ER vs. Urgent Care vs. Wait Until Monday
Working in the medical profession comes with an unspoken agreement to answer calls and field texts from friends with medical questions. Nothing fazes me at this point. I’ve had lengthy discussions about vaginosis before I’ve finished my first coffee; woken up to texts with photos of rashes, abscesses, or ingrown hair follicles with strings of crying emojis; and been asked several times if X, Y, or Z warrants a trip to the ER. Even as a nurse I am not immune to this conundrum of what does and doesn’t constitute an emergency. One summer, furiously deadheading an ancient English rosebush, I whacked my hand on the trunk and a thorn the size of a child’s thumb went through and bashed one of the slender bones in the back of my hand. Thinking it might be fractured—and, since I was in the midst of taking clinical microbiology, sure I had contracted Sporothrix schenckii, rose gardener’s disease—I indeed went to the ER because it was a Saturday afternoon. And I still want to kick myself for it.
At this fork in the road, with signs pointing to the emergency department, an urgent care center, or a U-turn back home to bed, most patients are at a loss, without resources to help them make a decision. Their best bet? The Internet. Phone a friend. Err on the side of caution.
These moments, when you’re feeling like a shell of a human being, can cost either a lot of money to address, or a lot of suffering to wait out. And waiting it out can be dangerous: Without the appropriate antibiotic, an infection can linger indefinitely, especially in harsh winter conditions and when people are under stress. Wounds dealt with at home that actually required medical attention can become infected, putting people at risk for systemic problems. Fractures that go undiagnosed can heal improperly. Serious dehydration or an immune reaction sometimes just needs medical intervention.
On the other hand, it’s likely that at one point or another you’ve regretted making the decision to go to the ER. You might have spent hours camped out in its various waiting rooms, finally advanced to a private exam room, and then waited endlessly for Dr. Schmoop to come in and tell you to take a high dose of ibuprofen, wasting you a good deal of time. Oh, and money! Emergency rooms are monopolies, and they take advantage of their market share. Take a hospital bill for services rendered and multiply it substantially, and you’ll have an idea of what an average trip to the ER costs. For stitches, $1,200. For an MD to pat you on the head and send you on your merry way—or, in more generous terms, for peace of mind—$500 to $1,700.
There are times when an ER is absolutely necessary (we will identify many of them soon). There are also countless circumstances in which an urgent care facility is a better bet—less expensive, with shorter wait times.
One of the first emergency departments in the United States was a two-bed facility at Johns Hopkins called the Accident Room. Patients were brought in via the town police wagon and treated free of charge. It all sounds idyllic compared to the chaotic holding pens we’re familiar with today.
The function of emergency rooms today is a hot-button topic in the medical community, where industry leaders have made serious efforts to stem unnecessary visits. Insurance companies have gone so far as to refuse reimbursement when they deem an ER visit unnecessary. “Save the ER for emergencies—or cover the cost,” reads a letter sent in 2017 to Blue Cross and Blue Shield customers of Georgia. “Going to the emergency room (ER) or calling 9–1–1 is always the way to go when it’s an emergency. And we’ve got you covered for those situations.” It continues, “But starting July 1, 2017, you’ll be responsible for ER costs when it’s not an emergency.”1
The trend isn’t a new one. For years US insurance companies have gotten away with denying claims based on the ultimate diagnosis when a patient goes to the ER. It means that if you have chest pain, think you’re having a heart attack, go to an ER, and find out it’s something nonurgent like a respiratory infection—you will be settled with the bill. First and foremost, this is unlawful, as the Prudent Layperson Standard, codified in federal law with the advent of the Affordable Care Act, states that reimbursement must be based on symptoms a patient is experiencing when they go to the ER, not the diagnoses. According to the American College of Emergency Physicians, insurance companies are taking advantage of political turmoil around the Affordable Care Act to push the envelope with these practices once again. It angers healthcare providers, this message sent on full blast to American patients that they’re not to cry wolf or there will be consequences. It means someone might endure a stroke or a pulmonary embolism without going to an ER out of financial fears. To assume that the average patient can distinguish emergency from nonemergency situations confidently is unconscionable, as often even medical experts don’t have this answer right away.
It’s true that patients without established care often use the ER for nonemergencies, burdening the system and causing longer wait times for true medical emergencies. Industry leaders have made serious efforts to stem unnecessary visits for this reason.
