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Prakash Chandran: Probably the last place anyone wants to go is the emergency room. But even so, we're all very glad that ones exist. How can we receive the most efficient care in the emergency room? And most importantly, how can we best prevent these visits?

Here to talk to us today is Dr. Raymond Rudoni, Emergency Room Medical Director for McLaren Flint and McLaren Fenton.

This is McLaren's In Good Health, the podcast from McLaren. I'm Prakash Chandran. So Dr. Rudoni, thank you so much for being here today with us. You know, things happen and, when things happen, like we think we need to go to the emergency room. But we also know that there are urgent care centers. So I guess my first question is around how do our listeners know when to choose the ER versus an urgent care center?

Dr. Raymond Rudoni: Well, good question. And I think those are fair questions to ask. And one of the things I try to tell people is that medicine or at least emergency medicine, when people have needs that aren't planned, if you will, it's always difficult upfront to know exactly how to tell patients how to choose. But here's my advice. Number one, if you have an opportunity to call your primary care physician, let's say it's after hours, let's say it's the weekend or a holiday, sometimes calling their office, they can provide some input to a patient or their family as to which type of service to choose. They have good insight as to what's being offered and sometimes can provide some advice that will maybe make it a little easier.

Number two, urgent care centers and emergency departments are set up quite differently. And the urgent care center has, you know, either a nurse practitioner or a physician assistant. And sometimes there's physicians there or physicians available. And then they have limited ability to do certain lab tests. Some can do x-rays, but they have limitations to the kinds of testing that they can order. It's not easy to always know which it is.

But for the kinds of medical conditions that would involve more than just a simple blood test or a urine test or maybe a simple x-ray, and there were certain symptoms that were consistent with strokes or heart attacks or bad injuries, those I clearly think would be the ones that you'd want to call 911 or specifically start off in the emergency department. I think anytime we talk about life or limb threat, those are clearly places for 911 or the emergency department.

The kinds of more simpler, less severe issues. maybe you sprained your ankle, maybe you've got a sore throat, I think those are the kinds of things that either calling your doctor or starting off in an urgent care center would probably be okay.

Prakash Chandran: Yeah. I like the framework of life or limb threat. That's a good way to think about it. So if you feel like yourself or a family member is experiencing one of those things, when is it okay to drive yourself or the loved one to the ER versus calling 911 or calling the ambulance?

Dr. Raymond Rudoni: Well, very good. And I think again, it's one thing they head into the ER, if somebody says, Look, I've had kidney stones before, and I feel like this is a kidney stone" or, you know, "I fell and I hurt my leg. I can't walk, but I clearly could get in the car and get to the hospital," I think that that's fine. But I think if your loved one or your family member again is experiencing the signs and symptoms of stroke, of heart attack, maybe a change in the level of consciousness or an injury that's more severe, a bad car accident, a fall, somebody that has trouble walking, those are the kinds of things that I clearly think that calling 911 would benefit patients and their families. If you don't know, I think it's always best to err on the side of caution in an emergency situation and call 911.

Prakash Chandran: Yeah. And one of the main reasons for that is that there's immediate care that they can give while they are on route to the ER, isn't that correct?

Dr. Raymond Rudoni: Absolutely. There are paramedics that are trained to start IVs and to check blood sugars and provide trauma care with splinting and immobilization. They can provide breathing treatments. They are trained in a whole myriad of things in the community to assist the evaluation and management of acute emergencies in the field. And frankly, they do a phenomenal job and we're very fortunate to have them. And I think when in doubt again, I would call 911 if you're really concerned again about life or limb.

Prakash Chandran: So one of the things that I'm reading here is that McLaren Flint recently opened a freestanding ER, in Fenton, Michigan. So tell us a little bit more about what a freestanding ER is and how it's different from the hospital ER.

Dr. Raymond Rudoni: Very good. The McLaren Fenton Emergency Department opened up last spring and it's a wonderful brand new facility. When you walk in, if you walk in, it would look a lot like an emergency department. It would have a centralized nurses station. It would have several critical care beds and then a whole slew of other individual beds, places for physicians to work. But it also has a central lab, that we're able to get results from very fast and a full complement of x-rays, which means CAT scan, ultrasound and plain x-rays such as for ankle sprains, if you will.

So we have all the capabilities of an ER and hospital, except two big things. Number one, we can't keep you overnight. So if you need an operation, if you need to be admitted, if you're in labor, if you're having trouble with pneumonia say or chest pain, and you need to be admitted, we would evaluate you, stabilize you and then transfer you to the hospital, to McLaren Flint, where you could be inside overnight.

