Saturday, May 1, 2010

A Better Trip to the ED, Part II

(Author’s Note: Yesterday I began to serialize an admittedly VERY long piece in response to an article by Eric Wahlgren entitled, “Emergency Room Docs Offer Inside Scoop: How to Get Treated Faster, Better.” (, November 29, 2009). It lists tips and techniques for improving the quality and outcome of your ED visit. Here’s Part II. His tips in italics; my thoughts in “stand-up” letters. Part III tomorrow. Same bat-time, same bat-channel.)

Call your regular doctor before you go: If you let your primary care physician know you're heading to the hospital, he or she may be able to call ahead and alert the staff. Often, the ER department may even be able to hold a bed for you if your doctor requests it. "If the doctor wants us to call them back, we'll try to see the patient quickly, at least to give them an update," says Larry D. Weiss, president of the American Academy of Emergency Medicine. "The care is more coordinated." If at all possible, go to the ER at a hospital where your physician has "privileges," or the authority to provide patient care. What's more, your primary care physician may have you directly admitted to the hospital, bypassing the emergency room. "Not everyone has to come from the ER," he says.

This is a great idea. Sometimes it actually works. The doctor talks to you, he or she calls us so we know the game plan, they fax in any pertinent lab data or orders, we are able to fight off the unrelenting pressure to fill the beds up and actually hold a spot open for you, and we can, in fact, expedite your care.

Here’s what’s more likely to happen. If you call your doctor’s office during business hours, the staff will tell you that they won’t be able to see you until next week, and that if you feel like it can’t wait you should go the emergency department. If the message actually gets to the doctor, you’ll get a call back. Your physician will then tell you that he or she is happy to see you in the next day or two, but will also say that if you feel you can’t wait you need to you should go to the ED. Of course, since you felt bad enough to call in the first place, you take this as a physician’s order to go immediately to the hospital.

Once there, you will be angry that we can’t get you immediately into a room because they are all occupied by patients waiting for the end of shift change so they can transported to the floors. When a bed does open up, you will want to know why your doctor is not here to meet you and why I am asking you questions about why you’re here. When I explain how the ED works, that I need to see you first to identify any life-threatening problems, you will want to know why I haven’t called your doctor immediately. When I explain that he or she has sent you here for us to evaluate you and to get information that will help your own physician determine your best care, you will feign understanding but become increasingly frustrated. Once I’ve done my assessment and gathered any needed labs or x-rays, I will then take time to locate your doctor (or whoever’s covering for them) and ask what he or she wanted us to do. They will tell me that either 1) they never talked to you, and it must have been the office staff, or 2) they’re on call for the doctor who sent you in and therefore have no idea what I’m talking about. At some point in this process, you will demand to why you’re still in the ED and not in a comfy bed in a private room upstairs because you were sent in to be admitted (something we already knew when you showed up at the door with bags packed, a clinical indicator we know as “The Samsonite Sign”).

If you actually have a doctor who not only calls you back after business hours, but talks to you and tries to help you manage the problem at home so you don’t have to come to the hospital, hang on to them. Take out a second mortgage, pay him in cows and chickens, if you have to, but hold on. You’ve found one of a dying breed.

Bring a list of your medications: Certain drug allergies or interactions can harm or even kill you. To begin treatment, doctors will ideally need to find out about all the medications you're taking…keep the names of your medications on a card in your wallet. Or throw your medications into a bag and take them to the hospital to show the staff.

This is absolutely the right thing to do. But please bring in your medications in their original bottles. Many people use a pill container that separates doses by days and hours, and that’s great for making sure you make the right pills at the right times. But without the original bottles it takes lots of time to decipher the exact medication by color, size, shape, and numbering. What’s worse is when the patient just shovels loose pills into a bag or box. It’s good for amusing the children, because you can shake it and the pattern of colors will keep changing like a kaleidoscope, but not very helpful for making you better.

The list is crucial for several reasons. First, it gives us a good idea of your past medical history even if you are unable to provide me with any information. If you’re brought in unconscious but you have a medication list in your wallet that says you take diabetic medication, I have a pretty good idea of where to start in your evaluation and treatment. Second, it can help alert us to side effects or drug interactions that may play a role in your illness or care. Third, it insures that we don’t consider you as using illicit drugs when you’re just taking the medications prescribed to you. A number of years ago I took someone to task for having barbiturates on their drug screen. Later I found out that the patient had been placed on Donnatal for stomach problems, a component of which is a barbiturate.

