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Anaphylaxis? Come to the ED. Runny Nose? Nope

Walker, Graham MD

doi: 10.1097/01.EEM.0000554854.64153.7f
    appropriate use of ED
    appropriate use of ED:
    appropriate use of ED

    A patient comes to the ED after not being able to walk for three days. Another comes in with a runny nose. Yet another injects himself with an EpiPen and calls 911. These patients are examples of something I heard Peter Rosen, MD, say in a lecture a few months back.

    One-third of patients are sicker than they think they are, a third aren't as sick as they think, and one-third of patients are as sick as they think they are. It was fascinating to hear about 40 years of emergency medicine history from Dr. Rosen's experienced point of view, and that idea stuck with me.

    Those percentages might need to be tweaked for your particular ED, but the concept really helped me understand my patients a bit better and see their perspectives, which is often challenging as a specialist who knows sick v. not sick and emergency v. not emergency. As a colleague told me, “The patient who has nothing wrong with him and doesn't need to be in the ED might be the sickest he has ever been in his life.” Relativity!

    I try to hearken back to my pre-med days and recall what I knew of medicine back then (not much), but certainly I had some level of understanding of normal and abnormal health. My only visit to an emergency department was a case of rapidly-advancing lymphangitis that responded to a dose of IV antibiotics. (Hopefully, I was as sick as I thought I was.) I would have never even thought of going to an ED for a cold or sore throat, and I'm pretty sure I would have sought emergency care if I were dragging my leg for more than 10 minutes and couldn't walk. But maybe not.

    When newly-minted interns show up in our ED, they are just as bewildered as I used to be. “A cough for a day? And he has an appointment with his doctor in an hour? Why would you go to the ED for that?” I shrug and say, “I've stopped asking. It doesn't really get you anywhere.”

    We see these visits every day, and it leads me to believe that many humans just have a really hard time knowing which symptoms are ED-worthy. Many others probably aren't even thinking if they're ED-worthy; they just don't feel well and want symptom management or answers.

    I also wonder how uniquely American a lot of this is. Patients are typically sicker, with higher rates of myocardial infarction rule-ins, pulmonary emboli risk, etc., when you compare them with European studies of emergency care. A few hypotheses:

    • The United States has less or worse public education about health and self-care. Health class is a running joke about puberty, pregnancy, and STIs in the American lexicon. When you think about it, doesn't it seem kind of crazy that Americans typically get almost no standard education about their bodies, normal and abnormal, and what symptoms are concerning? Or how to hold pressure on a bleeding wound? Or how to treat a fever, cold, sore throat, or sprained joint? This teaching is mostly expected to come from parents and family, which obviously doesn't work well if the family doesn't know how to handle these symptoms or endorses old wives' tales.
    • Americans have more anxiety and worry more about the body, which probably ties into our culture of youth and preventing, avoiding, and denying death.
    • U.S. citizens are more concerned about catching symptoms early, especially because many people are uninsured or underinsured and frequently hear stories about medical bankruptcy.
    • Americans distrust the medical system, which is part of the distrust of corporations and other large institutions, especially because we operate a for-profit system. It doesn't help that we often hear stories in the news about unprofessional or inappropriate conduct or conflicts of interest by physicians.
    • Many people don't know the variations of normal and abnormal or concerning and not concerning symptoms because we're not as close with our aging families or as familiar with what illness looks like.

    The best we can do as emergency physicians is to educate patients and say things like, “If this happens again, I want you to call 911 and come back to the ED immediately,” and “If this happens again, you can try managing this at home with over-the-counter medicines available at the pharmacy without a prescription. Nothing bad will happen to you if you try ibuprofen at home first.”

    It's not a lot, but it's a start to breaking up the thirds.

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    Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (, a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (, and The NNT (, a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter@grahamwalker, and read his past columns at

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