Sept. 22, 2008 -- I hope you never need to use the emergency room -- either for yourself or a loved one. But the truth is that there are more than 115 million ER visits each year in this country, so a trip to the ER at some time is bound to befall you or someone you know.
The ER has been lifesaving for many members of my family over the years -- my mother with a sudden heart attack, my father with dangerous heart palpitations and my son with a fracture and dislocation of his knee. My patients, including elderly nuns, end up in the ER for emergency care and attention, too. These personal and patient experiences have taught me a lot about how to get the best ER care.
The steps I will share with you may sound familiar. I have spent the past few weeks writing about the importance of taking charge of your own health, including collecting your medical records, getting the best hospital care and taking a health buddy with you.
So I couldn't help but respond to a recent research article that caught my attention in the July 2008 issue of the Annals of Emergency Medicine titled, "Patient Comprehension of Emergency Department Care and Instructions: Are Patients Aware of What They Do Not Understand?"
Researchers at the University of Michigan interviewed 140 patients or their caregivers about their recent ER visit. They questioned them about their diagnosis, treatment plan and instructions on leaving the ER. They then reviewed the medical charts. They found that there was a major mismatch between what the patients described about the visit and what was recorded in the medical record.
According to the study, more often than not, patients left the emergency room unaware of their diagnosis and instructions. Worse yet, patients didn't know that they didn't understand what was wrong or what their follow-up plan was.
If patients don't even realize they are uninformed, how can they ask good questions and take the best action when they get home?
It should be no surprise that not understanding your diagnosis and discharge instructions can lead to serious and potentially life-threatening and costly problems. An earlier study showed that up to one in five elderly Medicare patients are readmitted to the hospital within one month of discharge because they, too, didn't understand their instructions when they went home. The riskiest time to be a patient, it appears, is during the transitions of care -- such as on admission to and discharge from the hospital, emergency room or rehab setting.
Special Problems for the Elderly
I fear more for the elderly who come to the ER than for any other group. They often come alone, have multiple medical problems and a number of different doctors, and are often hesitant to speak up and ask questions. They often don't bring their medications with them or any other information other than their insurance card.
Let me share with you something that happened to one of my patients a few months ago. Patient A. was an elderly nun on many different medications, including digitalis, a common heart and blood pressure medication referred to as an ACE inhibitor, and a diuretic (to mention only a few). On the day of her ER visit, she suddenly became weak and had trouble getting up from her chair. The staff at her residence thought she may have had some diarrhea recently, as well, but was drinking lots of liquids (mostly water).
It turns out blood tests apparently showed she was low in potassium and her kidney function was a little "off." Multiple other tests, including an EKG and X-rays, were apparently OK. I examined Patient A. at her residence the following day.
Unfortunately, she knew very little about what happened in the ER. I learned about her low potassium and other tests from the staff member who went with her. When I asked what instructions she was given about her medications, taking extra potassium, and the actual written reports of her blood potassium and kidney test (I wanted to compare them to her previous test results) the ER apparently told the staff to "follow-up with your family doctor tomorrow."
I can't tell you how frustrating it is as a physician to be given so little information, yet be responsible for the patient's care. I needed to know so many things: What tests were done in the ER, what were the results, what were the conclusions, what treatment did she receive while there and what instructions was she given when she went home. ERs often don't send more than a photocopy of a preprinted instruction sheet home with patients and a few added instructions in difficult-to-read handwriting.
Tips for a Safe ER Visit
So what can you do to be sure that you not only understand what happened in the ER, but be sure you get the best follow-up care, too.
Bring all your health information with you. Your health history is the most important tool the ER physician has to help make the most accurate diagnosis. Carry an emergency health information card in your wallet along with your insurance card at all times. If you have started to collect your medical test results and consultations reports, bring them as well. This information may be vital to your diagnosis and care.
If you have nothing prepared or ready, then at the very least bring all your current medications (include over-the-counter ones such as ibuprofen) in their prescription bottles. A review of all your medications will give the ER doctor an important snapshot of the severity of your health conditions and how to treat you.
Bring a health buddy with you. No one, especially seniors, should go it alone in the ER. A health buddy can help give the medical history if you are too sick, take notes, ask questions, and assure that discharge instructions are followed. The nuns first taught me many years ago the importance of having someone accompany the patient into the examination room and stay by the bedside at all times. They call their health buddies "guardian angels."
Ask questions. As I have written before about asking questions and speaking up during a doctor visit: "If you don't ask, they won't tell. If you don't tell, they won't ask." Researchers have shown that if patients don't speak up and ask, often doctors will assume patients understand or do not want to know.
On the other hand, doctors can't know all that you are experiencing, so you need to speak up and tell all. Communication is a two-way street. Both patient and doctor need to provide the free flow of information. Questions should include what medications you should resume at home and which new ones should you take, what symptoms should prompt a visit back to the ER, and when to follow up with your family doctor.
Repeat in your own words what is wrong and what your plan of care should be once you get home. Do not leave the ER until you fully understand what happened, what is wrong, and what your care should be. The University of Michigan study found that all too often patients thought they understood what happened when they in fact did not. Your best bet is to repeat back to the doctor exactly what you believe happened and how you should proceed when you get home. Be specific about your medication plan, special diet or exercise, and when to follow up with your family doctor.
Ask for a copy of important tests or results to share with your family doctor. Many emergency rooms automatically send a copy of the ER report to the family doctor but only if they are on the staff of the hospital. Even then, this report can get lost or take a few days to arrive. I was not on the staff of the hospital that cared for my patient and I had no information to help me treat the patient I described above who came to the ER weak and was found to have low potassium. A copy of the lab tests and findings in the ER would have helped me determine what dose of potassium to use, the status of her kidney function and which medications I could safely continue. The nuns now automatically make it a habit to ask for a copy of important reports before leaving the emergency room.
As always, I welcome your comments, questions and your own personal experiences with the emergency room.
Dr. Marie Savard is an ABC News medical contributor. To learn more about Savard's health management system, download free forms and a sample letter to your doctor, visit http://www.drsavard.com and click on "Learn how to take charge of your health."