Should I Stay Or Should I Go? An emergency physician as an emergency patient… again.

Should I stay or should I go?iStock_000026176395_Medium

That’s the question I faced yesterday as I pondered whether I was sick enough to go to the emergency department for care. Yes, me. The emergency physician. You’d think such questions would be fairly easy, but they are far from such.

I’m sure people outside of my profession find themselves in similar conundrums when deciding whether or not they should seek care emergently or just wait to see if their illness is self-limited, as most are. Self limited means it’s going to get better on its own, so, basically, suck it up cupcake.

But, for those of us who work in the ED, actually venturing through the sliding glass doors as a patient is a little more complicated. We don’t try to make it that way, it just is. As providers, we see all those people who come in for our care in search of some magic therapy that will cure all their ills. As we assess them, our primary goal is to just make sure the afflicted soul doesn’t have some life-threatening malady. In addition, we try to offer them some symptomatic relief, most of which could be attained to a similar degree with over-the-counter medication and some bedrest.

Now, the last time I did a post about my own experience in the patient bed (Wearing the patient gown), I had gone to the hospital for chest pain and EKG changes. That was rather straightforward. No pondering needed.

Yesterday, however, my two days of a summer cold took a rather abrupt change. Driving 2 hours to take the minions to the Children’s Museum, I started off just a bit achy, thought my cold was just getting worse, but nothing bad enough to cancel the trip. Right around noon, I had some increase in the muscle aches (we call that myalgias), and felt like I was starting to run a fever. Also, not the end of the world. We stopped for some Tylenol and ibuprofen to treat the fever and the pain. Even with these wonder drugs, I actually had to leave the museum to lay down in the car while my emergency nurse fiancée weaved the children through dinosaurs and train displays. Still, going to the ED was not on my radar.

As we drove home, my thoughts shifted from, “Wow, I don’t feel well,” to “I bet this is what death feels like…”

I watched my heart rate hover in the 130s on my Apple Watch (yes, I’m an early adopter), even after my fever broke. At home, I laid down, my heart rate still in the 120s, then up to 148 if I stood up. Now, those vital sign changes can occur with fluid loss, such as working out in the heat, or vomiting and diarrhea, but I had none of those insults to my body. My respiratory rate was 22, which is also a bit elevated.

I provide you with all this background to say this. I have an entirely new respect for this entity known as SIRS (Systemic Inflammatory Response Syndrome). SIRS plus a source of infection is sepsis, which essentially means your body is really reacting to whatever infection it’s battling. Since one of my goals is to educate the public, I’ll teach you what the SIRS criteria are. You need 2 of these plus a source of infection to qualify as sepsis. Heart rate > 90, respiratory rate > 20, temperature > 100.4, white blood cell count > 12,000 or < 4,000.

Yet, despite all I know, my abnormal vital signs, and feeling like I had just been pummeled by Tito Ortiz in the octagon, I still debated whether or not I should go to the ED. Riding to the hospital, I wondered if I were overreacting. In the end, it was my rapid heart rate and my belief that some intravenous fluids would help me feel better that convinced me to enter under the sign titled: EMERGENCY.

Once inside, my heart rate did not magically improve (that was honestly my concern, because then I would have been declared a fraud!). My initial labs showed a white blood cell count of 25,000. Most of these were neutrophils, the subset of white blood cells that crank up in the presence of bacterial infection. While my x-ray was negative, my CT scan showed a pneumonia. Yes! I told you I was sick! So, pneumonia was my “source” of infection. That, coupled with my SIRS criteria, meant I had sepsis.

Two liters of iv fluids and some iv antibiotics later, I was on my way home. Did I feel better? Only ever so slightly that I was willing to rescind my DNR status (I’m joking). Actually, my fever and chills came back as I returned home, and I felt like death again. But, at least this time I had a diagnosis, and not a sissy diagnosis, either. Full-fledged pneumonia. Can you tell I revel in being validated as a “legit” patient? I woke up today markedly better.

There is a point to this story. Basically, when you feel so terrible, worse than you ever have, it’s probably time to be evaluated, even if you have the initials “MD” after your last name. Our bodies are remarkable at screaming at us when something is wrong. We just have to listen. What I had was early sepsis, something that is fairly easily treatable. But, without the fluid and the antibiotics, this would have progressed to severe sepsis or even septic shock. I’m convinced if I had not sought care from a colleague last night, I would have worsened to the point that I would be in the ICU today being treated for severe sepsis rather than sharing my good fortune with you.

What experiences have you had that left you with the thought you were glad you went to the hospital when you did?

MD, PA, NP: sorting the letters of health care providers

These days, there are so many different providers of health care, which one you’re seeing might be a source for confusion.  There are so many different letters involved, sometimes medical business cards are like a tornado of alphabet soup. There are MDs, DOs, FNPs, ACNPs, PA-Cs, and CRNAs. There may be more that I’m forgetting. On top of that, the various training levels doctors go through to become a “real” doctor is also somewhat difficulty for the public to follow. Let’s break it down.

