What Really Happens in the Emergency Room

From the ordinary and the bizarre to the downright miraculous, the experiences that happen inside the hospital emergency room vary from day to day. See what physicians are really up to inside our local ERs.

Nobody plans for an accident, injury or illness to occur. Kids spontaneously break their bones while playing sports. Strokes and heart attacks can strike suddenly. Stomach pains may wake you in the middle of the night.
It’s critical for emergency medicine physicians to have some knowledge in everything, whether it’s delivering a baby, handling a gunshot wound or taking care of a geriatric patient in his or her final moments. Any scenario can spontaneously rush through an emergency department’s doors.
According to the Centers for Disease Control and Prevention, (CDC), more than 130 million people visit America’s emergency departments each year – which equates to about 42 of every 100 persons. So what happens behind the ER doors?

The Inner Workings of the ER

Since all three hospitals in Rockford are trauma centers, the emergency medicine experts in our region care for patients of all ages and treat a wide array of conditions.
Throughout his career, Dr. Jason Bredenkamp has treated the bumps, bruises and scrapes that people walk in with every day. However, the emergency medicine physician at Mercyhealth Hospital-Rockton Avenue also treats patients suffering from car crash injuries, gunshot wounds, stabbings and other violent injuries. And yes, there are times when people put things in their bodies where they shouldn’t.
“We can provide definitive care, meaning we can treat and discharge a patient, or we get them to the appropriate specialist or level of care,” Bredenkamp says. “I think one of my biggest regrets is that I didn’t keep a journal during my 20 years of doing this. There are so many interesting cases that I forget. Nothing is really ‘unusual’ anymore.”
Most of the children that Bredenkamp treats have minor ailments – fevers, coughs, common colds, ear infections, urinary tract infections and occasional appendicitis. Young adults in their 20s and 30s typically arrive with infections, injuries and minor ailments.
Once people enter their 40s and 50s, however, things are different.
“That’s when chronic illnesses, heart attacks, strokes and other surgical emergencies occur more frequently,” Bredenkamp says. “But across the continuum, everyone is generally pretty healthy until their 40s and 50s.”
For Dr. Daniel Butterbach, emergency department director at OSF Saint Anthony Medical Center, one case in particular has stuck with him throughout the years. A 50-year-old man went into cardiac arrest while at a family picnic, and the odds of his survival were not favorable.
“The medics got there and began shocking him, and they brought him to the emergency department,” Butterbach says. “I went on to shock him multiple, multiple times. I didn’t think he had any function left.”
But a couple days later, after the man spent several days in the Intensive Care Unit (ICU), Butterbach was able to speak with him face-to-face.
“It was incredible – he was playing checkers with his girlfriend,” Butterbach says. “I explained to him how many times I had shocked him, and he showed me the marks on his chest. It was really a spiritual moment. Those kind of stories are what keep you going.”

A Nurse’s Perspective

Denise Book, RN, has been a nurse for nearly 45 years. Fourteen years ago, she became the nursing director of emergency services at FHN Memorial Hospital, in Freeport.
The job involves learning something new every day.
“As an ER nurse, you get to meet a variety of patients,” Book says. “You take care of brand new babies, children, the elderly and everybody in between. I really, really enjoy this type of nursing.”
When a patient walks into the emergency department at FHN, a nurse immediately begins to triage the person by assessing the degree of urgency to their wounds or illness. By speaking with the patient and by checking the patient’s vital signs – their blood pressure, temperature, pulse rate and so on – the nurse can develop an initial assessment of the patient’s condition.
The triage process determines the chief complaint within a potentially large group of people waiting to see a doctor. Those who are determined to have more urgent needs are treated first.
“Someone with a more severe presentation, such as chest pain, would need a bed faster than someone with an ear ache,” Book says. “It’s not first come first serve because that wouldn’t be safe.”
As long as beds are open, patients don’t need to wait. However, when the volume of patients goes up, a person with a minor ailment could potentially spend some time in the waiting room.
Once patients are taken back into the emergency department, it’s a nurse’s responsibility to talk with them and document any pertinent history to their medical complaint. When the physician arrives, the nurse provides assistance. Sometimes, a nurse can accomplish the necessary treatment or procedure independently.
Approved protocols are in place for select presentations.
“For example, if it’s chest pain, we’ll get an EKG (electrocardiogram) and labs started right away, along with a plan for definitive care,” Book says. “We have a Gold Plus Award from the American Heart Association for stroke care, and we’re also designated as an Acute Stroke Ready hospital by the State of Illinois, so if someone comes in with a stroke, we’ll move things along quickly per protocol because time is valuable.”
When a physician decides if a patient should be admitted to the hospital, discharged from the hospital or transferred to another hospital, a nurse carries out the next steps.
A nurse is responsible for communicating an admitted patient’s information to the subsequent caregiver. Discharged patients may need a prescription for medication, or instructions on how to further care for themselves. Transferred patients are prepared by a nurse, who also gives a report to the accepting facility.
“Communication is critical for all three scenarios,” Book says. “You have to make sure there isn’t a lack of knowledge at any point. It’s important for the patient’s safety.”

