Monday, December 10, 2012

The Emergency Room

When you have pancreatitis there are certain things that you can't manage to avoid, like the Emergency Room. I've spent a lot of time there in the past few months and I've come to know it quite well. So, I present the following examination of a typical Emergency Room visit for pancreatitis for your reading enjoyment.

The first step of the ER visit is making the call that you cannot handle the management of the flare at home anymore. This can be indicated by several different factors. For example, one might not be able to keep anything down, including medications, or, one's pain medication may not be effective against how much pain a person is in. By the time someone with a chronic condition makes the call that they cannot handle their condition on their own without medical intervention, they are in bad shape, this is not a "I stubbed my toe and I might have the flu too" kind of ER visit.

Then there is getting to the ER. I have learned that once a flare has gone past a certain point public transit is not an advisable transportation method. People don't seem to enjoy it when their fellow passenger is curled up in a ball in pain or fighting back a severe urge to vomit, not always entirely successfully. Typically, finding someone to drive you to the ER is the best option. Ambulances may be warranted under extreme circumstances, but luckily I have yet to encounter the need for that. Addendum: I have however been in an ambulance, I even knit in it. I was sad that I had to be strapped into the stretcher and like bolted to the floor, it was kind of a cool way to go from hospital to hospital. At least I can say I did it.

I am now going to use my preferred ER as the example of what happens when you get to the hospital. Knowing that each hospital is a little bit different, knowing that this is based off of one in particular might help. For those not in the know about which hospital I go to, you can have fun trying to guess which one it is based on its idiosyncrasies.

When you are walking into the ER there are doors that open automatically for you like magic. This is because there is a security desk right by the door and there are cameras that show them when people are approaching. It is kind of cool because then as a disabled person you don't even have to push the button, the doors just open, kind of like a crowd making way for you. Right as soon as you get inside there is a triage and registration station. It's partially glassed in, except for where you interact with anyone, so it isn't actually very secure or effective. The first question that you get asked when you walk in is by security saying "Are you here to see a doctor?" The security people manage the flow of people to triage. Most of the time I end up staggering in the door looking like absolute crap and using the little will I have left that isn't being spent wishing for better pain medication 2 hours ago if not sooner, to sit in the triage chair.

The triage nurse then asks the awesome question of "Why are you here today?" My answer rarely varies "I have chronic hereditary pancreatitis and it is flaring up" This is then qualified by some of the symptoms that would indicate that such as vomitting or pain, ability to keep food down. Then they ask when it started, take your heart rate and oxygen saturation, also your temperature. They also ask questions like "Who brought you here?"and "Have you been here before" recently the answer to that one is usually yes, and more recently than I like to admit. Triage is usually pretty brief though, it's just meant to assess how close you are to death and how urgently you need to see someone. While being in massive amounts of pain sucks, I am often not deemed to be in immediate danger of death, and score roughly in the middle of the triage scale, serious, but not emergent. The nurse also usually tells me that I'm not allowed to eat or drink anything from that second on, which really sucks because I know my pain meds are going to wear off before I manage to see a doctor and things are going to get even worse for me soon.

After triage you wait for two seconds for the nurse to pass your information to the registration clerk and the registration clerk to call your name. The registration clerk verifies that your chart is right, your address and doctor are right, and then places a bracelet on your arm identifying you as belonging to the hospital. The bracelets in this hospital are kind of cool because they put down who your doctor who is responsible for you is and which area of the ER you are going to, so you can have some idea of how seriously they are taking you, and how long it might be until you see a doctor. Then you go and sit in the waiting room. It is really really hard to sit on an uncomfortable chair when the pain meds are wearing off and everything hurts and there is nowhere to get comfortable. This ER has a giant TV I suppose to distract people for exactly that reason, but it isn't captioned so it isn't accessible. Plus, no one really wants to watch Judge Judy on some talk show anyway. Your wait time here could be 5 minutes or 2 hours. Sometimes they know how long it will be and will tell you, sometimes you are playing the mystery guessing game getting more miserable by the second. The one perk to the waiting room however is the people watching. This hospital often has many cases of alcohol or drug users and they are sometimes entertaining. It is also interesting to overhear phone conversations or in person conversations with people waiting and to hear some of the things that people come to an ER for. One time a girl was complaining that she was told she'd probably wait 6 hours to see a doctor because she broke her toe two days ago. I'm not sure how it became an emergency, but her outrage was quite amusing.

