I’ve been thinking about writing a post about emergency rooms, discrimination, and managing the risks for a while now, but I have spent so much time and energy avoiding ERs when possible that it was pretty low on my priority list.
However, I did need to visit an emergency room in September(actually, I went twice), and while the migraine that sent me there is still affecting me, I feel up to doing some of the necessary research for this post.
There may be followup posts about other facets of emergency room visits, but I need to start somewhere, so I thought I would start here.
Diversity of patients
Hospital emergency departments tend to have a very wide diversity of patients in every possible way. They need to assess and reassess patient needs and prioritize who gets seen when, and determine what treatments they get, and give each patient guidance on their next steps as necessary.
With all of these variables, ER staff runs a high risk of using implicit bias in their decision-making process. By that, I mean that whether intentionally or not, the staff will likely discriminate to some degree based on their own personal life experiences.
Al and my trip to the emergency room didn’t lead us to experience definitive discrimination, but we were aware of a few incidents of note.
When we arrived in the waiting area, I noticed that a black man was waiting to be seen and on the phone with somebody else. He told them he’d been there for an hour and a half and was still waiting to be seen.
I got called for the nurse’s evaluation maybe fifteen minutes after we arrived and when Al and I reemerged, he was gone.
I hope that he got called back for treatment at that time, but he definitely had waited a lot longer than Al and I did.
I distinctly remember another patient coming in, carried by(I presume) his mother. He was a young black boy, maybe 8 years old, and his entire left leg was wrapped in what looked like a cloth cast. She ran in carrying him, leaving her car at the entrance.
A staff member stepped in and spoke to her briefly, then reached out to the valet service to park the car, getting the keys from mom.
The staff member also ordered a wheelchair and seemed to be handling the check-in process, so that the mother and child could sit down and stay together.
That interchange is what’s supposed to happen, and I was glad to see it. I worry that it was the exception, not the rule.
Racism and sexism in emergency departments(and medical care in general)
in US hospitals, while patients are supposed to be triaged according to a quick health evaluation, patients often end up also being triaged based on socioeconomic status, race, presumed ability to pay for services, perceived pain/distress level, and at times perceived respect/politeness/assertiveness.
Sadly, this translates into worse outcomes for the people experiencing these biases.
As in most situations, white men tend to get the benefit of the doubt, women generally are presumed to exaggerate their pain levels, certain populations(especially those asking for strong painkillers) are presumed to be drug-seeking, etc.
Many of these biases are ones that the ER staff members are not fully conscious of, so calling them on their prejudice is more likely to result in further punishment or being ignored than in getting the attention you need.
While there is some work being done to correct these issues, many patients often face these problems(and many staff have the potential to be discriminated against by patients).
Al’s experience of bias and discrimination
Al and I have discussed his experiences, and as a Hispanic man, his family’s emergency room traumas started much earlier in the process and were much more associated with racism, classism, and triage than with less controllable elements of care.
Al has experienced food poisoning twice. When he was very young, his entire family ate bad fast food – he was too young to remember details, but I’m sure it contained many levels of unpleasantness.
His second experience with food poisoning, though, he remembers very clearly.
He was in such bad shape that his father literally carried him into the ER.
He was eighteen at the time, and is taller than his father, so this was a huge physical effort.
After his father signed in to the nearly empty waiting room, they waited for hours for Al to be seen, his father terrified that he would die while waiting.
When Al finally was seen, the doctors minimized his reports of pain, nausea and other symptoms, but reluctantly put him on an IV and did some testing.
As the tests came back, he slowly got improved treatment, as he had somewhat severe liver damage from the incident and other very measurable severe results from the food poisoning.
Once the doctors saw test results they did give him the appropriate treatment – but getting to that point took way too long, and Al was placed low on their priority list likely due to race and/or insurance status.
Bias based upon known diagnosis
Emergency rooms are not immune from societal stigma on mental health conditions, and generally, the primary service offered for mental health conditions are psychiatric holds due to suicidal (or homicidal) ideations.
