Bias in the ER
Over the past two-and-a-half decades, I’ve worked in about two dozen hospitals. While not part of this story, it is an important footnote.
“Hey,” my resident says. “Come look at this.”
It’s late evening and the ER is relatively quiet, for now. There’s no one in this hallway, and there is no obstacle course of people, wheelchairs, intravenous poles or stretchers along my path to the X-ray monitor.
“Jesus,” I say, looking at the screen. “Where is this patient?” My resident and I are just finishing up. We should be heading out in less than 30 minutes, and we’re seeing one-touch patients—sprains and strains, lacerations, skin infections. This patient, whoever he is, is going to keep us here longer.
“Still in X-ray,” he says. “Car accident. I don’t know why they didn’t put him in an acute care area. He’s in agony.”
My resident points to the chest X-ray. It’s a lateral view. “That’s a bad sternal fracture,” he says, “isn’t it?” It is a bad fracture, the inferior fragment displaced about a centimetre. “Do you think we should CT it?”
I point to another part of the screen. “Before you CT anything,” I say. “What about this?”
“Holy crap,” he says. “I didn’t even notice that.”
“Pull up the PA chest,” I say, “It’ll give us a much better look.”
Read: Dr. Raj Waghmare: Brothers
The patient’s chart is in my resident’s hands. He gives it to me and I begin scanning. Under “presenting complaint” it says “MVC.” We take brisk steps toward X-ray while I read the triage note and his vital signs. He was in a head-on collision about 30 minutes earlier and transported here by ambulance. At the scene, and now, he complains of severe chest pain. I see him, in a wheelchair just outside X-ray. He is clutching his chest.
“What happened?” I say, “Can you tell me about your accident?”
He lets out a moan and clutches his chest. “He doesn’t speak any English,” my resident says. “I got the history from the triage nurse who wheeled him over. Head-on car accident, complaining of chest pain, no other pain according to family members who were translating at the scene.”
“Where’s the family now?”
“They’re in the waiting room. The nurse said that there were too many of them so they wouldn’t allow them in.”
“Not even one?”
My resident shrugs.
I wheel the patient quickly to our acute-care area and ask the charge nurse for a room. “He needs an intravenous as well, and can we get him Dilaudid one milligram with Gravol. Nothing by mouth, and get some propofol please.”
“Why?”
“He was in a head-on car collision, he has a displaced sternal fracture, he has a large pneumothorax and he needs a chest tube.”
A nurse helps me get our patient out of the wheelchair and onto the stretcher. His lips are well-perfused, and he’s speaking (although I have no idea what he’s saying), and his radial pulses are strong. We put him on a cardiac monitor. His heart rate is slightly high, 110, but his blood pressure is strong, 160 over 100. His oxygen saturation is good: 94%.
“I need you to bring in his family,” I say. “I need to know what happened.”
The triage nurse is here now. She tells me that there were so many family members that they were interfering with her initial assessment, each one talking over the other, insisting that he needed immediate attention. If that’s the case, they were probably right. Security was called and the family members were moved to the waiting room. “Please,” I say, “just let them come in. At least one who can translate.”
A minute later, three family members hurry into the room. My patient is in his early 50s. I assume one of the family members is his wife. One, in her 20s, tells me in clear English that she is his daughter. They were not involved in the accident.
As they hurry to his bedside, another nurse appears. “You can’t all come in here,” she says. “Only one can come in.”
I find this odd. As I wheeled the patient to our acute-care area, I saw two other patient rooms each with three family members in attendance. “I need them here,” I tell the nurse. “This guy is in bad shape and I don’t even know what happened.”
“I know,” she says. Then she said to me, inches from my face, but loud enough for others to hear: “But they lie. They pretend they can’t speak English so their family members can come.”
She is an excellent nurse—skilled, caring and she is my friend—I’m not sure why she would say this. I’m also certain my patient isn’t lying about his linguistic skills. I’m sure that if I were in his position, I would have screamed out for pain medications in as many languages as I could until I was sure the doctor understood.
“What happened?” I ask his daughter.
She tells me that he was driving about 80 km per hour on a two-lane road when one car crossed over the median and there was a head-on collision. This happened about an hour earlier. He was in an older car, and whether or not it had airbags was questionable. In any case, no airbag was deployed and despite being belted, his chest hit the steering wheel. This is where he has pain, nowhere else. He takes an antihypertensive, is not on any anticoagulants and has no other significant medical or surgical history. He has no allergies.
“He has a collapse of his right lung,” I say. “Let him know that I’m going to give him pain medication through the intravenous, then we’re going to sedate him for just a few minutes. I’m going to put a small tube between his ribs. There is air trapped outside his lung and it’s compressing it. The tube will release this air and allow his lung to re-expand.”
She explains this to her father, and as we prepare for chest tube insertion, my resident and I complete a secondary survey. He has no injuries to his head, neck or spine and moves all four of his limbs easily (although moving his arms causes extreme pain at his central chest). His abdomen is soft, non-tender and a bed-side ultrasound reveals no free fluid.
“He wants to know what happens after the tube,” his daughter says.
“Once the lung is re-expanded, we will likely transport him to a trauma centre.”
She explains this to him, and he answers. His daughter looks at me again. “He says thank you, and he wants me to tell you that you are very nice.”
We sedate our patient, sterilize his skin, freeze the skin and soft tissues overlying his rib, then blunt dissect until we hear and feel the satisfying sigh of air. A chest tube is inserted and secured with a dressing and sutures. A portable X-ray confirms lung re-expansion. Because of his injuries and accident mechanism, I call the provincial transfer service. He is accepted at a trauma centre where later a pan-scan will reveal no injuries other than his sternal fracture and unilateral pneumothorax.
I update the family and ask if they have any further questions. I order additional pain control for his transfer to the city.
As I leave the room, another nurse takes me aside. “Hey,” she says. “Did you know that the driver of the other car came in at the same time?”
“Is he OK?” I say.
“You’re going to puke when you see him.”
“Why? Is he dead?”
She takes me by the arm. “Just look.” Several steps away, a well-dressed man is lying in a private assessment area on a stretcher. The head of the bed is raised 30 degrees and he’s texting. He looks so comfortable, he may as well be on a beach lounger. “He got a bed right away and literally walked there on his own, climbed in and relaxed.” And, because he’d been directed to an acute-care area, he’d been seen immediately by one of my colleagues. I’m sure he speaks perfect English and, although I’m guilty of the same bias that this story highlights, I guess that his parents and his grandparents spoke perfect English as well.
I didn’t puke when I saw him, but I did feel sick. Sick and angry.
That I’ve worked in over two dozen different hospitals over an area swept out by a 500 km radius is important because institutions don’t like to admit that such bias (and discrimination) can occur within their walls. So, I’ll only say that this incident happened at one of these sites, at some point over the last 25 years. Having worked at so many hospitals has taught me one thing, however. These incidents aren’t unique or isolated. They are common, and they happen everywhere, all the time, and censoring those who speak out doesn’t help solve this problem, it only promotes the continuation of such injustices.
Dr. Raj Waghmare is an ER physician. He blogs at theoverheadpage.com. His stories come from more than 25 years of practice.