Surviving The E.R., by J. in Montana

This article will focus on the latter half of the oft used phrase The End of the World As We Know It.  Operative portion being “As We Know It.”

As an emergency room (ER) nurse, I have the perspective of seeing on a daily basis, for patients and family members of patients, the end of their world as they know it.  While the world keeps turning for everyone else, a tragic disaster unfolds for them and life will never be the same.  I offer this article from the perspective of one who has seen a wide range of traumatic events and people’s reaction to those events, with the intention of helping to make these family-scale catastrophes less traumatic and painful, and perhaps even decrease their frequency or severity.

First, a caveat, this is geared primarily for the US healthcare system.  I have lived, worked, and traveled abroad and seen some of how other countries operate and much of what follows will be applicable to those other systems, but there will be small operational differences.  Your mileage may vary.

To begin with, the hospital in general and the emergency room in particular is a hostile and foreign environment to many, and for good reason.  A large percentage of patients are there with substance abuse and mental health problems.  There are sick and injured patients, demanding family members, not enough staff, screaming, yelling, vomiting, defecating and bleeding people everywhere.  And there are drug resistant and normal everyday microbes waiting for a host.  Into the middle of this chaos comes you or your loved one.  How to get the best out come possible?

For starters, don’t come.  I know if widely followed this advice would seriously disrupt the bottom line of many hospital ERs, who make their money on the non-urgent, well insured patients who come in for minor problems, but a positive financial impact on the department does not necessarily equal a positive health impact on the patient.  Actually the idea of a positive financial impact is a bit of a misnomer; precious few community hospital emergency departments in the country that makes money (excluding for-profit hospital groups), they operate at a deficit, but that is a discussion for another day.  

So what should you consider not going to the ER for?  While this should not be construed as personal or specific medical advise, in general the following things can be served equally well, if not better, by other means:

–          Orthopedic injuries.  If it is a sprain, strain, or even many fractures, odds are you don’t need the ER.  Sure, we’ll do an X-ray, give you some pain meds, tell you to ice it, and follow up with the orthopedist in 3-5 days.  And when you do, they’ll repeat the X-ray and the exam and give you a prognosis and treatment plan.  Why not skip the middle man?  More often than not, our treatment and recommendation in the er is totally unrelated to the X-ray, we only do the X-ray because people want and expect it.  But it doesn’t change anything.  RICE is the treatment: rest, ice/ibuprofen, compression, elevation.  The reason the orthopedic doc doesn’t want to see you for 3-5 days is the swelling must begin to recede for them to do a good evaluation.  So skip the ER for your sprains and strains and go straight to the orthopod or urgent care center even if you must wait a day, UNLESS: you have numbness or reduced circulation downstream from the injury, have major gross deformity (foot is pointed the wrong direction), or pain that is  more severe than than you can handle with ice and ibuprofen or that is out of line for what you would expect for the injury. 

–          Upper respiratory infections.  You have a cough, cold, sinus pressure, drainage, and feel ill.  First option, rest, stay hydrated, take Tylenol and over the counter decongestants and cough suppressants.  Next best, go see your regular doctor in a regular office visit.  Next best, go to an urgent care or walk in clinic.  IF you have high fevers not controlled with Tylenol and ibuprofen and body aches and feel like you have been run over by a train and have neck stiffness, then come to the ER.  If not…

–          Nausea and vomiting.  Groups with with belly pain this group is the number one chief complaint in the ER anywhere in the country.  This is because so many things manifest as abdominal pain, and some of them are true emergencies.  But if all you have is nausea and vomiting and can’t keep anything down, it is likely a stomach virus, one of the zillions of varieties of Noroviruses, for which there is no cure, only meds to reduce the nausea and iv fluids to maintain hydration status.  So what can you do to avoid the ER for this?  Ask your doctor ahead of time for a prescription for anti-emetics; Zofran (ondansetron) and Phenergan (promethazine).  There are others that work well, but I am partial to these two because the Zofran comes in both a pill form and a dissolvable under the tongue form in case you are so nauseated your can’t even keep a pill down and won’t cause drowsiness like the other anti-emetics.  Phenergan also comes in pill form, as well as suppository form, for the same reason.  It can cause drowsiness, though sometimes that is a desirable feature!  Many doctors are very willing to prescribe anti-emetics for just-in-case use at home, even more so than antibiotics.  This can also be a good foot in the door, so to speak, for getting your doctor on board with prescribing meds for just in case use.
–          Children with fever.  If your kid is more than a couple months old, and has a fever with no other specific symptoms, give them alternating doses of Tylenol and ibuprofen.  If this works to keep the fever down, they are able to stay hydrated and pee normal amounts, and have no other symptoms (neck stiffness, ear pain, abdominal pain,etc) then it is likely a viral bug and will get better in a day or two.  A fever in an infant under 30 days old however is another matter and should be seen by a professional.

–          When in doubt, call you primary doctor.  Often they will tell you to go to the ER, because they can’t see you or assess you over the phone and don’t want the liability of telling you it is no big deal, even when it isn’t.  So instead, go see grandma, or your grandmother equivalent.  Seriously, elders have been around awhile and those who have reared several kids often have a good idea of that sick vs not sick assessment tool.  Chicken soup, ginger ale, Tylenol, water, saltine crackers, and rest; these things really do work!

