Q&A: What to know about the emergency room before you have an emergency
Dr. John Shufeldt, a distinguished professor of practice in ASU’s John Shufeldt School of Medicine and Medical Engineering, on how emergency and urgent care works
Dr. John Shufeldt, an emergency medicine physician and distinguished professor of practice in ASU’s John Shufeldt School of Medicine and Medical Engineering, spoke with Doing Well about how emergency and urgent care works. Courtesy image
Note: This interview was originally published in Doing Well, a health news outlet from ASU Media Enterprise and ASU Learning Enterprise. Subscribe to Doing Well to get interviews with health experts delivered to your inbox weekly.
At some point, we’ll all need medical care we didn't plan for. Maybe it’s a sliced finger while chopping onions or a sprained ankle while hiking. Maybe it’s something bigger — a scary accident or sudden, debilitating pain.
In those moments, we often turn to the emergency department or — for non-life-threatening emergencies — urgent care. These systems act as the front-door for medical care. But because our health care system is complex and difficult to access, they also serve as a safety net — often treating people who weren’t able to access care elsewhere, or who didn’t know where else to turn.
To get an inside look at how emergency and urgent care works, ASU's Doing Well spoke with Dr. John Shufeldt, an emergency medicine physician and distinguished professor of practice in ASU’s John Shufeldt School of Medicine and Medical Engineering. Shufeldt founded NextCare, an urgent care company, in 1993, and it has since grown to over 60 locations in several states.
Short on time? Here’s what to know:
- Generally speaking, emergency departments are best for life-threatening problems: chest pain, shortness of breath, altered mental status, severe bleeding, stroke symptoms and major trauma, among others. Many minor illnesses and injuries can be handled at urgent care, where your wait time will likely be quicker and your bill will likely be less.
- A major reason emergency department wait times can be long is because a portion of patients in the emergency department are waiting for an available bed in another part of the hospital. That slows everything down.
- Emergency departments can help solve an urgent medical problem — but they can’t solve the larger barriers to care that often lead someone to their doors in the first place. Improving access to care will require thinking holistically about the challenges people face outside the hospital.
- When you need to seek medical care, having a medication list, medical history, prior surgeries, allergies and key family history at the ready is important. Details get lost in stressful situations, so getting those materials together ahead of time and keeping them updated can help you get better, faster care.
In the below interview, he discusses the difference between urgent care and emergency departments, how these systems act as safety nets for bigger health care access issues, and how patients can be better prepared when urgent health issues arise.
Note: This conversation has been edited for length and clarity.
Question: You launched your first urgent care after finding that the emergency room was often crowded with minor illnesses and injuries. Was there a specific patient or moment that made you realize that the system wasn’t working?
Answer: I remember a guy who came in and his chief complaint was: "I was almost stung by a bee. I used to work on a bee farm." So, I said, "Wait, I’m sorry, you were almost stung by a bee?" And he goes, "Yeah, I was almost stung." And I said, "Well, why are you here?" And he goes, "What happens if I almost get stung again?"
I remember thinking, where do you go when you’re almost stung by a bee? Not the emergency department. Then that translates to minor colds, cuts and bruises, UTIs, etc.
Q: How do people decide whether they need to go to urgent care or to an emergency room, especially when the symptoms fall into a gray area?
A: I think you should err on the side of caution, certainly, and also think: What may I need diagnosed?
Not all urgent cares have labs, and some of them don’t have X-rays; it varies by urgent care.
Anything that’s altered mental status, severe headache, chest pain, shortness of breath, severe abdominal pain, bleeding that you can’t control — emergency department. Most other things (urgent care) can handle. And if we can't, we are very quick to do an evaluation and then call 911 and stabilize them until a paramedic gets there. But my suggestion would be err on the side of caution.
Q: Urgent cares are growing significantly, and they’ve played a role in addressing non-life-threatening emergencies. But in the emergency department, long wait times and overcrowding is still a pretty common issue. What do you think is driving that?
A: A lot of the challenges that EDs have now are holding patients. There’s enough sick patients that you can’t get a bed in the hospital, so you hold them. I don’t know if you’ve ever watched the show "The Pitt" — it’s pretty realistic. In "The Pitt," they say, oh, we’re holding X amount of patients before they go upstairs. That’s reality. So if you have a 70-bed emergency department, you might be holding 40, 30 patients. That’s really a big part of the problem.