And the other thing we don't have at the freestanding ER, is we don't have the ability for consultants to come down and help us. So, for example, if we needed an orthopedic surgeon, if we needed a general surgeon for an appendix problem, if we needed a laborist for a woman in labor, we would have to stabilize those individuals and get them to the McLaren Hospital.

So we are a freestanding ER, in quotations. Freestanding means we stand alone, but we truly are alone in that once patients require further service within the hospital, that we have to send them to the hospital for that service. But that's a smaller percentage of patients than all the ones that we see and many of our patients are able to get complex care in many ways, x-rays, CAT scans and blood work, like you do in a regular ER, but most of the time we're able to evaluate them and send them safely home and they get emergency services, which is much better than an urgent care center, if you will, because of the technology and the resources that we have.

Prakash Chandran: So, one of the things that we spoke about is you should go to the ER when there's life or limb threat. And I imagine that there are a number of conditions that fall underneath that umbrella. But one of the things I was interested in is are there certain times of year during which you see more of a certain type of condition in the ER?

Dr. Raymond Rudoni: You mean certain disease entities that are more common in one time of year than the other?

Prakash Chandran: It could be disease-related, it could also be environment-related, like maybe it's colder, so people are slipping or getting into accidents more. Maybe speak to that a little bit.

Dr. Raymond Rudoni: Yeah, absolutely. I mean, clearly, obviously at Michigan with four seasons, there's summer and there's winter and the kinds of environmental-related emergencies that we would see clearly corresponded to seasons. I think it's fair to say when flu season gets here in the fall and winter, we see a spike in our flu cases. You know, clearly, we could talk about the COVID pandemic, but I think that's probably a whole separate discussion. And we tend to see more injuries in the summer when it's warmer and people are outside. So yes, there's definitely some seasonal variability and predictability to the types of things we see at a higher frequency, depending on which season of the year we're in.

Prakash Chandran: Yeah, that makes a lot of sense. Another thing that I wanted to ask you about based on your experience as an emergency physician, maybe talk about some significant cases that you've seen that you thought, you know, this could have been preventable.

Dr. Raymond Rudoni: Well, you know, again, categories, just off the top of my head, I would say that we deal unfortunately with a lot of problems with substance abuse. And whether substance abuse is alcohol-related or drug-related, you see all those types of ailments from people that theoretically could be preventable if they weren't addicted or involved in those kinds of substances. And then there's the injuries that are associated with using those substances. Again, whether they're alcohol and drugs and associated falls and head injuries from them and automobile accidents and motorcycle accidents. So clearly, you can look at that as being preventable.

And again, there's the kinds of things, there's child safety issues with our kids wearing helmets. Are you keeping an eye on them in certain types of play areas, whether it's a trampoline or something like that? You know, there are some things that could be deemed preventable if we weren't engaged in the kinds of activities that we sometimes engage in.

So, yes, I think that's a fair question. And I think that that's just off the top of my head a couple of examples that might, I guess, correspond to somethings that would be a preventable or if we didn't do that, or we would have done that, we wouldn't have ended up in the emergency department.

We do see firework injuries every year around the 4th of July. Many of them are preventable. we still see people put their fingers in running snowblowers to try to unclog them every winter. Those are preventable. I think the answer is yes.

Prakash Chandran: Yeah, absolutely. And it's crazy, even with all the education that's out there, you still see people, for example, in motor vehicles not wear their seatbelts. I imagine you still see people coming in because they haven't worn their seatbelt and they're not secure when they get into an accident.

Dr. Raymond Rudoni: There's no question. Yep, people that still aren't wearing helmets, people that still aren't wearing seatbelts, no question.

Prakash Chandran: Yeah. So one thing I wanted to ask you about, and I'm sure everyone is wondering, sometimes when we go to the ER, other patients arrive after we arrive and yet they're seen before us. So can you tell us why that is?

Dr. Raymond Rudoni: Yes, I can tell you. In the emergency department, there is a term which you may have heard of before. It's called triage. And triage is a term that means to sort. And in the emergency department, we sort by category, we sort by acuity, meaning we have a way to identify and evaluate a patient, whether it's by history or vital signs and EKG, something that we can see on the patient or hear from the patient, which makes us determine, are they a level 1 down to a level 5, which means are they the sickest of the sick to the most minor of the sick.

And we are held responsible for doing our very best at all times to assure that the people who are the sickest and the most ill, the most injured, are tended to first. And so there may be people waiting in the waiting room and an ambulance shows up with a very sick patient or a very injured patient, or somebody walks through the front door and there's a waiting room full of patients, and they have certain disease entities or vital sign parameters or things in their history, which we know are associated back again to the life and the limb threat. We have to move them through the system and get them to provider as quickly as we can even if it means going ahead of some patients who have already been there.