Then you are called back into the ER. If there is anyone with you they will not be allowed to come in at this point. They lead you past many cubicles filled with sick people like yourself, until you are placed into your own cubicle. Then you get told to undress entirely from the waist up and put on an ugly hospital gown. In some cubicles the curtains are complicated to work and it requires some creative positioning to ensure modesty. Naturally as soon as the nurse comes back, they have no issues with the curtains and then you feel really stupid. Inside the cubicle there is a stretcher, typically a chair for a visitor, somewhere to hang an IV pole, and a vitals monitoring system. There is also various life saving equipment like oxygen and things like that poking out from the walls in case you suddenly start to become closer to dying than they originally thought.

Once you have changed the nurse comes in and demands to know why you are here. This particular hospital also has an abuse program so they take advantage of the fact that they have separated you from whoever brought you to ask you if you are being abused and feel safe in your living situation. That being said, I think they would get more disclosures if this wasn't done in a monotone robotic way that implied they were asking because they had to and not because there was any desire to listen should there be something to say. They also ask about allergies, previous health conditions and try to take a history both a general one as well as a history of how you ended up in the ER that day. I bring along a host of paper with a lot of that information printed out because under pressure I don't do a good job remembering the things I'm allergic to, what medications I take at what dosages, or even what all of my diagnoses are anymore. I also find that doctors and nurses really appreciate that. Then, I argue with the nurses about doing my blood and starting an IV because I'm allergic to every adhesive under the sun except for one they don't stock in the ER so I have to carry it with me. Only, the nurses hate it because it doesn't let them see the IV site, but it is kind of that or no IV site so they can't win. I do. Then they struggle to poke holes in my arms and find my veins to steal my blood, and I kind of enjoy that part because it is a good distraction from everything else going on in my body since I'm still without pain meds. Then once they do that they take all of your vital signs again and abandon you.

Sometimes the nurses will go away to confer with the doctor and come back for more tests, more blood drawn etc. before the doctor sees you. Other times it is just an endless waiting game waiting for the doctor. Usually at this point you are allowed to be reunited with whoever brought you to the ER so that you aren't at least forced to endure waiting on an uncomfortable stretcher in pain with a not warm enough blanket wearing a stupid hospital gown and various medical monitoring equipment all by yourself for hours on end.

Then the doctor shows up, and they try to take your history all over again. Then I point out they have it from various discharge summaries and my own medical summary. Then inevitably they ask me how I got pancreatitis. I really worry about doctors when they don't understand what hereditary means. I know it is super rare to get it that way, and to see it next to pancreatitis, but there ought to be some comprehension of what the word means. Inevitably the doctor will suggest that sometimes with pancreatitis you just need to get on top of the pain and nausea so admission isn't guaranteed so they will play it by ear. I am now often asked what pain medication I would like and the dosage. It is then still at least another 20 min- 1 hour before I actually get pain or nausea medication. Then I usually have to argue with the nurse that I really do need the full amount the doctor prescribed because I really am in that much pain, just years of dealing with this disease mean that I hide it well. Then we wait. Sometimes an hour later we do more pain medication. Often they decide to call in GI. Then GI doctors show up and do all the exact same things that the other doctors have done already. They decide that hey! I'm having a pancreatitis flare, and I need pain medication and fluids. They also decide that I should have some x-rays or an ultrasound to see my pancreas and if I have stones or if my stents have pulled a disappearing act or are stuck somewhere they shouldn't be. Then, they decide to admit me, which was the end game from before I walked into the hospital anyway, but we had to play by their rules. Admission though is the part where the ER ends, since hopefully once you are admitted there will be a bed waiting for you on some part of the hospital very shortly thereafter.

And that is more or less, the typical ER visit with pancreatitis. Or for most serious but not deadly things, like pretty much any GI disorder.

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