Second, I think there’s a general level of lack of medical knowledge about what constitutes an emergency, what doesn’t, and then a lack of resources. The emergency department is a safety net. You have to see anybody that walks in with an emergency medical condition.
Q: One of the things that we see continuously on "The Pitt" is the frustration that patients experience when they’re waiting a long time to get seen by a doctor. How do providers decide which patients get seen first?
A: Generally speaking, in urgent care, it’s first come, first served. You do a level of triage. So somebody’s sicker, you bring (them) back more quickly. Same in the emergency department. Some people will call an ambulance even when they’re not sick (or) emergent to try to get in the ER quicker — and those folks are often rerouted out to the waiting room.
I think most emergency departments are pretty good at rapidly triaging and treating patients. Mondays are always busier. If you come in on a weekend night, you’ll probably wait a little longer.
Q: What is the process of triaging like?
A: Triage and assessment are often done by a nurse, but it can be done by a paramedic, physician, PA (physician assistant), or NP (nurse practitioner). They do a rapid assessment of a patient. We always call it the sick versus non-sick. So sick, back quicker; non-sick, wait.
Non-sick might go to a different part of the emergency department. Sick might go back to the critical area of the emergency department. It’s looking at patients’ vital signs or chief complaint and doing a cursory exam to make a rapid assessment of their severity and something called ESI levels. The lower the ESI level, the sicker they are. ESI-1, critically ill — trauma, stabbing, gunshot, heart attack, stroke. ESI-5 — I’ve had a sore throat for a week, I think I’m pregnant, those sort of things.
Q: How might people prepare before going to the emergency room or urgent care — for themselves or for a loved one?
A: Probably the best thing to do is to say: Here’s a list of my medication, here’s my past medical history. If you have a list of: Here’s the surgeons I’ve had, the medications I take, and the medical problems I’ve been diagnosed with, the family history I have, and the social determinants of health I have, I smoke a pack a day, whatever it is — having that right out of the gate makes life so much easier because people forget it in the heat of the moment.
Q: I can imagine with all of the heightened emotion and the anxiety of needing to go get care, you would forget quite a lot of things.
A: Some of the things you witness in the emergency department are pretty upsetting. You bear witness to some horrible stuff, even as a patient. So you have all these confounding variables. I walk out of the emergency room at 3 a.m., and it slaps gratitude in your face: I’m walking on my own. I’m breathing on my own. I have a roof over my head. I don’t have food insecurity. And I’m not sick in the emergency department.
It’s those little things as a physician and as a nurse you get to do on the worst day of people’s life, where these little things make a big difference. One of the best things I did was buy a homeless guy a pair of shoes. It was because he had burned feet and he was intoxicated. I went out and bought him a pair of Nikes and came back and put them on his lap. So when he sobered up, he was like, "Oh my God, there’s a pair of Nikes on my lap."
There’s this book by Oprah called "What Happened to You," which I totally love. You hear people say, "What’s wrong with them?" The real question is, "What happened to you?" People end up in these situations for many reasons they can’t (control) — it’s a zip code lottery.
Q: One of your focus areas is expanding access to care in rural areas, especially for Indigenous communities. What do you think are the primary barriers to expanding health care access in rural areas?
A: It depends on the rural area. I worked at an Indian Health Service facility in Oklahoma, and it was in a town next to a city, so no one was driving far. Most patients lived pretty close. Conversely, in South Dakota, patients might live 30, 40 miles away on roads that are often not plowed in the winter, filled with ruts in unreliable cars and ambulances that can’t get out there. So a lot of it’s just pure access to care.
There’s a huge disparity of health care in the United States. I had a sense of that, but 11 years ago, it was like the proverbial "aha" moment: A patient I was treating in a reservation close by a major city needed a CPAP machine to wear at night, and because he didn’t wear one, when he came in, I had to intubate him. I saw him a couple of weeks later, and I said, "What happened? How come you weren’t wearing your CPAP? Does the mask not fit? Because I can help. I can do whatever it takes." He goes, "No, John, I don’t have electricity." And that was my aha moment. How was this OK, 90 miles from Phoenix in the United States? It’s abhorrent.
That’s a problem in a lot of reservations — lack of running water, electricity, access to care. There’s food insecurity, job insecurity, mental health insecurity. There are so many variables that need to be addressed.
Learn more about how ASU’s John Shufeldt School of Medicine and Medical Engineering is training the next generation of physician-engineers.