Please also try to write down the actual name of the medication on your wallet card. You’d be surprised how many “little pink pills for my blood pressure” are out there in this world. It would also be nice if your list was focused on current medications. While I’m glad to know you used an entire case of Proctofoam for that nasty hemmorhoid in 1984….pretty amused to know it, actually, and you can be sure that in a matter of moments everyone in the ED will know about it…it’s probably not terribly relevant to your chest pain unless you’re a plantiff’s malpractice attorney, in which case your heart and rectum tend to be one and the same.

Have your medical records and tests handy: Another major slowdown for doctors in the ER can come from having to order medical records and tests from other hospitals or departments to get the full picture of your condition. Having copies of them will speed up the process, doctors say. "They may still need to order new blood tests," says DailyFinance columnist Russell Turk, a (physician). "But if they have a (previous) test, they have a much better idea of what's changed."

As with the medication list, this is a top-notch idea. Copies of your most recent lab tests are invaluable. So is your most recent electrocardiogram (EKG), and I truly believe that every patient who’s had one should keep a copy folded up in their wallet or purse. And if it’s possible, have a copy of the discharge summary from the last time you were in the hospital. That gives us a great record of not only your last admission, but also usually provides a good synopsis of your entire medical history.

While records are great, please know that I cannot read your entire three-inch thick file of past MRI’s for back pain. (One of my first patients during my residency…a very nice lady…came to the hospital with a notebook of records. On the cover, in stick-on gold letters, it said “Mrs. Gloria George, Evangelist, A Shook-Up Life!”) Nor do I respond positively when, on the occasion that I ask what brought you to the ED, you throw a manilla envelope at me and tell me to read it. Nor am I endeared with you when you tell me not to bother asking you for information, because it’s “all in my records.” There was a reason you came to the ED at that very moment, and you’re the one who knows what it is. So I will keep asking you ad nauseam, because that’s the only way to find out.

Here’s some other suggestions of things not to do with your medical records. Don’t tell me that you’re not willing to sign a release of information for your records from another hospital when you’ve been someplace else and have now arrived in my ED. Most people are happy to do so because it they understand that it enhances their care and prevents unneeded testing and costs. When someone doesn’t want us to know more about them, the red flags go up.

You’ll also want to actually read your medical records before relying on them as support for your requests. About a year ago a patient came in complaining of back pain and requesting additional medication. She showed me her records from a pain management specialist that she said would tell me she needed pain pills. I did read the record, including the note from the pain management specialist that said the patient had abused her pain medications in the past and should not receive medications from any other source. There was also a copy of a signed contract from his office indicating her agreement to these conditions. That was fun.

Even if you’re had the foresight to bring us records with only the best intent in mind, please note that there are some things we really don’t want to know. Two weeks ago an elderly man came in with constipation. With him was his attentive and loving wife, who had dutifully recorded every bowel-related action over the past fortnight, including detailed notations as to volume, color, timing, and character. Sometimes there were up to five entries per day. Folks, it’s enough to say “I haven’t had a normal BM in 10 days.” Really it is.

Here’s what you do to make life easy for everyone. Get a three by five index card. On one side write down your current medical problems and your most significant past issues (medical issues, not the girl who dumped you in high school). On the other write down your current medications. The size of the index card is important. A three-by-five card is eminently portable in a wallet or purse, and it’s a limited space. If it’s not important enough for you to fit onto the card, it’s probably not going to affect your care in the ED.

Make sure your hospital treats what's ailing you: Knowing ahead of time whether the ER to which you're heading actually has the right staff and resources to treat your problem will save you time. If your teeth get knocked out in a car crash but the hospital you visit has no dentistry unit, you may have to be transferred, costing valuable time. Same goes if you drop off a suicidal friend at a hospital that has no psychiatric ward.

Great idea, especially for problems that are not time-critical such as psychiatric illness and chronic issues. A corollary to this is that if you have recently been admitted or had a procedure done by your doctor at a specific hospital, it makes sense to go back to that hospital where they already have your records and the physicians already know you. (Given my penchant for naming made-up axioms after myself, I hereby dub this advice “Rodenberg’s Law of Return.”)

That being said, it’s critical to not delay care by going to a farther hospital in a true emergency. Where EMS services are available, a paramedic may choose to take a patient to a more distant hospital due to clinical condition. While the hospital may be more distant, the paramedic has the capability to notify the receiving hospital of the patient’s condition so specialty services can be activated, and to manage any further problems on the way. If you’re on your own, it’s probably best to take a patient with a serious medical condition to the closest facility for stabilization. Once stabilized, the patient can then be transported by ground or air to another hospital for specialty care.

Oh, and good luck finding that ED with a dental unit. When you find it, let me know. I’ve got a lot of referrals to send that way.

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