For all its shortcomings when it comes to nonemergencies, the ER represents what is, to patients, the most direct path to care. It’s a sensible point of access to the medical system for those who navigate it infrequently. Just as those who don’t speak fluent French recognize the phrase “merci,” patients who don’t know whom to call or where to turn if they run a high fever still recognize an ER as a building that houses people and resources to help. The ER is a universal symbol. The luminescent red cross stands for “help.”
It’s interesting to look at the sources of information we call on to interpret the severity of a medical situation. Pain. Whatever medical knowledge we have. Memories of our past experiences, or the story of another’s. Something we heard on the news or through the grapevine. It’s frequently a combination of all the information traveling through our emotional brain and memory stores as we decide what to do and where to turn.
A better method starts with classifying emergent medical situations into three categories: medical crises, emergencies, and urgent medical situations. Doing so will help you get what you need efficiently and economically when you are in distress and need medical intervention. I’ve based the following sections on the triage system used in emergency departments.
These are moments when individuals find themselves pinned between life and death. When your limb is lying next to you on the floor, or your lips are turning gray-blue, or your heart stops working. These include anything impacting the ABCs: airway, breathing, or circulation (see here). In situations like these, there’s little decision-making to be done—call 911 and get to the nearest ER.
These fall slightly below medical crises. Not all are immediately fatal in nature but require equipment, procedures, or expertise only available in a hospital setting, and therefore warrant an emergency room visit. They’re also typically time-sensitive. Examples include severe abdominal pain (which might indicate appendicitis) or deep lacerations. Remember that ER providers have a focused scope of practice relating to trauma and emergency, so ERs are typically not the place to seek a diagnosis for a chronic illness. Any diagnosis given in this setting should be reassessed by a specialist or discussed with your PCP.
The following situations should send you to the emergency room immediately or to call 911:
Breathing that is compromised or difficult
Chest pain that is severe, radiating, of sudden onset, or accompanied by perspiration, shortness of breath, or nausea
Severe abdominal pain (of a nature markedly different from cramps or the average stomachache)
Severe pain in the lower back that intensifies with moderate finger pressure at the very bottom of the back
Sudden changes in mental status, balance, speech, or perception of language
Sudden paralysis, numbness, or weakness of a substantial portion of the body
An alteration in mental status that indicates the patient is at risk for harming themselves or others
Severe heart palpitations
Rapid swelling of any body part
Falls (in frail and/or elderly patients, especially if they take blood-thinning medications)
Sudden change in vision or loss of vision
Broken bone
Dislocated joint
Laceration that does not stop bleeding after five to ten minutes while putting pressure on it
Head or eye injury
Severe burns
Seizure (when the patient does not have a history of seizures)
Severe flu with dehydration (see here)
Fever that climbs above 103° (for adults), lasts for more than two days with minimal response to OTC medications, or is accompanied by a rash
Fever of 100° or higher for a newborn baby
Vaginal bleeding during or after pregnancy
Unrelenting vomiting and diarrhea
The rule of thumb is that if what you’re experiencing has a sudden onset, poses a threat to basic functions (ABCs or psychological functions), may lead to losing a limb, or is a physiological function that changes rapidly in a way that is foreign to you, you should go to the ER.
Urgent medical situations are those that cause you severe distress that won’t subside without timely intervention. Ideally they would be addressed by a primary care provider or a specialist you see regularly, but when those resources aren’t available quickly enough, you should go to urgent care. In a medical crisis always call 911, but if you’re in doubt about a course of action for anything other than a medical crisis, look into an urgent care center.
Sometimes circumstances will leave you little choice between urgent care centers, but often you will have some flexibility in where you go. (See here for how to choose the best ER for your situation.) Like ERs, urgent care centers vary in quality. Some are excellent, employing retired ER docs with loads of experience, while others are just set up to capitalize on low-lying fruits like colds. These aren’t places to get a refined assessment or manage an acute manifestation of a complex illness. Before the need arises, locate a solid urgent care facility in your community (you can actually Yelp them to read reviews!) so you don’t have to randomly pick one while holding a tourniquet to someone’s arm. I went to an urgent care center with my friend just last summer and couldn’t shake the feeling the place was a setup and everyone was playing hospital. There was something a bit Las Vegas about the whole joint—a flashy logo, a fancy front desk, bad art, and fake plants, but the exam rooms had cluttered cardboard boxes scattered around in corners and on the floor like a warehouse. And no sinks inside the exam room! The nurse in me died a small death.
