Living Lupus by Andrea Witlin, DO, PHD.

How to decide which ER facility is best for YOU

Let's face it, when emergencies strike even the calmest, most level headed among us panics first and thinks calmly later. The first response always seems to be: "this can't really be happening to me, especially now!" We're always sure that we're overreacting and that this newest insult to our body will suddenly disappear. The truth is that sometimes we do overreact especially given our respective medical histories and their associated risks. But it's not our job as patients to overthink. Our job is to get seen as quickly and appropriately as possible and let the medical professionals sort things out. So first, we need to be prepared.

Preparation for your emergency:

OK, we've established that emergencies never happen at a convenient time, so how do we prepare and cope? Some of the examples below will depend upon the complexity of our respective medical conditions, family obligations, and geography. First, keep a list of allergies, your pertinent medical history, and medications (prescription and over the counter). Pre pack at least one day of your “key” medications (especially if you’re taking specific or uncommon disease related medications, brand only meds, or those that may not be readily available in a timely fashion). Don't worry about meds like vitamins or Tylenol. A day of vitamins can be easily skipped. Tylenol is either readily available or should be avoided depending upon your specific emergency. Wait until the emergency physician sees you if you have any doubt about what regular meds to take.

Have a bag packed and ready to go as if you were an expectant mother. You don't want to be running around looking for the right overnight bag or outfit to wear to the ER when you just fell down the steps! Likely you'll need to make a bunch of calls so make sure you have your cell phone charger handy to bring with you. Make arrangements with neighbors, friends, or relatives for rides to the ER, watching your kids (or picking them up from school), or feeding or walking your pets, etc.

Learn about your local ambulance squad. Are they volunteers or are they on site and immediately available for response. What is their response time? Is it quicker for you to get in the car and get to the facility of your choice? But let’s be real, if you are in too much pain, unable to move, or have lost consciousness, going in a private car (even with a driver) is not an option. In a true emergency, the local squad will take you to closest appropriate facility (not necessarily where your doctor is).  Do they charge extra for their services? Do they require dues or contributions for you to get their service? If so, this may cover the cost of your emergency services and will be money well spent. Lastly, put their phone # on your speed dial. Sometimes it may be best to call 9-1-1 from a landline phone (to facilitate identification of your location). Make sure to tell the triage operator your location especially if you are calling from a cell phone so that the closest emergency personnel will be notified in the timeliest fashion.

Types of facilities that treat patients in an emergency:

You don’t get to choose where you get taken when you call 9-1-1 (see box for examples). You will likely be transported to the closest facility that provides the services that you require. An exception to this “closest facility rule” can be when your “emergency” requires a specialized service that is NOT available at the nearest facility, e.g., an obstetric emergency or a complicated trauma or burn.

Another “technical or administrative” issue is what facilities are covered by your insurance and where your doctor has privileges. Remember, in a “9-1-1 type” emergency, go first, and sort the details out later. You cannot be denied emergency care for any of the above reasons. But, you may want to research these issues during your “preparation” phase.

So what types of facilities do you have to choose from? Many urban and suburban locations now have urgent care facilities for minor illnesses and injuries. They may be located in shopping centers, strip malls, or free standing locations. They are staffed by a physician (sometimes with emergency training) and so have been referred to as a “doc in a box”. Most have hours of operation from 9AM-9PM and no appointments are necessary. Some are affiliated with specific insurance companies, health plans, or medical centers. Likely, the facility will have basic X-ray available (that the physician “reads” while you are there). Depending upon the facility, “films” may be networked to a radiologist in a remote location. Blood work and cultures can be obtained, but need to be sent out for interpretation. Plan a “field trip” to your nearest urgent care center for one of those days when you are feeling well. Inquire as to what services they offer, if they are amenable to treating someone like you (and your level of disease complexity), and their respective hours of operation. Urgent care can be great options for sprains, strains, and broken bones; cuts, scrapes, and stitches; colds and flu; and earaches, allergies, and simple infections. These aren’t a substitute for a regular visit with your PCP or rheumatologist. They are also NOT appropriate for serious health conditions such as chest pain, stroke, heart attack, abdominal pain, or shortness of breath. If you are unsure about the severity of your emergency and/or your condition worsens while you are being seen at the urgent care facility, they will transfer you by ambulance to the nearest ER and you will have lost valuable treatment time!

Your nearest community hospital ER may be a little less convenient (you may have to wait longer to be seen) than the nearest urgent care facility but they will have on-site X-ray and lab (and thus more timely results). They will likely have other physicians (and specialists) available to call for consultations. They will admit you to that hospital if your condition warrants admission. But they may not have access to the complicated (and specialized) tests and subspecialists that our disease complexity may require. So as part of your “preparation homework” discuss these possibilities and choices with your PCP and rheumatologist in advance. They are your “go-to” advisors who know your specific conditions (and how they best match up to your local facilities).

A university or trauma ER may your best option depending upon the severity of your emergency and the complexity of your underlying disease. These facilities are staffed by board certified ER physicians and usually have multiple and varied subspecialists “in-house” who are readily available to respond to your emergency. They have complicated x-ray procedures available (CT, MRI), and likely have more laboratory options immediately available (than your local community hospital ER). The “downside” of these facilities is that they may be a little less personal. They also tend to be teaching hospitals (meaning that you may also be seen by students or residents). All in all these are a great “first stop” if it is likely that you will be admitted to the hospital, have a complicated life threatening emergency, and/or your physicians (or their associates) are on staff there.

Call 9-1-1 for sudden or unexpected medical conditions that could cause significant harm or death without prompt attention. (see table below for examples). In next month’s article, we will focus on what to expect when you arrive at your chosen facility.

Call 9-1-1 for problems such as:

Chest pain
Severe head injury
Stopped breathing
Severe shortness of breath
Loss of consciousness
Major burns
Severe bleeding
Vomiting and/or coughing up blood
Persistent vomiting
Change in vision
Suicidal feelings

*Living Lupus is a column providing helpful information to those affected by the day-to-day challenges of this complex and puzzling disease.  It is written for those with lupus, by those with lupus. If you have something you would like to share, please contact the Lupus Foundation office at 800-800-5776.

This current series on various aspects of emergency care is authored by Andrea G. Witlin, DO, PhD. She has been a practicing physician for 25 years and a fellow lupus patient.