Prakash Chandran: Yeah, I think that makes a lot of sense. And, you know, still though, I think we all have this experience when we go to the emergency room, sometimes there's just a lot of waiting that's involved. Just because to your point, there are people there that need quicker attention than you do. So are there ways to minimize the time spent in the ER waiting room?

Dr. Raymond Rudoni: First of all, nobody wants to wait in the waiting room and we certainly don't want people waiting in the waiting room. Again, we talk about pre-pandemic emergency departments and post-pandemic emergency departments. You could spend two hours talking about. But I think it's important that the answer to your question is yes. I think if you come to the emergency department, you're going to get a medical screening exam. You're going to see a nurse. You're going to get vital signs. You're going to get a history taken. You may get an EKG. You may have your blood sugar checked. You may see a doctor or a physician assistant upfront while you're waiting to get some more information. And we will make a determination because we have to, based on the resources that we have as to who we can get back right away and who has to wait. But if you're one of those patients that has to wait and, while you're waiting, things change, they get worse, your pain gets worse, your breathing gets worse, your nausea gets worse, your symptoms get worse, then it's very important to explain that situation and to update how you're feeling with the triage staff so they can reevaluate you and recheck the kinds of vital sign parameters that they did initially. And if things aren't getting better stabilized and truly getting worse, then we will find a way to get patients tended to quicker than they would have.

Unfortunately, if you show up, as of late and it's been busier than normal and for some other reasons that we could talk about if you'd like, waiting room times have been a little longer than we've experienced. And a lot of times, there's not a lot that we can do to get people back as quickly as we would like. But clearly for those who get worse, the answer's yes. Let somebody know and we'll take another look at you.

Prakash Chandran: Yeah. And is there any way to like kind of do pre-triage? For example, if I am coming in with myself or a loved one, is there like an online check-in process or some way to say, "Hey, listen. I'm on my way. I'm filling out information so you don't necessarily have to take it there." Is there any process like that that's put in place?

Dr. Raymond Rudoni: Yeah, we have the ability to do some pre-check-in kind of scheduling through our McLaren website, specifically for the Fenton ER and at times the Flint ER, where you can go online and it's called InQuicker. And you can actually look at available appointments if those appointments are available and you can put your name on there and sign up for a visit and show up and be seen as quickly as possible by a provider. But it all depends on availability to time of day and now the time of year and some other parameters. So, the answer is yes, but there are some limitations to that based on again time of day, day of week, time of year and again what's going on with the pandemic.

Prakash Chandran: So Dr. Rudoni, you've been an emergency physician for quite a while here. And as we start to close, I just wanted to ask if you had any suggestions for our listeners, just in terms of staying safe and avoiding the ER in the first place.

Dr. Raymond Rudoni: Yeah. I think it's very important that if patients are fortunate to have a primary care provider or a doctor that cares for them and their family, you know, always start by trying to reach them or their answering service of their covering physicians, because many times making a call to your doctor for some things can eliminate a visit and you can be seen the next day in the office. There's no question about that. That's the first place to start.

Clearly, there's a lot of people who look online for medical information. I see more and more people doing that now as well. But I also think at the same time the emergency department is a place where most people don't want to come and they don't know what's wrong with them. And if they knew what was wrong with them, they probably could eliminate a lot of their visits, but they don't know because that's not what they do for living. And so I always tell patients whether I don't know who they are or they're my family and friends, when in doubt, go to the hospital, especially when it comes down to the things that we've talked about earlier with injuries, signs of stroke, signs of heart attack, breathing abnormalities, changes in the way people are acting and the kinds of things that could potentially be life-threatening. if you don't know, you have to have it looked at. And many times we reassure patients and we do some testing and we send people home. And that's great and that's part of our job. But unless we have a chance to look at you and do some testing, we don't know. And so we're in the business of kind of trying to help people figure out who needs to stay in the hospital overnight for further care and who can be safely discharged to follow up with their doctor.

Prakash Chandran: Well, Dr. Rudoni, this has been a really informative conversation. Thanks for all of the advice and information. We really appreciate it.

Dr. Raymond Rudoni: Very good. If there anything else I can do or service I can be to you, let me know. I'm here at any time.

Prakash Chandran: Thank you so much. That's Dr. Raymond Rudoni, Emergency Room Medical Director for McLaren, Flint and McLaren Fenton. To learn more about emergency medicine at McLaren and the new Fenton ER, visit mclaren.org/fentoner. If you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you.

This has been another episode of McLaren's In Good Health. My name is Prakash Chandran. Thank you for joining us and we'll talk next time.