We spend a lot of time talking about making the emergency department experience better for children, and we probably still have a long way to go. The emergency department is an inherently scary place, to which we add a series of painful tests and procedures. No one visits the emergency department for fun. Decreasing anxiety and pain is an essential job in any emergency department. However, none of that is unique to pediatrics.
The emergency department is a scary place for children, but that is also true for adults. There is noise, chaos, and uncertainty no matter what your age. You come through the doors feeling sick, no matter what your age. Sutures, IVs, and blood draws hurt no matter what your age.
True, adults can rationalize some of the pain (I know this IV hurts, but they are doing it for my own good) and are generally better at advocating for themselves. However, I fear we may be ignoring adult distress because older patients aren’t nearly as cute.
On a recent shift, I was watching an episode of SpongeBob Square Pants with a child while we completed his exam. It got me thinking. If I was sick enough find myself in the emergency department, and had to lie on an uncomfortable stretcher for hours, surrounded by frightening alarms, worrying that I might be dying, wouldn’t I also want a TV so I could watch that delightful sponge who lives in a pineapple under the sea? (Or, I guess, something more age appropriate.)
EMLA for IVs and LET for lacerations are considered routine in children, but I have never seen them offered to an adult. Why?
3 hour waits will always be annoying, but in most emergency departments they are currently intolerable. You sit on uncomfortable chairs, inhaling the germs of the multitude of sick patients surrounding you, without easy access to water, or the other necessities of life such as WIFI, and never knowing whether you have 10 minutes or 10 hours left to wait. (Not to mention, all this time you are wondering if your abdominal pain might mean you are dying.) Most airports are more comfortable than hospital waiting rooms, and that is not a standard we should aspire to.
We can do better. The basic principles are the same. Take the time to introduce yourself and develop a relationship before jumping right into the physical exam. Explain why exams and tests are important, and let patients know what to expect. The specific techniques will vary (I am not routinely searching for frogs in my adult patients’ ears), but the underlying principle is the same: recognize the individual as a (potentially scared) human first and a patient second.
This post isn’t about solutions. Perhaps future posts can tackle the many ways hospitals can be improved. Today, I simply want to point out that emergency departments are inherently distressing environments; that adults get scared too. Adults, after all, are just big children. We should all embrace our inner pediatrician, and focus on making emergency departments less scary of patients of all ages.
If you have thoughts on ways to improve the emergency department experience and make it a more humane place for patients of all ages, please share them below.
Morgenstern, J. Why do we ignore distress in adults?, First10EM, August 20, 2019. Available at:
12 thoughts on “Why do we ignore distress in adults?”
I’ve been routinely ordering LET for adult lacerations for years. I think it should be a standard nurse-initiated protocol. Also, emergency provider compassion (not just empathy, but active compassion) has been shown to be associated with less pain and less anxiety in surgical patients, which I think should be applied liberally to all ED patients.
That is why you are one of the true leaders in our field. I still get funny looks when I ask for LET for adult patients, but I agree – LET should be applied to every laceration at triage.
The first time I did it, I wondered why I’d never thought about it before. EKG for chest pain in triage, LET for lac in triage
Read many articles about being nice to our ER patients, many of whom arrive with self-inflicted illnesses and being financially responsible for their care never crosses their mind. Yet when I visit practitioners, from optometrists to cardiologists, I’m treated with no respect or compassion, and often demeaning behavior. Part of this may be related to being one of the most vile creatures on earth today, the “old white man.”
Being treated this way makes me stop and consider how I treat my patients and hope I give them more consideration.
I agree with Hannibal Lecter that “discourtesy is unspeakably ugly to me.”
A couple of years ago I learned comfort talk by Elvira Lang. It includes hypnosis, but also a different way to approach a patient and use language. “this is going to hurt” makes it hurt more! It changed my practice. (and also raising my 3-year old daughter)
There is great evidence that an injection of local anaesthetic prior to cannulation significantly reduces the pain of cannulation. Some old evidence that LA injection it is even less painful than insertion of a 22 gauge cannula.
I’ve found that using a 29g insulin syringe to inject a tiny bleb of LA prior to cannulation makes the entire experience almost painless.
I’m not sure why this isn’t a more common practice. Maybe mostly because it’s slightly inconvenient? There also seems to be a feeling that patients should be tough enough to deal with the pain of a cannula. Most are, but I think it’s nice to at least let them be the one to make that decision.
Fantastic post. A very rich reminder. Thank you
I don’t know how it works in Canada, but in America, the first place I would start is charging people money to use the Emergency Department. This would accomplish several things, including decreasing patient flow, decreasing those coming with mild or frivolous complaints, and increasing patient compliance with treatment plans. In general it’s a win-win situation. It is not a utopia however I do recognize that.
