Surviving the Emergency Room, Part 7: The Grand Finale

The journey of our Surviving the Emergency Room series has reached its end. You’ve arrived, been triaged, and have seen the doctor. Now, the grand finale, what everything has been building to: just what are we going to do to you?

Fireworks

Your discharge won’t include these. Probably.

The Dispo

Your disposition, that is, what we are going to do with you when we’re done with our evaluation, is something we’ve been thinking about since you walked in the door. Getting patients out of the ER and into the appropriate aftercare environment is as important as treating their medical problems in many cases. Roughly 80% of you will be going home. The sprained ankle has been splinted, the laceration repaired, the abdominal pain found to be a bladder infection for which antibiotics have been prescribed. The remaining 20%, though, will need in-patient care.

The decision to keep you in the hospital is based on a number of factors: the severity of your illness, the need for surgery, the likelihood your problem will respond to out-patient treatment, the fact that your symptoms, though relatively minor, could represent a life-threatening condition and need to be closely monitored, (this is especially true if your complaint was “chest pain”, you are middle aged or older, and have risk factors for heart disease, like diabetes, hypertension, a long smoking history, and family members with heart attacks), and whether or not you have a safe place to go. If you are elderly and living alone, you could be admitted for a day or so until arrangements can be made to place you in a supervised living environment until you are able to care for yourself.

You might disagree with our decision to keep you in the hospital. It is your right to do so. We are not the police, the ER isn’t prison, and, provided you are competent to do so, it’s ultimately your decision to make whether to stay or go. We can only give you our best advice. If you choose not to take it you will be asked to sign an “AMA” form, indicating you have chosen to leave the ER against medical advice after having had the risks of doing so clearly explained to you. By signing this form we are shielded, somewhat, from liability should bad things happen that could have been avoided or mitigated had you chosen to stay. Refusing to sign it isn’t going to give you much of an advantage, because your refusal will be witnessed by another member of the staff and noted on you medical record.

It is also possible you will need to be transferred to a different hospital. Usually this will be for a “higher level of care”, meaning the services you need are not available at our facility. Examples of this are the psychiatric patient needing admission to a psych hospital and the patient with an obvious heart attack needing to go to the place with a catheterization lab and cardiac bypass capability. Or maybe you cut some tendons in your hand and we don’t have a hand surgeon on call. Whatever.

In some cases it’s an insurance issue. You have an HMO that contracts with a specific hospital, you are stable to be sent there, and you are willing to go. And, to be honest, it could be a lack of insurance issue. You have a problem that requires the services of a specialist and we don’t have one on-call because he doesn’t want the exposure to uninsured patients. We will evaluate and stabilize you in the ER, no questions asked, but we will have to send you elsewhere for definitive care.

The Discharge

If you are one of the lucky 80%, it’s time for you to go home. Before leaving you will be given an explanation of what just happened. This should include your diagnosis, your test results, and your aftercare instructions. Ideally this information is given to you by the doctor, but regardless of whom you are speaking with it’s essential that you pay attention, understand what’s being said, and ask questions if you don’t. It’s been a nerve-wracking experience, you are anxious to be done with it. Force yourself to focus for a few minutes longer.

If you are given prescriptions to fill, be sure you understand what the medicines are for and how they are to be taken. The pharmacist can help you with some of this later, but the more you know when you leave the ER the better. If you have restrictions and are going to need a note for work or school, now is the time to ask for it.

You will also be given specific instruction for follow-up. You will be told to call your doctor in a day or two, or return to the ER at some specified time. Don’t screw this up. The treatment you received in the ER may not have been definitive, the diagnosis, tentative. You need to follow up as directed to be sure you have the best possible outcome. We can’t always tell you what you have based on the ER visit alone. We can tell you what you don’t have, and we will have ruled out most of the really nasty things, but in many cases the final diagnosis will require further outpatient evaluation.

If you have been given pain medicines or other drugs that make it unsafe for you to drive, you will need someone to take you home. This is where Friends and Family are useful. If you are alone, we’ll call you a cab. We can’t legally dispense medications from the ER. You should make arrangements to fill your prescriptions on the way home.

The Aftermath

And so at last we arrive at this. Congratulations, you survived the ER visit and you are recuperating from whatever it was that sent you there. The experience is fading into a vaguely unpleasant memory. Then, one day, a week or so after the visit, you go to the mailbox and find a bill. Over the course of the next few weeks you get more bills. Bills from the hospital, from the ER doctor, the radiologist, the pathologist and from whomever else consulted on your case that day. The amounts are staggering. Don’t panic. Yet.

Your insurance company is getting the same bills. It will take more weeks for the bills to be processed and payments made. Only after this has been done will you know how much of the total is your responsibility. For an emergency visit that amount is usually very small.

If there is no insurance company involved please refer to the earlier post on The Insurance Card. Contact the various entities and make a deal.

If for some reason you were unhappy with your emergency room experience a note to that effect can be sent to the hospital’s CEO. Your complaint will be investigated and if there is substance to it, corrective measures will be taken. It is an interesting coincidence that many patients only realize their displeasure after the bills have begun arriving. Regardless, we take your comments seriously.

On the other hand, any compliment you might have will be greatly appreciated. Take the time to make a call or send a note extolling the virtues of the nurse, tech, doctor, or whoever made your experience bearable. We love that stuff. And who knows? You might see us again some day.

Wrapping Up

We hope you found this series entertaining and informative. An awareness of the concepts and procedures, the do’s and don’ts, and some of the why’s and why nots we’ve shared with you will definitely come in handy, should the need arise. Until then we wish you good health, good luck, and only happy accidents.

The Full Series

The Surviving the Emergency Room series can be found in its entirety on our blog. Thanks for reading, and feel free to send us whatever comments or feedback you might have.

Dr. Jim Pagano, MD, FACEP, is the chief medical officer of Precision Scribes and has over thirty years of emergency medicine experience. He’s seen everything an emergency physician can see, and more than a few things they should not.