There are usually fewer mental health supports available than people who need them, and the quality of available help varies tremendously. This particular issue is pretty much endemic to the US.
Most ER staff has minimal training around mental health support and management, and can easily make incorrect assessments, assumptions, or interpretation of behavior.
Along those lines, often a ‘psychiatric’ label tends to encourage them to ignore any complaints patients make, including sensations, pain, or memory issues – which may very well be the actual health problem, as opposed to their mental health condition.
Again, this isn’t necessarily true of every single person working in the ER, but there’s a strong chance of such dismissals.
Along similar lines, conditions that are entirely patient-reported or don’t align well with expectations often either confuse ER staff or lead them to disbelieve the patient.
For example, Functional Neurological Disorder(FND) is one of many conditions that have a lot of stigma within medical circles(if it’s recognized at all), and its management is often challenging in the ER.
I did not go to the ER because of my FND, but instead, I went due to migraines.
Unfortunately, migraines are another condition that ERs often fail to fully understand or respect, so the whole thing was one heck of a fight, and the reason I went twice was that they did not carry through properly on any aspect of my treatment the first visit.
While my second visit led to better results, it still left a lot to be desired, and the improvements that occurred were primarily because I was firm bordering on strident in my insistence on proper treatment, and was willing and privileged enough to be able to consistently push back until they took the appropriate actions.
My experience of bias in the ER
My FND symptoms become extremely obvious when I am under stress – I often limp, flail my arms, rock back and forth, have full-body shakes or alternate among symptoms.
My first problem in the ER is getting the staff pointed in the right direction for treatment since my movement symptoms aren’t the problem, but symptoms of the severity of my stress.
I had to make very clear from the moment I limped into the ER that I wasn’t looking for help with my movement symptoms, but that I was there for help with my migraine – and that my neurologist who worked in that hospital had recommended this treatment.
I mostly succeeded in this, and despite the admitting nurse’s surprise at my movement symptoms(and them sending a wheelchair for me), the message seemed to have gone through.
The doctor at the ER seemed to listen to me, and we had a very civil conversation about my needs, having a CT run to be on the safe side, and she started me on IV treatments that sounded right.
However, I was sent home before my headache was broken and the prescription she sent me home with was for valium, rather than a migraine treatment. Basically, she looked at me primarily as an anxious patient, rather than a person with a migraine.
When I returned two days later, I demanded that a neurologist be sent down, and eventually, they complied.
The neurologists gave me completely different information from the ER doctor(she guaranteed she could break my headache there and couldn’t, they explained that breaking the migraine there was unrealistic), but prescribed a migraine medication that did help a bit, and made sure I had the additional IV treatment option.
While it was a fight(and over six months later, I still have the migraine), I was able, eventually, to get the treatments I needed.
Many people managing issues like mine would have a harder time getting to the ER and likely would not have the spoons to go back if things went wrong.
Also, I had a low-pain-level migraine, which was highly unlikely to be deadly(the CT scan was the test to confirm that there wasn’t a potentially deadly issue, like stroke or brain bleed).
Do you really need to go to the ER?
The most basic precaution you can take is to simply think twice if you’re considering a trip to the ER.
If what you have seems like a heart attack, stroke, severe break, or other emergency-room worthy injury, go in and don’t back down on your insistence on needing treatment.
If you are less certain about the severity or your symptoms are milder, maybe you need to talk with your doctor instead of heading to the ER.
I have had really good luck with communicating with my doctors when I’m in questionable health.
Many doctors have some time carved into their schedule for emergency cases or are willing to call you back during business hours to go over your symptoms or concerns.
You do need to be definitely their patient to do this, which is why I place so much importance on having a strong relationship with your doctor.
I have made emergency-ish calls to my Primary Care Physician(PCP), my dentist, my gynecologist, my neurologist(s), and my allergist. All of their offices responded the same day, and I either heard directly from my doctor or was brought in for an appointment that day.