Personally, I disagree. I think there is pretty good evidence that user fees just stop people who really need care from seeking care, and you end up with worse health outcomes. Furthermore, people with minor complaints have never been a problem for flow in any department I have worked. I can see people with minimal complaints and discharge them home in minutes. For most funding models, minor complaints are actually a boon for an emergency department and for the physicians. It is the bed block from the inpatient side and the complex patients that cause problems, and user fees solve neither of those issues. In fact, user fees would make a lot of our problems worse, because if I am paying you, you better believe I expect pillows, private room, and rapid service.
Thank you for your reply. I suppose we have different experiences. First, I am casually aware of evidence that user fees stop people who need care from getting care. I have heard that before, however I have not read the evidence behind that. But I believe the evidence exists (I just don’t know how good it is). On some level, I can see someone saying “I’m having chest pain, but the local ER costs $50 so I don’t want to go”, but on another level, if you having crushing chest pain, the choice between paying $50 or the chance of cardiac arrest and death seems like an obvious choice. Moreover, I have a hard time believing “all” outcomes are worse, because that would suggest those who seek primary care (where there is typically payment) are worse than those seeking emergency care. Are there worse outcomes for those who pay ER co-pays vs those who don’t? I think that question is impossible to answer because the patient cohorts are different.
I can see minor complaints being easy to dispo in minutes. In reality though, where I work, they often linger around for 30, 60, even 90 minutes. But that is usually due to process and systems problems, of which there are a litany, rather than delivering medical care. For instance, in an all RVU model, it doesn’t pay to discharge someone. You only generate revenue when you take care of a patient. So if a ER provider can choose between two options 1) picking up the next unseen patient, or 2) discharging one of his completed patients, the ER provider will (almost always) pick option #1.
Anyway, absolutely you are correct that the hospital benefits from volume and there is no incentive for the hospital to want lower ER patient volumes. Another systems / process issue. I think in the US we are slowly going to move away from FFS model and move towards value-based model where a hospital will receive a lump sum from the state and/or federal government to take care of the patients in their region. So the more patients come to the ER, more will be spent, and there will be less profit.
For what it’s worth, anecdotally I have vastly different experiences at the two hospital systems I work at. One is a hospital system that is available for three cities with a population of about ~250,000. There are about 50,000 ER visits a year. It is largely a low-to-medium socioeconomic population of ER visitors. We routinely see people who missed dialysis just because they didn’t want to go, women showing up to confirm they are pregnant, chronic orthopedic complaints, and innumerable number of other complaints of that nature. I also work in an integrated health care system (Kaiser) in an city with a much smaller patient population of about 50-75K people. I simply don’t get the same kind of complaints that I do at my other hospital. Now is this due to the copay? Not entirely (but it is part of it.) It’s hard to measure because one group of patients is more educated than the other, one group has better access to health care than the other, one group has more money than the other. And I have encountered those who want pillows and bedsheets and want antibiotics for their 5 days of a viral sinus infection at Kaiser, and I often capitulate because it’s just not worth the time to argue with them.
So something just doesn’t seem right that seeing an ER doctor who has little to no training in anything else besides emergency medicine should be free, and not only free but also obligated by law to evaluate the patient. And it is the most expensive form of medicine delivered as well. While seeing a primary care doctor, whom I believe are the most important doctors in our society, who know more than emerg docs (sometimes debatable!!!), with a much reduced cost of delivering care, it is ok to erect financial barriers.
In my experience in the US (I’m not sure where you currently practice), the ER is a free resource for many, and free resources are abused. And it creates a real problem for delivering good, EB, compassionate and efficient health care. I also happen to believe that anyone who needs health care should pay (something) for it, but this is a separate argument and not what the purpose of this particular blog post. (As an aside, I think true emergency care and not the “primary” care delivered in US ERs, should be paid for with tax dollars).
Thank you again I’m a first time poster but I eagerly read your material and think it’s a fantastic resource for ER physicians. I’m going to see if I can find some research evaluating copays and health outcomes.
I have shied away from the evidence around healthcare economics for a while. It is complex, and doesn’t really give great answers, and you are also guaranteed to piss someone off. But an evidence review of the impacts of user fees in healthcare might be a good idea. I’ll add it to the list.
I am surprised to see you refer to emergency care as free in America. That is certainly not the impression we get from abroad, especially with all the reporting of massive bills recently. I would have thought there would be a significant financial disincentive from showing up to an American ED.
To get back to the idea of patient expectations – I think you could get a lot of insight from working backwards. Why do so many patients show up to the ED, when we know there are better options for them? Obviously we do offer some experience that they value. I assume it is the ability to get high quality care and all tests and treatments on site. However, exploring what patients value in the ED might allow us to export those qualities to outpatient clinics, which might do a better job redirecting patients than user fees ever could.