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Monday, October 21, 2013








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

http://www.survivalblog.com/2013/10/-surviving-the-er-by-j-in-montana.html

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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 peoples 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, *dont 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
dont need the ER. Sure, well 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, theyll 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 recom-
mendation in the er is totally unrelated to
the X-ray, we only do the X-ray because people
want and expect it. But it doesnt change any
thing. RICE is the treatment: rest, ice/
ibuprofen, compression, elevation. The reason
the orthopedic doc doesnt 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 cant 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
cant even keep a pill down and wont 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 cant see you or assess you over the phone
and dont want the liability of telling you it is
no big deal, even when it isnt. 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 isnt distracted
with pain and illness, who wont 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 cant 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 doctors 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 dont 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
isnt 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 dont 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 dont 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 doesnt matter if you
are religious, they wont 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 didnt plan for this to happen. If
I had a nickel for every time someone told me
they didnt have time to be in the ER, Id 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.