likely. This may involve doing some diagnostic testing – blood tests, x-rays (including CT scans), etc.., and/or it may involved getting an opinion from an expert consultant. All of these tests/consults take additional time. The thing to keep in mind, however, is that the ER is really the ONLY location that essentially any patient with essentially any problem can come and get some pretty definitive “same day” answers about an acute health problem or injury. No other office or clinic has such ready access to such a wide array of diagnostic capabilities as the ER. Outside the ER, the evaluation of a new problem may take days to weeks (or even months). That makes a several hour evaluation in the ER seem a bit more reasonable doesn’t it?

If, however, you are a patient with “a simple cut,” you might still have to spend more time in the ER than you'd like, because your care providers may be simultaneously dealing with multiple other patients with more serious illnesses or injuries. This doesn’t mean that YOU are less important to them, just that YOUR MEDICAL ISSUE appears less urgent at that point in time. Many ERs have developed alternative “tracks” (e.g., “fast tracks”) for patients with less urgent problems to get in and out of the ER faster, without getting tied up in the more critical care going on at the same time. Nevertheless, even these resources are finite, and may, at times, be pushed beyond capacity.

So, if you find yourself playing the “waiting game” in your local ER, try to be patient. Take some solace in the fact that you are not requiring “intensive resources” to take care of your problem (remember, no one wants to be “an interesting case”!). You should feel empowered to request an estimate of how long your wait might be, but a hint here: try to be as nice as your situation will allow you to be. If the ER is really busy, the staff is likely "feeling the heat!" You might even smile at your nurse or doctor when you ask about the waiting time. That ought to catch us off guard!

Bottom line: the vast majority of ER care providers really want you to receive the best, most expeditious care possible. I know that if we find someone in my own ER that doesn’t have that mindset, he/she will be moving on to another place of employment – hopefully with one of our competitors!

Stay alert and stay safe.

- Dr. Bob

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