“Inappropriate Use of the E.R.”: A Story of How an Emergency Physician Needed the E.R.

As emergency physicians who are trained in acute resuscitation and thrive in high-stress situations, we tend to roll our eyes at the less acute complaints our patients come in with. “Back pain for three months? Headache for a week? Why are they here now?” Patients, too, complain about this. “Can’t they see it’s not a real emergency and go see their primary care doctor? This must be costing our healthcare system a fortune!”

A couple of months ago, something happened that made me question this so-called “inappropriate use of the E.R.” Let me tell you about a previously healthy young woman, an emergency physician, who came back from her shift at the Brigham & Women’s E.R. feeling a bit under the weather. She was a little nauseous, but was able to eat the Chinese take-out dinner that her husband brought back. Right after dinner, she went to bed, but couldn’t sleep because she developed a gnawing abdominal pain. Then, she began throwing up, and kept throwing up at least ten times in the next hour.

Being a physician, she came up with a differential diagnosis. This was most likely stomach flu: a simple viral illness. However, stomach flu generally involves diarrhea, which she didn’t have, and she really didn’t have other viral symptoms. It could be bad food, but her husband ate the same thing (and she, being Chinese, was sick of Chinese food always being blamed as the culprit). Any woman could be pregnant, and though the suddenness of her symptoms made that less likely, an ectopic pregnancy was theoretically possible.

So she set about to self-diagnose and self-treat. She sent her husband to the local 24-hour CVS to buy a pregnancy test and to pick up a nausea medication that she prescribed herself. The test was negative and the medication made her vomiting stop, but as the morning came, her abdominal pain was still there. In fact, it was now localized more to the right lower side, and it hurt her to walk.

I’m sure you see where this is going. You’re probably thinking to yourself whether you would have bitten the bullet and gone to the E.R. to make sure you don’t have appendicitis. Well, this young woman was me, and I was trying to avoid checking in as a patient, getting the radiation from a CT scan, and burdening our overtaxed healthcare system. Fortunately, I was able to call and find out the E.R. attending that day was an ultrasound specialist. She did me a favor to ultrasound me, and found that my appendix looked fine, but my intestines looked inflamed—consistent with stomach flu. I got my diagnosis, and over the next few days, I recovered with no radiation and my appendix intact.

Had someone like me actually checked in as a patient, I could see how there might be grumbling from the providers. “A young woman with stomach flu who’s actually getting better—why is she here?”  “If she doesn’t want a CT, why did she come to the E.R.?”

What I learned from this experience is that it’s always easy to say in retrospect that the patient didn’t have to come to the E.R. In the moment, when the patient is scared and in pain, it’s not so clear. Even as an E.R. physician myself, I couldn’t tell if what I had was something benign that would go away on its own (stomach flu) or an acute process that required urgent intervention (appendicitis). How can we expect our patients to know whether their chest pain is the same angina as usual or a heart attack, or whether their swollen ankle is a sprain or fracture?

My flirtation with the E.R. has made me more sympathetic to our patients who come in with seemingly “non-E.R.” complaints. It also has me thinking on the larger scale about proposed policies that impose penalties to our patients for using the E.R. Don’t get me wrong; there is a need for more primary care doctors, and our patients will benefit from increased access to primary care. However, patients don’t always know whether they have primary care versus emergency complaints. So I turned out to have stomach flu, something a primary care doctor can address. But had I been a “normal” patient, I wouldn’t have been able to treat my own symptoms and then walked into get a favor from a specialist physician—surely, I would have had to check into the E.R. to be seen. Would it have been fair to penalize me for that E.R. visit when it turned out that I had a less-than-emergent illness?

It’s important that our policy-makers consider that even well-informed patients with good access to primary care need the E.R. For our part, we as emergency physicians need to stop complaining about our patients and embrace our duty at the frontlines of medical care, sorting out all patient presentations and working to diagnose and treat all of our patients.

Portions of this article appeared in my column for CommonSense, the newsletter of the American Academy of Emergency Medicine. Thanks for reading; I welcome your comments.

6 Ways to Fight End-of Summer Blues

Summer is coming to an end. Feeling down around this time is quite common, especially for those of us who live in colder climates and can see the winter approaching. Here are 6 ways to fight those end-of-summer blues:

#1. Get sunlight. Seasonal affective disorder (SAD) affects up to 10% of people. You may not have full blown SAD, but use the same treatment—and the same preventive measures—to feel better. Soak up the sunlight. Open your blinds at home. Find areas at work that have natural light; perhaps take breaks in a room where the sun streams in or that’s near a skylight. Choose to walk the longer route on sunny days. Eat lunch in the park. Even if it’s chilly outside, the sunlight itself will help you.

#2. Exercise. Physical exercise alleviates stress and makes you feel healthier and happier in general. When you exercise, natural endorphins kick in that improve your mood. It may be particularly helpful if you exercise outside; a brisk power walk when it’s light outside will help you get fit, feel better, and soak up sunlight! Aim to have at least four-40 minute episodes of aerobic exercise per week.