Handling a Heart Attack or Stroke

With an average of 200 patients per day, SwedishAmerican Health System, a division of UW Health, is usually at capacity. Dr. Jason Layman, the emergency department director, is used to treating 20 to 30 patients in a shift.
So when a stroke or heart attack happens, it’s essential for him to be focused.
“Every minute is critical,” Layman says. “If you have pneumonia or a urinary tract infection, you still have hours or days before that becomes serious. Triaged people in the waiting room might become frustrated, but they have to understand – when someone has a heart attack or stroke, they need to be seen first.”
Delaying treatment for a stroke or a heart attack, even for minutes, can make the difference between life and death, Layman says. That’s why SwedishAmerican regularly conducts practice drills for both heart attack and stroke scenarios.
“We practice to be a well-oiled machine,” Layman says. “There’s a lot of cross-representation between radiologists, CT techs and even the lab, so if there’s a STEMI alert or a stroke alert, everyone knows what to do. We collaborate to make sure the scenario plays out with the best outcome.”
ST-Segment Elevation Myocardial Infarction (STEMI) is the official term that physicians use to describe a classic heart attack. A myocardial infarction (MI) refers to the death of a portion of the heart muscle due to blood flow interruption. “ST segment elevation” refers to a particular pattern seen on an EKG when a heart attack is occurring. Symptoms of a heart attack include shortness of breath, pain or pressure in the chest, pain or pressure in one or both arms – especially the left arm – and sudden sweating or clamminess.
A stroke is the sudden death of brain cells due to a lack of oxygen. This occurs when there’s a blockage of blood flow to the brain or a rupture in an artery that leads to the brain. Symptoms include a sudden loss of speech and/or paralysis of one side of the body.
At OSF Saint Anthony, Dr. Butterbach works with pre-hospital providers for most heart attack and stroke occurrences.
“Sometimes we’ll get a surprise through the front door, but typically these patients arrive via ambulance,” Butterbach says. “We work closely with paramedics so that they know what to do in these scenarios. They’ll start to treat the patient right away and they’ll call us ahead so we can be ready.”
Typically, Butterbach has up to 10 minutes of warning from the paramedics. He’ll be waiting at the emergency department door when the patient arrives.
In a stroke scenario, the patient is never put in a room. Instead, he or she is immediately brought to a CT-scanner to obtain x-ray images of the brain. Meanwhile, a nurse prepares an IV for the patient and lab tests are ordered. In other cases, the patient may go from the CT-scanner straight to the neurointerventional suite to physically remove the clot.
“There’s a lot going on to streamline the process because we need to save the brain,” Butterbach says. “I’ve got a solid team that can manage multiple emergencies at once. It’s what we do all the time. We have a very efficient system.”

Coping with Stress

Of course, it’s wonderful to save someone’s life. But medical professionals who work in an emergency department are frequently under high pressure, especially when treating the sickest of patients. The job comes with a risk of burning out.
“Some shifts at Mercyhealth go by without any really sick patients, but some days it can be stressful and you need a few days to recover,” Bredenkamp says. “You have to focus on the task at hand and let the emotions play out after your shift.”
Mercyhealth has a level 3 neonatal center – the highest rating achievable – that provides newborns with exceptional care. However, even with the best of care, no hospital is immune to unexpected deaths.
“Me personally, the toughest thing is treating critically ill children,” Bredenkamp says. “Those are the cases that hit me hard later on if not in real time. It helps to have an active life outside of work. Family time, golf, travel, exercise – you need things to enjoy so you’re not thinking about work when you’re at home.”
Dr. Layman has a debriefing with fellow SwedishAmerican employees whenever a child passes away. It doesn’t matter if the waiting room is full.
Everyone who interacted with the child takes a moment to grieve.
“The death of a child will always affect you,” Layman says. “It’s important that it does, but you can’t let it affect your ability to move forward. There will always be more people to help. It’s not a game or a contest – you will never ‘win.’ You have to get to that point mentally and emotionally when you realize that, although you’ll never be done, you can still make a difference over and over.”

Prioritizing Your Health

There’s no right or wrong reason to go to the ER. None of the emergency departments in our region will turn you away.
“If it concerns you, it concerns us,” Book says. “Your health isn’t something to take for granted.”
At all hospitals in our region, the decision to seek medical attention results in compassionate and empathetic care. Whether your problem is trivial or severe, ER staff are always ready to help.