Wall Street Journal Article > Dr. Sullivan's recommendations

Emergency Care - Improve Your Chances for a Good Outcome

There are several things you can do to help make your next ER visit, or your family member’s next ER visit, a success. Of course the ER physician and nurse will do everything possible to maximize the quality of medical care and minimize the possibility of medical errors. However, little has been offered to the general public in terms of participating in medical care, choosing the correct hospital, and influencing the outcome of the medical experience. You can have a positive impact on the outcome of your medical experience. The following recommendations may help you become an important part of the medical team:

Be proactive relative to your particular life situation. If you live in a small town you may not have medical alternatives. But those of you in medium to large towns may have several choices as to where you could seek health care. Call 911 for any acute emergency. However, in most cases you will not need to call an ambulance, and will be able to choose which hospital to drive to for emergency services.

1. If you have young children, identify the best hospital in your location for the care of children. Call all the local hospitals and find out which has superior pediatric services. For example, does the hospital have a section of the emergency department dedicated specifically to pediatrics? Does the hospital have a pediatric intensive care unit? Does the hospital have an orthopedic physician on staff that specializes in pediatric broken bones? A hospital with these services provides sophisticated pediatric care and may be the optimal destination when your child is ill.
2. If you are in mid-life, you may require cardiac services for a heart or other cardiovascular-related problem. Not all hospitals are created equal. Recent medical literature suggests that if you have a cardiac-related problem you may be best served by hospitals with 24-hour cardiac intervention services. This means that the hospital has cardiologists present to perform cardiac catheterization and angioplasty around the clock. If these services are not available in your location, you can be transferred to a hospital that does provide them. But where the heart is involved, usually the sooner the better. Transfers take valuable time that you may not have. Again, be proactive and consider these issues now, and identify the best hospital for the treatment of symptoms that are cardiovascular in nature.
3. Does your local hospital provide a full spectrum of cardiac-related services? If angioplasty does not work to open up your coronary artery you may need cardiac bypass surgery. You may be best served by the local hospital with both interventionalist services and cardiovascular surgical services. If interventional procedures don’t work you can always be transferred to another hospital for cardiac surgery. Why not be an informed consumer of medical services and consider these issues now? If you have the choice, consider using the hospital that can provide a full array of cardiovascular services.
4. Patients in mid to later life may be in need of care for a stroke or stroke-like symptoms. In cases of obvious stroke always call 911 for rapid access to the local emergency medical system. You should know that there are new therapies for stroke that may stop or reverse the stroke process. In recent years, studies have shown that clot-busting medications called lytic agents may, in a small group of patients, have a remarkable and potentially life-saving effect. Again, not all hospitals are created equal. The lytic medications can be remarkably helpful but can also cause dangerous intracranial bleeding. Therefore, these medications must be used according to a strictly controlled regimen. Some hospitals are qualified to use these medications for stroke and some are not. Some hospitals are actually certified in stroke care by the American Stroke Association and others are not. When researching which of your local hospitals are sophisticated in these various treatment areas, ask whether the hospital is certified by the American Stroke Association, or has a program to provide clot busters to stroke patients. Ask whether the hospital is a Primary or Comprehensive Stroke Center. Comprehensive Stroke Centers can manage the entire spectrum of stroke-related problems.
5. For those of you with students off to college, consider the likelihood that within 4 years your young adult family member may need to visit an emergency department. If the problem does not require ambulance transport, your child will probably have no idea where to go or what to do. Find out what hospitals are close to the school and explain what to do in case he or she requires a trip to the ER.

There are several things to consider when presenting to an emergency department for medical care. Always bring your medications or a medication list with you, and know what medical conditions you are being treated for. However, your participation on the ‘team’ can go way beyond your medication list:

1. It is important to consider the human side of both patient and physician in the face of an acute medical problem. In looking at a large number of ‘failure to diagnose’ cases, it is apparent that both the patient and the physician ‘minimized’ the likelihood of serious disease. As a result, the correct diagnosis was missed. For example, you may seek emergency medical care after experiencing a pressure-like feeling in your chest, which could be angina or a heart attack. Patients often explain, “It just feels like gas.” In fact, gas seems like a great answer because you would rather have a gas-related problem than a heart attack. The physician feels the same way. The physician also hopes that you are having a gas-related problem and may follow your lead toward the wrong conclusion. But when was the last time you went to the ER for gas? You can be an invaluable member of the team by carefully describing the new feelings you have developed. Don’t suggest conclusions and do not minimize the feelings you are having. It is critical that the ER physician has a complete understanding of what you are experiencing.
2. There are times when the patient simply knows better than the doctor. For example, if you have had a heart attack before, you probably know if you are having another one. Patients who have suffered from kidney stones absolutely know when they are having another attack. In one case reviewed by Dr. Sullivan a patient said to the emergency physician, “I am having a heart attack, it is just like my last one.” The emergency physician disagreed and discharged the patient. The patient thought the ER physician was wrong but did nothing about it. Don’t let the medical practitioner make that mistake. If you feel that the physician is headed down the wrong path, challenge him. If necessary get your family doctor on the phone. Although this may not be welcome news for many physicians, it is better to work through a challenge right away than to miss or delay a diagnosis.
3. Your vital signs. During your emergency department visit the nurse or physician will usually take vital signs. Vital signs are just that – vital! For most of your life your pulse, breathing, and blood pressure will fall into a safe physiologic range. A significant abnormality of one or more vital signs can be an important marker of a serious medical problem. Ask about your vital signs. If there is an abnormal number ask the physician or nurse to explain the reason for it. For example, your blood pressure may be elevated. That may simply be because you are visiting an emergency department! However, it may be related to a new onset of hypertension and your blood pressure should be rechecked at some later time. A pulse rate of 120 is very abnormal and you should not leave the ER without having it rechecked to make sure it is back to normal.
4. Know your families’ medical history and your own medical history. During your ER visit you may be asked certain questions about your family and your own medical history. If you have a simple laceration this information is probably not relevant. But in many cases it is. For example, if you present to a hospital with chest pain, it is important to know whether your parents suffered from heart attacks. The ER doctor always needs to know if you are pregnant because that is a risk factor for certain conditions, such as blood clots. Your history of surgical procedures may be critical to the current analysis of what is wrong. Always be prepared to offer this information when asked. If you are not asked, but you have important family or personal medical history, offer that information to the physician.

These suggestions can lead you down the road to better health. The vast majority of emergency physicians and nurses are highly qualified and competent in the provision of emergency care. Remember that the ER environment can be extremely hectic and overwhelming. You do not want to be making critical decisions in such an environment without having thought through the process beforehand. While it is impossible to be prepared for all of life’s contingencies, the vast majority of visits to the ED would be improved if the patient and/or their family members were better prepared.