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Topic: Emergency Rooms: More evidence of limitations (Read 627 times) |
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Bob_Johnson
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Emergency Rooms: More evidence of limitations
« on: Oct 15th, 2007, 8:07am » |
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While this report is specific to migraine I see no reason to consider that the outcomes would not be as poor--if not worse--for CH.
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From: HEADACHE (journal)
Less Is Not More: Underutilization of Headache Medications in a University Hospital Emergency Department
Posted 10/11/2007
Madhavi X. Gupta, MD; Stephen D. Silberstein, MD; William B. Young, MD; Mary Hopkins, RN; Bernard L. Lopez, MD; Gregory P. Samsa, PhD
Abstract
Objective: To gain knowledge of episodic headache patients who seek care at an urban university emergency department (ED), to evaluate the care they receive and to examine the impact of the ED on these headache patients.
Background: In the United States, 1% of all ED visits are for the chief complaint of headache. The ED has a significant role in the identification and treatment of primary headache sufferers.
Methods: Patients who presented to the ED with a chief complaint of headache were prospectively administered a patient survey, the PRIME-MD Patient Health Questionnaire, and MIDAS. Inclusion criteria: any patient 18 years or older with a nontraumatic headache of less than 1 month in duration. The patients included had episodic headache. Exclusion criteria: any patient with a history of a lumbar puncture or epidural procedure in the previous 7 days or those with chronic daily headache. Patients who met criteria were asked questions about headache type, health care utilization, satisfaction, co-morbid illnesses, and demographics. A neurologist independently reviewed the ED chart.
Results: A total of 219 of 364 patients were eligible and consented. The median age was 34. Most (147, 67.1%) were women; 104 (47.5%) were diagnosed with migraine or probable migraine by chart review; 36% did not have enough information for a neurologist to code a diagnosis. Relatively few headache-specific medications were used 24 hours prior to ED arrival. Only 5% of patients were on headache-preventive medication. Patients commonly received neuroleptics (dopamine antagonists 98 [67.5%]) or opioids (93 [64.1%]) in the ED; however, 74 (33.8%) subjects received neither medication nor IV fluids. Upon leaving the ED, 21.8% were pain free and 89 (40.6%) patients were asked to follow-up with a physician. A total of 137 (62.6%) patients had no documented discharge medications. One person received a prescription for a preventive medication. Sixty-four percent of those who returned the diary reported that the headache returned within 24 hours of leaving the ED.
CONCLUSIONS: MIGRAINE ICHD-2 CRITERIA ARE UNDERUSED, AND PATIENTS ARE UNDERTREATED IN THE ED. MANY PATIENTS LEAVE WITHOUT A DISCHARGE DIAGNOSIS, OUTPATIENT MEDICATIONS, OR INSTRUCTIONS. ED PHYSICIANS COULD HELP IDENTIFY THE MIGRAINEURS AND CHANNEL THEM TOWARD APPROPRIATE OUTPATIENT TREATMENT.
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| « Last Edit: Oct 18th, 2007, 8:47am by Bob_Johnson » |
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Bob Johnson
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midwestbeth
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Re: Emergency Rooms: More evidence of limitations
« Reply #1 on: Oct 15th, 2007, 1:42pm » |
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Went to the ER once about 12 years ago for migraine. Never again. I was treated like a drug seeker / hypochondriac.
Since I've had ch, my hubsand has begged me a couple times to just go to the ER. Never going to go there for ch. I would rather be at home in agony than in the ER where I would not get the relief I was seeking.
Beth
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clusterwife
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Re: Emergency Rooms: More evidence of limitations
« Reply #2 on: Oct 15th, 2007, 7:30pm » |
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Yep, bad choice. We went there, the nurse was so rude, like he was faking it. All I can say is, karma's gonna get her. Leah
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VinceFromOhio
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Not tonight - I have a headache
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Re: Emergency Rooms: More evidence of limitations
« Reply #3 on: Oct 15th, 2007, 7:31pm » |
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I too have been treated as a "drug seeker". Generally, I won't go to the ER unless I've passed "hour five" of a hit. If I can't beat it myself using Imitrex, O2, ice, compresses, etc....and I'm still suffering at the 5 hour mark, I generally give in to an ER visit.