#3. Eat summer foods. In the summer, we tend to eat healthier than in other seasons. Meals are filled with fresh fruit, raw vegetables, and big salads. Keep this up! Just because the weather is changing doesn’t mean we have to load up on the carbs. Aim to have three of these “summer meals” a week. Bring fruit and vegetable snacks to work instead of potato chips. Choose a salad over a carb-heavy lunch. A change in diet can help you feel significantly better.

#4. Sleep early and well. As it starts to get dark earlier, shift your schedule gradually to the earlier side. Make sure you are getting at least 8 hours of sleep every night. Waking up earlier helps you get more sunlight, and good sleep hygiene is essential to good physical and mental health.

#5. Keep reminders of summer with you. Display your pictures of summer vacation. Use lotions and scents with coconut and other summery smells. Light a scented candle, and break out the bubble bath. These little touches can make a difference.

#6. Make good plans for the rest of the seasons. Have some things that you are looking forward to in the fall and the winter. Perhaps it’s a vacation, or party, or other event--maybe it's as simple as viewing the fall colors. Celebrate the little things too, and treat yourself often. There are reasons to embrace the other seasons too! And if all else fails, summer isn’t that far the future again.

I'd love to hear your thoughts and comments about my blog and videocast. What do you use to combat those end-of-summer blues?

5 Medical Truths Your Doctor Wants You to Know

 Today's healthcare consumer is constantly barraged with conflicting information. Does wine prevent or predispose to cancer? Should I eat certain foods or avoid them? Is this new medication going to hurt me or help me? Many issues are still controversial, but there are some things that have a large amount of evidence behind them. Below are the 5 things that I want my patients to know:

1) Antibiotics will not help the common cold. Colds are caused by viruses, and antibiotics kill bacteria, which is a whole different type of organism. All of us have been through colds. We know that they are unpleasant--lots of sneezing, coughing, body aches, fever, feeling run down. All of us also know that colds will go away on their own. Some patients will swear that taking antibiotics will help them, but we know scientifically that this is not true; the cold is self-limited and was going to go away on its own anyway. Much better than taking a pill that doesn't work is to strengthen your immune system, and prevent the cold from happening in the first place. Get adequate sleep. Eat a healthy diet. If you do have a cold, drinking lots of fluids and taking tylenol and ibuprofen is key to your recovery--not antibiotics.

2) A CT scan will not help a headache. Having a headache, just like catching a cold, is unpleasant. Your head throbs. You might feel that you can't concentrate and go about your daily activities. While there are potentially serious causes of headache, the vast majority of them are due to tension headache or migraine. These will go away with time. Again, over-the-counter medications like tylenol and ibuprofen can help, as can rest in a quiet, dark room and lots of fluids. A CT scan will only show what you DON'T have, and, in the vast majority of cases, will not help make your diagnosis--and certainly won't make you feel better.

3) Every test has potential side effects. Patients often ask their doctors for tests to figure out what's wrong; in the same way, doctors often rely on tests to save them time of speaking to patients to make the diagnosis. The problem is that tests can only tell you what you DON'T have, and not what you actually have. Studies have shown that actually sitting down with the patient and talking to her will much more likely yield the diagnosis than any test. And every test has potential side effects.  CT scans involve radiation, and studies have shown that each individual scan increases your lifetime risk of getting cancer. Some CTs and MRIs involve administering contrast dye that could cause kidney damage. Even the simple blood draw can lead to complications like infection and bruising. This is not to say that you should never get tests done; it's just a reminder that tests are not always the answer, and that you should make sure you know ahead of time what the risks and benefits are of every test.

4) Lifestyle changes make a huge difference. Study after study show that the single most important contributor to decreasing your risk of heart disease, for example, is your lifestyle. You can take pills to decrease your blood pressure, lower your cholesterol, and control your diabetes--but even better is to eat a healthy diet with low saturated fat and exercising. Similarly, the single biggest risk to health that is preventable is smoking. Within even a few months of stopping smoking, the risk of cancers and heart disease begins to decrease. Don't get me wrong: it's not easy. Working on your lifestyle requires far more investment in your time and energy than popping a pill. But it's the most effective way to really make a difference in your health.

5) Aspirin is one of few medications that's been definitively shown to help you. Big pharma would like us to believe that the newest and greatest drug is the best thing out there to prevent heart attack and stroke, but actually aspirin is one of very few medications that's proven its weight. It reduces the risk of hear attack and stroke, and some studies are demonstrating that it may even be preventative against cancer. People who experience chest pain get aspirin first, before they get anything else, because it is the one thing that helps them if they are already having a heart attack. Not everyone needs to take aspirin, and there are some for whom it may be harmful (all medications, just like all tests, have side effects), but this is one more reminder that the newest and greatest isn't always the best; sometimes it's the tried and true that you need.

