Urgent Care or ER?
It can be difficult to know when an injury or illness requires an urgent care clinic or a trip to the emergency room. In this month’s blog, Board Certified Emergency Medicine physician Dr. Mickiewicz discusses some basic rules of thumb for when to visit each facility.
Understanding the Emergency Room
The modern emergency room (ER) is an incredible place – a state of the art facility staffed
24/7/365 with highly skilled personnel. It offers the latest medical technology and is typically attached
to an inpatient hospital which can provide a wide variety of services and consulting services. The mantra
of Emergency Medicine is “any patient, any time”. This refers to the fact that an ER is required to have
the staff and equipment available to stabilize a wide variety of patients, from tiny babies with
respiratory distress to trauma victims to elderly victims of cardiac arrest.
ER Pricing Structure
But all that equipment, training and expertise comes at a cost. The ER is an expensive place to receive
care: the average bill for an ER visit is high and rising fast. In 2016 the average bill was $1917, up 31%
over just 4 years (https://www.beckershospitalreview.com/eds/cost-of-er-visits-increased-31-between-
2012-16-5-findings.html). If you have insurance, some of that cost will of course be covered but
expensive co-pays and large deductibles are now the rule rather than the exception with most types of
insurance. To add to the confusion, sometimes a hospital that IS in network with a patient’s insurance
will contract with a physician group or ER staffing corporation that IS NOT a part of your insurance
network. This is not something that is advertised, so patients assume their entire stay is covered by their
co-pay and deductible only to get surprise bills after the fact for thousands of dollars
(https://www.vox.com/2018/5/23/17353284/emergency-room-doctor-out-of-network). If you don’t
have insurance, then you will be billed the entire amount of your stay. Sometimes patients can work out
a payment plan, or negotiate a cash discount, but the cost will be substantial either way.
Treatment Based on Severity
Also, the order in which ER patients are taken care of is based on acuity. Those with minor illness/injury
are seen only after those who are more ill are treated and stabilized. Emergencies are random events
which cannot really be predicted. Say I show up to my local ER with a backache at 2 AM: I might be seen
right away or the doctor might be busy trying to save someone in cardiac arrest or with a gunshot
wound. If that’s the case, I’ll have to wait my turn. The department might be half full when I get there or
there could be a packed waiting room. Those are some of the reasons why the typical length of stay for
an ER visit is measured in hours, not minutes.
So how do you know when you need the ER versus your family doctor or trusty local urgent care? For
starters, every situation is different, and we have to begin by emphasizing that these are general
guidelines and not specific medical advice. Here are a few things to ponder if you are on the fence about
your healthcare destination.
Trust your gut.
I believe humans have survival instincts which tell us when we are in danger. Severe,
sudden pain can be a sign of something catastrophic. Maybe that flank pain is “just” from a muscle
strain, or a kidney stone (extremely painful but not generally life-threatening), but it could also be from
a ruptured abdominal aneurysm. In that instance, your health and even survival might very well depend
on getting prompt specialized treatment as soon as possible. If you are experiencing a sudden, brand
new, severe problem that worries you, it might be best to listen to your instincts and head to your
nearest emergency department.
Say you are experiencing shortness of breath. If it is mild, for example a cough that is
just limiting your activity a small amount, then this is likely something that doesn’t need an immediate
trip to the ER. On the other hand, if you can’t even walk across the room without stopping to rest or
have to shorten your sentences to 2-3 words because that’s all you can get out, odds are you have a
serious problem best taken care of in the ER setting. The key question to consider is whether or not your
symptoms are new or severe: your usual migraine headache is one thing, the worst headache of your
life with fever and neck stiffness is something entirely different. Most urgent cares do not have the
diagnostic and treatment capability that an ER does and so very ill or uncomfortable patients are often
just better off being treated in the ER.
Hurt, but how bad?
Most lacerations and orthopedic injuries can be treated in the urgent care.
But there are some symptoms which are indicative of an emergent situation. Bone protruding from a
wound, for example, means a fracture is “open.” Those injuries typically require IV antibiotics and
immediate surgery. Severe bleeding that does not stop when pressure is applied is a sign that an artery
might be injured. Loss of sensation or function (if a finger is numb or won’t bend properly for example)
might mean a tendon or nerve is injured. A limb that appears deformed or has a new bend to it might
mean a fracture is present that needs to be reduced (straightened). All of these injuries generally
require repair or evaluation by a specialist (such as an orthopedic or hand surgeon).
What brings you in today?
Certain types of medical issues are pretty tough to properly work up and
treat in the doctor’s office or urgent care. Acute neurologic complaints (sudden weakness, seizures,
changes in level of consciousness, confusion) for example are beyond the capability of most office
settings to promptly evaluate and typically require the ER. Chest pain can be tricky. If a patient’s history
is concerning, they are at high risk for coronary artery disease or a pulmonary embolism (blood clot to
the lungs) or have concerning ECG/chest x-ray findings then we might recommend an immediate trip to
the ER or even calling an ambulance for safe transport. On the other hand, we might be able to safely
diagnose and treat a non-life threatening cause of chest discomfort, such as shingles, reflux or chest wall
pain. Honestly it can go either way.
If there is time, call.
So if you are on the fence about where to head, and are sure you don’t need an
ambulance, call your doctor’s office. They might be able to resolve your issue over the phone or work
you into their clinic schedule. Most emergency departments forbid their staff to give medical advice
over the phone. That means most people who call the ER will get a generic “we are happy to see you
here” type response that won’t really be much help. On the other hand, if you are considering a visit to
the urgent care but want to be sure they’ll be able to help, it’s OK to call ahead and ask. Generally you
will get a pretty good idea as to whether or not they can meet your needs. Another thing to keep in
mind is that different urgent care offices can have different capabilities or providers with varying levels of
expertise. So, one place might be very comfortable draining an abscess or repairing a wound that
another would send on the ER. It just depends on their staff and training.
Sometimes we have to send folks to the ER after we see them here in the urgent care. We know that
this is frustrating, but at the end of the day your safety is our #1 priority. My personal rule is that if I am
going to worry about you to the point where I’ll have problems falling asleep that night, I’m going to tell
you to go the ER. It may be expensive/busy, but the bottom line is that if you need it, you need it.
Hopefully this material answered any questions you might have on this topic. Whatever is ailing you, I
hope you feel better soon!