Thursday, December 31, 2009

Tips (Marin IJ)

Unless you’re a masochist, a trip to your local Emergency Department (ED) is most likely an unpleasant proposition. Such a journey is replete with anxiety-provoking features; an impersonal waiting room, sharp needles, blood (often your own), shrill alarms, and uncertainty about what’s coming next.

It’s not surprising, then, that most people don’t consider the logistics of an ED visit ahead of time. But they should. Not doing so is like going into the backcountry without a “ten essentials” survival kit – things will probably turn out fine, but you’ll be awfully bummed if they don’t. Fortunately, with some simple preparations, you can minimize both the risk and the hassle of a sudden illness.

Last weekend, during a busy ED shift, I asked a patient what the worst thing about his visit was. “I think you know,” he replied, “…it was the wait.” Sadly, that captures an unavoidable reality about Emergency Departments and brings me to my first tip – be prepared to wait. Of course, most of you know this already. But nonetheless, some people still think that an ED functions like a restaurant – first come, first served. This is simply not true – many different variables determine who gets seen and when, but the bottom line is that we triage based on severity; the more life-threatening your illness appears to be, the quicker you will be seen. Thus, if you come to the ED with a gouty toe, expect to wait, but if you have a crushing chest pain and are asked to wait, something is wrong and you should speak up. And if your gouty toe can’t stand the ED waiting room, you might consider alternatives– your regular physician offers personalized and (usually) cheaper care. A visit to the web (Kaiser members can visit or a call to a health advice line can offer helpful perspective. If you do end up on your way to the ED, bring a book or perhaps your Christmas Kindle. I recommend loading Complications by Atul Gawande.

Speaking of complications, one that makes all emergency physicians nervous is aspiration –vomiting stuff from your stomach to your lungs. This is of particular concern during procedures that need sedation. So, if you’ve taken a bad tumble and your arm is as floppy as a fish, avoid stopping at the drive-thru on the way to the hospital. If you do eat or drink anything, it may delay your procedure by up to six hours.

While food is off the table at this point, clean underwear is not. Most patients in the ED will be expected to strip down to their skivvies, (in order to get a complete physical exam) so you might as well make a point of donning a clean set. Like underwear, another thing that should be up-to-date as you enter the ED is your list of medications. You will undoubtedly be asked about your meds, so rather than relying on your memory, have a card ready in your wallet. Be sure you include over-the-counter medications and supplements and note any drug allergies. Given the ubiquitous computer, this may seem unnecessary. But, believe me, it is extremely helpful – I trust diligent patients’ written records of their medications more than the ones I find on my computer screen.

Once you’ve made it through triage, set your cellphone to vibrate and get ready to tell your story. This is vital – how you communicate with your doctor at this juncture will go a long way towards determining the appropriateness of your work-up. Once a medical professional (doctor or nurse) arrives, start with compliments (we all like them!) and avoid gender stereotyping – there are many male nurses and a whole lot of female physicians, and most of us dress very much the same. After you’re done with the pleasantries and have figured out who is who, be clear about why you came to the ED and about your expectations. In the ED, we are very good at recognizing and treating emergent medical problems, and not so good at treating chronic ones. So, tell us what is new and, when you are being questioned, stick to that subject as much as possible. For example, you are likely to befuddle your doctor if you interrupt his line of questioning about abdominal discomfort to tell him about years of foot pain.

Finally, as the visit unfolds, consider this; more tests do not necessarily mean better care; questions about your diagnosis and treatment are better at the end of your visit than the beginning; and every pet owner should have a back-up pet sitter. Amazingly, pet care seems to be (in my unofficial estimation), the #1 reason why people leave the ED against medical advice. I’m an animal lover myself, still, it is hard to understand why someone having a heart attack leaves the hospital so that they can take Barky out for a pee. But, it happens frequently. So please, set up an emergency pet-care system – a list of people who can take care of your pet while you take care of yourself. Don’t be afraid to ask hospital personnel to help you make those phone calls. Better to stay in the hospital for a day or so then to stoically make it home for one last walk with Barky.

There you go, tips from someone who’s been there before. I hope you won’t have to put them to use.