Thursday, July 8, 2010

Lessons From The Local ER

When even the gravitational pressure from resting my head on a pillow became unbearable, I decided it was time for a visit to my local ER. Believe me: I did not look forward to this visit. When you tell someone in the ER that you have a migraine, they usually smile and nod, and then put your name at the bottom of the list with a little sticky note next to it that says "NO NARCOTICS." Little did I know that it was medical judgment -- not my medication habits -- that would get me in trouble this particular evening.

This was my first trip to the ER for a migraine, although I've been getting them for years. Since about 2008, my doctor and I have had them mostly under control with Topamax as a prophylactic (daily preventive medication) and Fioircet as a PRN ("as-needed" medcation taken right away to squash the headaches when they start). But this time, nothing worked. And I was honestly not sure how I would make it through the night with such intense, knifing pain. I know this is a cliche, but it really did feel like someone was trying to penetrate the area above my right orbital bone with an ice pick. Or it could have been a chisel ... anyway, you get the idea. It hurt. A lot.

Surprisingly, once I arrived at the ER, I got called into the triage area less than 10 minutes from when I checked in. "OK, I can live with this," I thought. The nurse took my vitals, which were pretty normal for me, and then asked me how bad my pain was, on a scale of 1 to 10. I didn't even hesitate. "10."

The nurse quickly and efficiently ushered my to room "number C" (that confused me a bit, in my addled state -- a number, and a letter, together ... never mind). After a few minutes, a physician's assistant, Stephanie, came in. She promised me pain meds and a CT scan. The former, I expected. I would have gotten down on my hands and knees and kissed Stephanie's feet for a shot of something, ANYTHING. But an emergent CT scan? At 9:30 p.m. on a Wednesday night? Hm. "OK, they pay those guys the big bucks for a reason," I told myself, and decided not to argue. Even though, in the last five years, I've had one CT scan and two MRIs, all completely normal. (Thank you, BlueCross & BlueShield of Illinois.)

Got my shot, went to the CT room. Not too much of a wait at 9:30 p.m. I think the tech was glad to see me, in all honesty. He looked bored, and was quite chatty. Once that was all done, it was back to the ER waiting room to (guess ...) wait for the results.

My husband, Geoff, and I had a bit longer to sit this time. But finally we made it into another curtained-off room. This time it was "Kevin," another PA, who came to greet us. As I expected, the test results were normal. Not that I really cared, because what I'd come for -- headache relief -- had arrived more than an hour earlier.

But Kevin had it in for me. "When you come in here and say your pain is a '10,' that means it could not get any worse," he told me. "That means you could have a gunshot wound and it wouldn't be any worse."

I just sat there, confused. "Well," I thought to myself (though I didn't dare share any of this with Kevin), the nurse asked me how bad my pain was. I rated it based my pain experience, and this was the worse pain I'd ever had, so giving it a 10 seemed a natural resposne." Based on my understanding of the pain scale.

Now Kevin was telling me that I'd mislead the medical personnel, which had caused an unnecessary CT scan, and unnecessary time in the ER for both of us. But that was based on his understanding of the pain scale.

I'm not about to say that I'm right, and Kevin is wrong. He is the PA, after all, and is trained in such matters. I'm just a lowly pre-med student, with aspirations of someday doing a rotation in the ER and handling just such a situation.

What I am saying is that there was a serious breakdown in communication. And a serious mishandling of that breakdown.

First of all, it was the nurse's responsibility to explain to me what she meant by a "1" and a "10" on that pain scale. I Googled it just now, and there is conflicting information on the Web. The National Institutes of Health simply states that pain of 7 to 10 is "severe" and "disabling" and intereferes with "ADLs" (the activities of daily living, such as eating, brushing your teeth, etc.). Another chronic pain Web site I looked at described people experiencing a 10 as "bedridden" and "possibly delirious." The site stated that "few people will ever experience this level of pain." These two sites obviously have different ideas about the intensity of a degree-10 of pain.

So ... who is right? Answer: It doesn't matter. What matters is that people on both ends of the scale understand, and are using, the same rubric for comparison. Otherwise, the results are meaningless. It's like transferring a hockey score to a basketball game, without using any kind of conversion factor. For example, picture this game score: Chicago Bulls -- 92; Chicago Blackhawks -- 5. Ummmm ... Who won? Right. Makes no sense. Because they're on a different scale, and the numbers mean different things.

It's about communication, first of all. And that communication was certainly lacking during my ER visit this week.

Beyond communication, working in any medical environment -- ER or otherwise -- requires some empathy and understanding. And Kevin just didn't have it that night. Maybe it had been a long shift, or a really hard day. I get that. But that's still not a reason to blame a patient for not "getting" something that wasn't properly explained.

When I think about spending time in the hospital, I usually think about spending time there as a volunteer, or a shadower, learning the "how-tos" of taking care of people. Developing a good "bedside manner," if you will. Hence the title of my blog. But sometimes you learn just as much by watching people and observing what you don't want to repeat. That was my experience this time around. And as unfortunate as it was, I learned an important lesson from it.

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