I’ll start with the docs, since that’s the one I’m most familiar with. After 4 years of college and 4 years of medical school, these physicians graduate with a doctorate degree, either Medical Doctor (M.D.) or Doctor of Osteopathy (D.O.). These two types of schools are similar, but the osteopathic school tends to be more holistic, using some manipulative techniques to assist in healing the body.

After medical school, these young doctors go to residency. This is specialty training, and it lasts 3-5 or more years. Yes, even your primary care doctor, or the old term “G.P.” is a specialist these days. While in training, these guys are actually doctors (as soon as they get that M.D. or D.O. degree), but they aren’t ready to take care of patients on their own. Gradually, over the course of their training, they are given more and more responsibility and autonomy. After residency, most of these physicians will go out into practice, and a small number will become subspecialists, which requires a fellowship. During that time, these doctors are no longer called residents. They’re called fellows. Eventually, everyone ends up as an attending physician, the proverbial “real doctor” everyone at teaching hospitals wants to see.

As you engage the health care system, you will also encounter midlevel providers: nurse practitioners (NPs), physician assistants (PAs). In most situations, these people work under the supervision of a physician, but that varies from state to state.  These providers are a great resource, and help make more health care available to more people throughout the country.  Just like doctors, some are great, and some are not so bright, but that’s true everywhere. Most are very intelligent and provide excellent care. I would not hesitate to receive care from a good midlevel provider.

Nurse anesthetists (CRNAs) are nurse practitioners who work in the operating room delivering anesthesia to patients. Again, these folks usually work under the supervision of an anesthesiologist, although this, too, varies by state. The CRNAs are trained in all matters of anesthesia care.

In summary, medicine is a team sport these days. In an attempt to deliver quality but cost-efficient health care, there are an increasingly diverse number of players on that team. Don’t hesitate to ask questions about each person’s role in the care you’re receiving.

What interactions have you had with various or less-traditional providers?

What happened to the old ER?

It’s still called the ER by most people, but those of us who work there like to think of it as a department, not a room. Thus the term Emergency Department (ED) is what is used by those of us “in the know.” In years past, the ED was a place where you would go with an emergency and you might see some lackey just out of medical school, with very little training, taking care of real patients. So, ERs got a bad rap. The quality of care you were about to receive was a crap shoot. And, sometimes the dice were cold…

Times have changed for the good. In most EDs, especially in larger cities, you get your care from an emergency physician who has done 3-4 years of specialty training to be able to stabilize whatever emergencies show up at the front door. Mostly we care for the walking wounded and those with all ranges of illnesses, some mild, some severe, and everything in between. Health care has evolved to the point that the ED is quite the safety net for access to medical treatment. Doctor’s offices get booked up. Sometimes they want a little coin before they’ll see you. Or, you might be too ill for what they can handle in their office.

Regardless of one’s ability to pay, the time of day, or the number of other people seeking treatment, walk into an emergency department, and you will be taken care of. At least for your urgent or emergent medical needs. The sicker you are, the better we are. Crushing chest pain, sweating, trouble breathing? We’ll probably shine. Just wanting to get “checked out” for that nagging groin pain that has been there for 10 weeks? We’re not that full of awesome. Wanting a 2nd (or 5th) opinion for the itching teeth the Mayo Clinic, Cleveland Clinic, and Dr. House himself couldn’t diagnose? We’re probably going to disappoint you.

Sometimes a person just needs some relief from his symptoms. Not necessarily  a diagnosis. Often, we can help with that. We can provide some pain relief, reprieve from your nausea, fluids for dehydration. While we’re easing your suffering, our number one job is to make sure you don’t have an emergency that is life threatening. Often, we’re better at telling you what’s not causing your symptoms than what is. Because, simply put, we rule out badness. I may not know what is making your chest hurt today, but I’m going to do my best to make certain it’s not a heart attack or a blood clot in your lungs. When I discharge you with belly pain, I have tried to rule out that you had a process going on that requires surgery on an emergency basis. And, I’ll send you home with some instructions of things to look for that should bring you back. Try as I might, I sometimes miss what’s going on. For that, there are return instructions. If you were discharged for undiagnosed chest pain, and later are sweaty, have an elephant sitting on your chest and you can’t breath, go back! Sometimes we’re…how should I say this? Wrong.

So, the next time you’re plagued with an illness or injury that requires a trip to the ED, understand that you’re being cared for by a specialist. If you’re hurting, we’ll try to make you better. We’ll try to rule out horrible things that you really don’t want to have. And, we’ll try to direct you to your next best stop on your road to recovery.

On a personal note, how have you seen your local ED change over the past 10-20 years?