Situations that can be handled by urgent care include symptoms with a more gradual onset, symptoms causing you severe discomfort that cannot wait several days for aid, or minor injuries that can’t wait for intervention:
Upper respiratory infection
Flu
Ear pain
Migraine
Pain or burning with urination
Persistent diarrhea
Swollen tonsils
Vomiting
Mild asthma
Broken bone of the wrist, hand, ankle, or foot
Minor trauma, such as a common sprain or shallow cut
The decision here is ultimately personal, but there are resources to help you make it. The best way to determine if something can wait is by contacting a medical professional. If you have a primary care provider or care established with a specialist—even if it’s been a while since you saw them—you should call them and ask for advice if you’re not sure if you should go to the ER, urgent care, or their office. If it’s after-hours, they may have a physician or nurse on call you can speak to.
If you don’t have an established PCP or are unable to get through to or get advice from your routine provider, try calling a friend or relative in the medical field, if you have one, and ask for their advice.
Many insurance plans include a free telephone advice line staffed by nurses 24/7, all trained to walk you through decisions around medical emergencies. Some, like Blue Cross, offer online doctor visits with a $10 co-pay. They’re available 24/7 and they can offer prescriptions. This can be a helpful benefit to take advantage of if you’re in a bind, can’t get to a PCP, and want to avoid an urgent care trip.
A point that factors in here is that while something might be able to wait until the weekday for attention, your level of discomfort or your schedule may not allow that. If you don’t have a PCP, finding one and setting up an intake appointment, then getting the issue addressed is unlikely to have a quick turnaround. Your PCP may not have availability. You may not be able to get to your clinic the coming weekdays as easily as you could on the weekend. As long as your situation does not fall within the medical crisis, emergency, or urgent medical situation parameters outlined above, factor these in as you make your decision, with or without the help of medical professionals via telephone.
The emergency department (ED) is the gatekeeper of the hospital, and most pathways to admission commence in its lobby. Beyond scheduled surgeries, only rare exceptions allow you to go around the ED. It’s possible if you have a primary care provider advocating on your behalf and a condition that warrants urgent hospitalization for monitoring or stabilizing. In most cases, though, if you try to enter a hospital any other way you will be told flatly to go check yourself into the emergency department.
There, an ED doctor will review your case, run necessary scans and labs, and consult with a hospitalist or specialist to make a decision about whether you’ll be admitted. Ensure that your primary care provider, the one who knows your health history, is looped into that conversation. If possible, call your provider’s office en route to the hospital and ask them to call the ED prior to your arrival.
In many emergency situations (such as broken bones or blunt traumas), your capacity to make decisions about where you’re taken and who’s consulted will be compromised. But in situations between minor and life-threatening, you may have the chance for some decision-making. When this is the case, take note of the following:
Every primary care provider has “privileges” at select hospitals. Gather this information about your PCP before there’s an emergency. When there is an urgent situation, try to choose a hospital ED where, once you’re admitted, your PCP will be able to see you and help manage your case.
It is extremely difficult to go through one hospital’s ED and then get admitted to a different hospital. Choose an ED attached to a hospital you feel comfortable being admitted to, based on its trauma level, certifications, and proximity to your home.
For those with children: Designated pediatric EDs are much better equipped and trained to work with little ones—the cuffs and masks are miniature and the providers specialize in pediatrics. You can locate one at http://www.childrenshospitals.org.
This may come as a surprise, but you actually have a choice about which hospital an ambulance takes you to. When responders arrive, they will immediately assess you and determine if your condition is time-sensitive and/or life-threatening. If you’re not incapacitated, you can request to be taken to a specific hospital, even if it’s farther away. It may be worth slightly delaying treatment in order to go to a better hospital, or one where staff are familiar with your case. Exercising this option only makes sense if you’re familiar enough with your condition and the ins and outs of the hospital systems in your community to make an informed decision. This might apply to cancer patients, elderly patients with chronic conditions, or patients with a condition that has exacerbations meriting a trip to a specific ED.
The paramedics will not be able to take you to a hospital that falls outside of their registered zone, or a hospital ER that is on divert and not taking new patients. If these are not obstacles and you still truly disagree with the paramedics’ plan, you can ask to sign a waiver that relinquishes liability for the delay in treatment if you choose a hospital farther away. The message here: Paramedics are trained to strategize and get you to the place that can best attend to your emergency as quickly as possible. You can be involved in making this decision with them, but only in certain circumstances. It shouldn’t come at the expense of distraction from the patient, or lost time.