So that addresses over half the patients I see in my ER on any given day.  What about the rest, the real emergencies that really need help?  How can you prepare for these and handle yourself and your loved ones best?  Here are some tips:   

Bring an advocate.  Someone who isn’t distracted with pain and illness, who won’t be impaired by meds, and who can ask questions, write down answers, observe that things are being done right and in a timely fashion, advocate for pain control, and generally look out for you when you can’t look out for yourself. 

Have a list of medicines you take, the doses, frequency, and what they are for.  Also a list of medical problems you have had or are being treated for, and a list of prior surgeries and any allergies you may have to medicines.  Your primary doctor’s name and phone number are also helpful.

Now what if you are the advocate, what should you bring and how can you help?

Bring: snacks, water, and reading material since you may be there a while.  Notebook and writing stick is also helpful to keep track of things.  Phone and a charger!  Many hospitals have poor signal and your phone will chew through battery faster searching for a signal.  Maybe a smart phone, tablet, or laptop, so you can research tests, meds, and diagnosis and things the docs and nurses are telling you.  

Ask questions.  In a polite and genuine manner, ask what the anticipated side effects of meds are.  Rather than simply agreeing to treatments, ask (again in a polite and respectful manner) what the options are.  Ask what the consequence would be of foregoing a particular diagnostic  test (such as CT scan).  If there is anything you don’t fully understand, ask, and then repeat back to the person who explained it to you, in your own words what you think you understand.  If you think the patient you are advocating for needs more pain meds, ask.  If you observe people not washing their hands before touching the patient, ask.  If no one has been in to see the patient and you are not clear on what you are waiting for, ask.  You may notice a theme here.  Most nurses and many doctors too like to teach and help patients and family members who are genuinely interested in learning and want to be healthy.  On the other hand, NO ONE likes to be hassled, bothered, pestered, criticized, or challenged.  Your goal as the advocate (or patient for that matter) is to be perceived as the former rather than the latter.  Be extra nice and tactful when making requests and asking for things, to avoid setting up an adversarial dynamic.  Instead, ask what you can do to help, for example getting warm blankets, repositioning the patient or boosting up in bed, getting water, etc.  Even if there is nothing for you to do, offering is nice. 

Even if it has been a long time you have been waiting, remember that is a good thing (usually).  The national average is over an hour before being seen by a provider, and over 2 hours until disposition.  In many big city ERs it is not unusual to spend 6-8 hours in the ER.  Remember, as I often tell people, you never want to be the most important person in the ER.  If you are the patient everyone is rushing into the room to see, that is usually a very bad sign.  Remember, this isn’t a clinic, this is the EMERGENCY room.  If you have the option, maybe you should have gone to an urgent care or walk in clinic; they are usually faster and much less expensive.

Understand the balance of power in the ER.  As a patient, you do have the right to refuse treatments or tests.  Some doctors may try and steam roll you, saying that if you don’t want their help, then there is nothing more that they can do for you.  This gets into tricky territory; if you are not having a dangerous or life threatening emergency and you are merely sick or in pain, then technically they are right, they don’t have to treat you further.  Better to not get into that adversarial position, instead asking questions instead of making demands.  If you can explain your concerns and illustrate your comprehension of the situation, you stand a better chance of negotiation what you want with the doctor.  Remember, in the ER most of the people we deal with are not rational or normal.  If you can demonstrate that you are a rational and sane individual, we are happy to work with you, but we do not assume that is the case, that is for you to demonstrate, because experience has demonstrated to us that patients are all crazy and mostly not that bright.  You can be the rare exception, and this will benefit your care.  By the way, you always have the power to leave when every you want.  It is called AMA, or “Against Medical Advice.”  Be aware however you will still get bill for assessments and treatments performed up to that point, and insurance generally will not cover a visit if you leave AMA. 

If things are really bad, ask for or accept the help of the chaplain.  It doesn’t matter if you are religious, they won’t push prayer on you unless you ask, what they will do is be a resource for you.  They can make calls for you, ask questions for you, help coordinate arrangements, relay information, liaison with other departments and staff, relay concerns, pretty much what ever you need from a non-medical standpoint.  They are one of the few resources you have as a patient or patient advocate who probably knows the system better than you and is there with the sole job of assisting you.  Religious or not, if things get bad, take advantage of the chaplain’s services, even if it is just a safe place to blow off steam or vent concerns or frustrations.

Clearly you didn’t plan for this to happen.  If I had a nickel for every time someone told me they didn’t have time to be in the ER, I’d have a nice little hedge on inflation.  But before it happens you can take steps to be a bit better prepared for disaster.

JWR Adds: Hospital Acquired infections (HAIs)–also known as nosocomial infections–are spread at alarmingly high rates, even in First World countries. These infectious diseases can include MRSA, ESBL-producing bacteria, Vancomycin-Resistant Enterococci (VRE), Pneumonia, and Psuedomonas Aeruginosa. For this and other reasons, I recommend avoiding purely elective in-hospital procedures, such as cosmetic surgery. Do you really need a smaller nose, a pointy chin, or “permanent makeup”? Probably not.

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