I did make it very clear that I was not okay and was concerned about my safety, and I had very specific questions or concerns that I was able to articulate.
For example, when my migraine set in, I called my neurologist and discussed my options. He prescribed the right medications so I could pick them up right away, and I didn’t visit an emergency room until he advised me that it was a logical next step.
Last winter, after having bronchitis in the fall, I started coughing and having trouble breathing. Instead of panicking, I tried to relax and got better control over that symptom, then called the allergist my mother recommended, and got an appointment that day, after I explained what had happened.
By handling it this way, I guaranteed that I spoke to somebody who knew me and wasn’t going to jump to conclusions. I avoided the stress that goes with an emergency room visit.
I also saved money, as emergency room visits are notoriously expensive.
If you do experience a true emergency that requires a trip to the emergency room, by all means, do so.
I’m just suggesting that you double-check with yourself to make sure that you only go to the emergency room when you absolutely need to.
Making the most of an ER visit
If you do need to go to an emergency room and there isn’t a better option, you are already a step ahead because you know that you will likely be dealing with bias.
Be as clear as you can be on what you’re feeling and where you’re feeling it, have somebody with you to back you up(if possible), and don’t back down until you get the testing or treatment you need.
Whatever your identity or diagnosis, be prepared for the likely fights and try to head them off at the pass if you can.
For example, as a woman, I am prepared for the possibility that my pain level will be undervalued or undermined.
There isn’t a lot I can do about it, other than be consistent in my statements and expression of pain levels, and to avoid pushing for any particular pain medication, to help avoid being accused of drug-seeking.
As a woman with a history of mental illness, and a poorly understood neurological disorder, I need to protect myself from the mental health stigma as much as possible.
I explain how FND works to the people managing my care, differentiate between whatever I’m dealing with and my FND symptoms(which are likely to occur due to the stress of whatever’s happening and from simply being in the hospital), and I make sure that I only go to the ER if the problem I have can be measured by the tests the ER is likely to run.
For example, I did go to the ER when I badly twisted my ankle late on a Friday afternoon. The pain and bruising were severe enough that I feared a broken bone.
It was too late to get into a doctor, and most offices would be closed Saturday and Sunday.
I focused very specifically on my ankle injury and they X-rayed the injured area and were able to reassure me that the bone wasn’t broken.
I did also need to explain that trying to hold me down for the X-ray would only make things worse, and to repeatedly tell them that I wasn’t there for the movements, but only for the X-ray.
When it comes to having a backup, Al comes with me to pretty much all my appointments.
I’m (usually) fine on the self-advocacy front, but Al helps me to stay calm and get my symptoms under the best possible control.
He is able to back up what I’m telling the staff and help signal to them what does or doesn’t require a response on their part.
Think about who would be more (or less) helpful for you if you needed to go to the ER – somebody who can advocate for you if needed(especially somebody that can help mitigate those biases), and who can help you maintain your calm, minimize your trauma, and/or help you express your needs.
Yes, there is bias in ERs, but you can manage those effects
Just like most institutions in the US(and other countries), your treatment in the ER can be affected by biases that employees hold. Often, these staff members don’t even recognize that they are biased, or these decisions are made on a subconscious level.
You deserve to be treated the same as everyone else, but that very simply may not happen.
Sharing these concerns(or suspected actions) isn’t likely to help you in the moment, so do your best to focus on protecting yourself.
If possible, only go the ER in the case of a truly life-threatening emergency, or something that needs immediate treatment when your more standard methods aren’t available(such as a broken bone on a weekend or holiday).
Also, if you go to the ER, be prepared to fight for the proper treatment, and if possible, bring along a solid reliable person to help you stay calm and to advocate for your medical care.
While you do deserve to be treated better, it simply may not happen, so do your best to mitigate those risks and stick to your guns as needed.