I hope you enjoyed these medical truths. Do you agree with them? Disagree? Are there other truths and myths that you'd like to share, or that you'd like me to look into? I'd love to hear from you. I am also starting a new YouTube Channel. This article appears as a video. Please let me know what you think!

Guest Blog: My Patient Safety Journey and a Tribute to Katherine Eileen

This week, I am honored to host a guest post by Dr. Julia Hallisy. Dr. Hallisy is the co-founder of the Empowered Patient Coalition. She writes about her daughter's battle for life and how it formed the basis of her work to advocate for and empower patients.

My daughter lost her life to an incurable cancer. Unfortunately, her journey was made even more challenging by life threatening hospital-acquired infection, misdiagnosis, and significant and permanent loss of lung function from septic shock. My husband and I knew that we were facing a great battle with Kate’s malignancy but we never counted on the ravages of medical error, miscommunication, and medical care that was fragmented and chaotic.

I promised Kate that I would finish the patient education and empowerment work we started together so that others could learn from our experiences and hopefully avoid many of the adverse events we faced. This was the beginning of my patient safety efforts, including the formation of The Empowered Patient Coalition non-profit organization. My patient safety journey has always been inspired by the strength and wisdom of my late daughter, Katherine Eileen. Kate taught us to search for our happiness, to choose to see the good in people, and to treasure every small kindness, every tender mercy – because there were many.  It was a joy to see the world through Kate’s view and even when her spirit was dampened by debilitating illness, she never let her own pain or sense of fear make her immune to the suffering of others.

Empowering patients to be informed and engaged medical consumers is a pressing and challenging goal for all health care organizations. Our organization provides many innovative consumer education materials, including “The Empowered Patient Hospital Guide for Patients and Families”- a free, innovative resource that offers practical information for the public to use in their quest for medical care that is safe, effective, and patient-centered. The goal of the hospital guide is simple – to present the public with practical tools and information to help navigate the often baffling and confusing world of hospital care.

Our current health care system is finally addressing the need for patients to participate in their medical treatment. While I am excited at the progress we are making, I am also concerned that we are changing the rules of the game and asking patients to step up to the plate without giving them the basic knowledge and skills they need to truly be members of the team. I know first-hand what it feels like to realize that you need to play an integral role in your child’s health care, but then struggle at the bedside because you don’t know the questions to ask or how to get the help you need. I know what it feels like to watch harm reach my child because I was not able to be an effective advocate. I work to share my hard-won lessons so others coming behind me have an easier journey. There is no reason for others to keep doing it the hard way.

When I arrived at my fork in the road and had to decide between a lifetime of anger and sadness and a path of advocacy in honor of Kate’s memory, there was no other choice but to choose Kate’s way. So, every day I work in patient safety efforts because I envision a health care system that will be able to prevent so many of Kate’s struggles, one that will support families when adverse events happen, and one that will include patients and advocates as valuable members of the health care team.

Thank you, Dr. Hallisy, for your courage and for your inspiring work. 

Are you a patient advocate? I would love to speak with you and to feature your story. Please use the comment below or contact me.

My Mother's End-of-Life Discussion That Changed How She Died

I am a physician. The hardest thing I’ve ever had to do was to end my mother’s life.

My mother was diagnosed with breast cancer at the age of 47. After a seven-year battle that involved multiple surgeries and countless rounds of chemotherapy, she decided that she had fought long enough. She didn’t want to suffer any more. Initially, I didn’t agree with her decision: she was still young; her doctors were hopeful; and there were still some therapies that she hadn’t tried. Over the course of many painful discussions, I became convinced that she had thought through everything. It was her choice to die peacefully and at home. She signed paperwork to this effect and entered home hospice care.

Unfortunately, as with many patients’ wishes, hers did not get fulfilled. One day, her breathing became labored. My father panicked and brought her to the local hospital. By the time I arrived, her blood pressure was dangerously low and she was barely breathing on her own. The ICU doctors were hovering, ready to put her on a breathing machine.

I could have never imagined how hard it was to ask everyone to stop their efforts and let my mother die. There was paperwork clearly documenting her wishes, yet the doctors and nurses asked me multiple times whether I wanted to change my mind. My father and my sister both knew her wishes too, yet they, too, were paralyzed by the thought of letting her go.

Since my mother’s death, I have been on the other side of these discussions as the emergency physician talking to patients and their families. I have learned that less than 30% of families have these discussions, and as a result, many patients end up with life-prolonging measures that are very likely to be against their wishes. As hard as it may seem to have such end-of-life talks in advance, it is many times harder when the patient is in extremis and the family is distraught.

Last week was the two-year anniversary of my mother’s death. In her memory, I urge you to have a discussion with your family members now about how they want to live, and to die. Make sure your doctor knows, and that you have paperwork documenting these wishes. That way, you will be able to honor your loved one’s final wish, and you will know what to do when you are faced with the most difficulty decision of your life.