Monday, October 24, 2011

Autumn is a season where sport seasons intersect. Football, baseball and hockey invade each other’s territory and as a spectator it is a reminder that time is a matter of mindset and expectation. Going to a baseball game allows time to be suspended because there is no game clock. The rhythm of the game and pace of play depends on circumstance and the game ends when it ends. Football is dominated by the clock. An hour game can last for three times that long and fans are as mindful of the clock ticking down as they are about the action on the field. Depending upon the situation, the clock can be a friend or an enemy. Time is critical in medicine as well but its usefulness as a diagnostic option is being challenged by an ever increasing business mindset.

Many hospitals have chosen advertising strategies that promote short waiting times to be seen in the ER. Billboards and websites boast how long or short it will take to see the doctor. Waiting for medical care can be the most frustrating experience, especially in an emergency room. The visit isn’t planned. Presumably time is of the essence because the patient and family have presented with a perceived emergent situation and the patient has no control of the future. Ironically, the doctor also has no control over the time situation. Who is seen next is a very fluid situation. Studies have shown that a single trauma victim can have a ripple effect and tie up hospital resources including departments far away from the ER including lab, x-ray and OR and can delay care access for many patients hours. Triage demands that the next patient to be seen isn’t always the one waiting the longest; instead it is the sickest or most injured.

Time becomes a factor even after the doctor shows up because the game clock is skewed. In the world of television, from House to Grey’s Anatomy, tests and treatments get done immediately and everything is wrapped up in 44 minutes plus commercials. In the real world, the clock can be schizophrenic. It is the enemy when dealing with heart attack and strokes where clogged blood vessels need to be opened immediately or else heart and brain tissue are lost forever. Similarly, trauma resuscitation goes quickly to prevent permanent damage because of injury. However, the clock is often an ally, where time may be well spent in observing the patient and may potentially prevent unnecessary tests and procedures.

Some procedures just take time to do. A CT scan of the abdomen often requires that the patient drink contrast that will help outline the bowel on the x-ray images. It takes an hour or more for that liquid contrast to filter its way through the intestine and bowel. The scan itself may only take 10 minutes but there may be hundreds of pictures that have to be read by the ordering doctor and the radiologist. If an abdominal CT is needed, the patient can count on a couple of hours or more of waiting. Blood tests can take time to do as well from minutes to hours. Newer bedside testing technology can cut the wait time significantly but at a cost. Quick test turnaround time means less time observing the patient and seeing how things evolve. Watching doesn’t cost money, it just costs time.

Waiting in the ER is like baseball. Time and expectation depend on the situation. A ballgame that is moving along quickly can get stalled if the pitcher checks the runner at first too often, if there are pitching changes or numerous visits to the mound by the manager. In the ER, a sick kid or a patient who goes into cardiac arrest can stop the flow of the ER and potentially the whole hospital. The next patient and their needs can’t be predicted and the only thing that can be offered to those forced to wait is an apology and an explanation.

In a perverse way, waiting to be seen in the ER might be considered as a positive. It means that somebody else is sicker, hurt or suffering more. Somehow that is small consolation when watching the clock tick away and deciding whether it is a friend or an enemy.

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