Doc, Should I Go to the ER?

| Graceful Health

By Dr. Kenneth Rudd, MD, MPH, MHCDS from Grace Cottage Family Health & Hospital

How do you know when it’s time to go to the hospital Emergency Room versus seeking care elsewhere?

Because I work as both an Emergency Room doctor for Grace Cottage Family Health & Hospital in Townshend, VT, and as a primary care doctor for Dartmouth-Hitchcock in Lebanon, NH, and have also worked for an Urgent Care Center, I enjoy helping patients navigate the best place to go for healthcare.


The Primary Care Advantage:

My main advice, which I have seen hold true all over the world, from living in China for seven years, to studying Public Health, to working at Dartmouth College and the World Health Organization on international healthcare collaborations, to global primary care research on shared decision making, is, whenever possible, see your primary care provider (PCP).

What doctor knows you best?  Where do you have relationship and trust? If it isn’t with your PCP, then find a provider that is a good fit for you and build this. The relationship that develops between you and your PCP is your key to long-term health.  No one knows your health status, health history, and your treatment preferences better. No one is more familiar with your life circumstances and your common stresses. No one has better access to your health records.  No one can better put your present ailment into the context of you.  Your PCP is the best one situated to make complex and difficult diagnoses when there is time to work things up.

Primary care is hard work, and most primary care doctors are in it because we really do care and because we are relationally oriented.  That’s the heart of practicing medicine for me. It’s what I love about being a family doctor, what gives it meaning. I know people; I know my patients’ situations; I have the honor and privilege of being with them in their greatest moments and during some of the most difficult ones, from birth to death.  So, for the best, coordinated, quality, reasoned, cost-effective, long-term, you-centered care, go to your PCP.  If this sounds like a shameless plug for your PCP, it unabashedly is!

The ER:

Though the ER has its disadvantages, it’s a great place and I love it.  We’re there for you when you need it—whenever you have an Emergency.  All ERs, including Grace Cottage’s Emergency Department, are open all day and all night, every day of the year, 24/7/365, and are ready to deal with anything that walks through the door.  Every ER can determine what is needed, perform comprehensive work-ups in real time, and will address your needs either then and there, or by stabilizing you and transferring you to a higher level of care, or arranging for a future outpatient work-up.  (Incidentally, if you know you need a higher level of care, like surgery, and you have the time, go directly to that hospital’s ER, as this will speed things up.)

The ER is for anything potentially life or limb threatening or severe or that can’t wait.  If you have an emergency, don’t go to your PCP, as they will just send you on to the ER.  You can only live three minutes without oxygen, so for anything affecting breathing and/or circulation (like asthma or COPD, allergic reactions affecting your airway, chest pain, severe or GI bleeding), call 911 to take you to the ER because you might not make it driving. Also, because your brain is so important, things like stroke symptoms, vision loss, speech problems, paralysis, seizures, mental status changes, passing out, and severe headaches all qualify as emergencies. Unbearable pain, severe dehydration, continual vomiting, significant trauma, and suicidality can also be life and limb threatening and thus warrant a trip to the ER.

But don’t go to the ER if you don’t need it. There are drawbacks to the ER. First, your PCP will generally give you the best possible care for you (sound familiar?). Second, the ER is the most expensive place to get your care, regardless of your medical problem. This may not seem important if you have insurance that will cover you wherever you go for care, but the reality is that we all ultimately bear the cost for wasteful spending on medical care, for example through escalating insurance premiums, so unnecessary expenditures do come back to bite us in a very real way. We should all be the best stewards we can be of every healthcare dollar we spend, whether insurance “is covering it” or not.

I see a trend in U.S. healthcare (and the culture as a whole) that is moving away from the key relationship with one’s PCP.  There’s a lot of pressure from the system undermining this, including a tendency to see a different provider every time you go for care, and the drive from patients to have more convenient and more immediate access.

Enter Urgent Care:

Urgent care centers have found a niche in the U.S. Their primary value is convenience. They can address urgent (but non-emergency) issues that occur when your PCP’s office isn’t open, and the only other option is the ER. They offer faster in-and-out care than the ER for non-emergency things, and at comparable prices to your PCP’s office, rather than the more expensive ER. They are good for straightforward urgent things that come up and don’t need as much long-term care, like sore throats, urinary tract infections, upper respiratory illnesses, ear infections, sinusitis, minor sprains, minor burns, insect bites, and mild dehydration.

The downside is that urgent care centers do not have access to your past health history and records. They don’t know how the current problem fits into the context of any chronic conditions and patterns you have. They don’t have your trust and rapport like your PCP does. They can take care of you quickly, doing minor investigations of blood work and/or x-rays. But if it can wait, your PCP is the best place to go. If you do go to an urgent care center, you should always inform your PCP afterward and schedule follow-up through your PCP.

People really should not go to the ER merely for convenience, but occasionally it happens, and the ER does take all comers. When you do go to the ER for non-emergencies, know that you run the risk of waiting a long time because the ER is not first-come, first-served; emergency situations always take precedence.  Also, if you can choose your ER visit timing, it is generally best to go during daytime hours when there are more resources available.

Finally, whenever you’re in doubt about whether to seek emergency care, if possible, call your PCP for advice. If, however, you think or feel you need it, don’t hesitate to call 911 or go straight to the ER.

I hope to see you in the clinic soon, and not in the ER!

Dr. Rudd is the father of six children. He earned his M.D. and Masters of Public Health degrees from the University of Connecticut. After completing an Academic Medicine Fellowship at the In His Image Family Medicine Residency Program in Tulsa, OK, he received a Master of Health Care Delivery Science from Dartmouth College.