The last time I went, my wife drove me there. When I walked in with my towel pressed against my right eye and rocking back and forth, I'm just sure they thought I was a doper going through withdrawl. Without asking many questions about things that had worked for me in the past, the young ER Doc - after establishing that I HAD been treated for CH before - informed me he had cleared me for morphine. I immediately scolded him, "Are you KIDDING ME?!? Opiates and strong pain killers just get me STONED....the headache is STILL THERE and I can't FIGHT IT!!!!" I asked him for my usual ER treatment:
a) plastic syringe of lidocaine up the right nostril
b) 60 mg of Toradol (intravenously)
c) 25 mg of Phenergan (in the same IV, to keep me from getting nauseous from the Toradol)
d) O2 - although I now have this at home
Now, this was an UNDERSTANDING ER physician. Most of the time, you get idiots who have NO IDEA how much you're suffering. You say "Cluster Headache" and they look at you like you're out of your mind....or say something like "Oh, a Cluster Migraine?" The Toradol is a non-steriodal anti-inflammatory that seems to abort within minutes. I asked for it in pill form but my doctor told me it wouldn't work the same.
Funny sidenote about the ER:
Once, I was attended to by a female emergency room physician. She saw how much I was suffering, and immediately began suggesting Demerol, Oxycodone, etc...
I replied, no those won't work. She became VERY insistent, "Those are the STRONGEST things we can give you!"
In the heat of my pain and agony, I said....trying to be POLITE, "No, sweetie, you don't understand, pain killers don't work for......" Well, that's all I was able to get out of my mouth. In spite of the fact that she was standing in front of a human being suffering pain akin to childbirth, she TORE INTO ME for my use of "SWEETIE" while addressing her. She screamed, "SIR I'M A MEDICAL DOCTOR, NOT SOME COCKTAIL WAITRESS". I was nearly in tears trying to apologize....I hadn't meant anything bad by it....and yes, I did use "sweetie" because I was addressing a female who was younger than I, but I didn't mean it in a sexually condescending way. I WAS IN THE MIDDLE OF A MAJOR HIT.....which had lasted more than 5 hours.
Anyway....sorry this is so long. My solution to the ER problem: I had my family physician write me a permanent letter. I take it with me to the ER if I have to go. It's not a "prescription" per say, it simply states "This is what I recommend for this patient if he's coming to the ER complaining of a cluster headache attack". His letter basically states the treatment I already detailed earlier in this post. DON'T BE AFRAID TO ASK YOUR DOCTOR FOR A LETTER LIKE THIS. If the ER staff thinks it's fake, they can always call him. Lastly, it helps when you're not there to ask for narcotics.
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| « Last Edit: Oct 16th, 2007, 8:26am by VinceFromOhio » |
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RayU
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Re: Emergency Rooms: More evidence of limitations
« Reply #4 on: Oct 18th, 2007, 3:08am » |
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I was in the US (Sugar Land TX) earlier this week and got hit - didn't have anything with me as I wasn't expecting it for another 2 months. It was 2am in the morning (neighbouring hotel rooms obviously thought they had a screamer living in room next door...)
Was due to fly back to London later in the morning and knew there was absolutely no way I could fly without having an abortive - so after riding out the cluster I ventured out to nearest ER. Arrived in ER at 3.30am looking rough and no longer in pain. Triage nurse initially thought I was there for some good pain meds, but when I got to see a doctor he knew condition and understood! Gave me prescription for as much Imitrex as I wanted and a letter for airline.
Got hit again on flight back to London but fortunately had injections with me.
Long story short: had a good ER experience.
(The $$$ it cost to fill the prescription was not a good experience though....)
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