A Day and A Night in the ER

 Welp, it's happened again. After waiting longer than I should have, I called the advice nurse about my increasingly uncomfortable condition. She said I needed to be "seen" within the next four hours; I should go to Urgent Care or the ER. Mkay? The nearest Urgent Care run by my HMO was 47 miles away. There is a Primary Care run by another outfit in my little town, and as it happens they take my insurance, so I've been able to go there for immediate care, but not this time. They wouldn't be able to see me for at least 24 hours. Low on staff, high on patients. Mkay? 

So the choice was the Urgent Care way out there. They could see me in a couple of hours.

I got there and was informed they were running behind, but they'd get to me as quickly as they could. It was only about an hour later (c. Noon) when I was called in to the examining room. BP and temp were OK; I was alert, coherent, ambulatory -- with some difficulty. Described symptoms and problems.

"Dude, you need to go to the ER, stat."

Oh fuck. I hate the ER. Nothing but turmoil, stress and strain, lack of care, waiting and waiting and waiting while the place fills up with more and more suffering, disease, madness and pain. What is the point. 

The nearest ER as it happened was another 15 miles or so away, and the Urgent Care said they would call over and let them know I was coming, and they said it would probably be less of a wait there because they would probably have fewer patients.

Mkay. We get to this ER, and truth was there were hardly any patients in the waiting room. Five, maybe six. Most had already been triaged. Some had been seen and were waiting for test results.

It was calm. Very little obvious suffering. Quite a few people came in while I was waiting for triage (c. 30 min). Nearly all were members of one family there to see their relative who was being treated inside. They were allowed in two by two. 

Triage was straightforward, and I was told to wait in the lobby. They'd see me inside as soon as they could. 

More patients came in while I waited. More visitors came to see the one special patient as well as other patients in treatment. Some of those who arrived were in really bad shape. Extreme pain, unable to walk, one couldn't even sit and her wheelchair ride was torture for her. Some appeared to be having strokes or heart attacks. 

And believe it or not, all of those I saw in serious distress were treated promptly and compassionately by the very young staff, none were left to linger unattended. Some were treated directly in the lobby, others were wheeled or ushered into the ER treatment areas, but none were neglected.

This was astonishing. I have never been in an ER where staff did not neglect the patients, ignored their suffering, even disparaged those who sought treatment. I have never been in an ER where prompt treatment of severe conditions was the rule. I have been in ERs where staff had no interest in or consideration of patients waiting, and where patients died while waiting without any care at all. The cynicism and contempt for patients in some ERs I've been in has been off the charts, and it's happened so often, in so many different ERs in California and New Mexico, I took it for granted as just the culture of these places. It's outrageous, but there you are.

This was an entirely different situation altogether. I didn't need immediate treatment, though I would have appreciated the pain medication I eventually received had it been administered while I waited. I got an xray within an hour of arrival, but had to wait to be "seen." My distress was minimal compared to some of the patients who sought care, and everyone who needed immediate care received it compassionately. Those of us who had to wait mostly did so with equanimity; so many others were in much worse shape than we were.

After about 5 hours waiting in the lobby, I was called in to the treatment area and assigned a room where I was introduced to the nurse and CNP who would be treating me. Both were kind and positive. As it turned out, the nursing staff would have a shift change in an hour, but the CNP stayed with me throughout. 

Treatment would take just about 8 hours.  During that time, I received a CT scan, pain medication, Ringer's lactate, anti-nausea and anti-inflammatory medication, and two different treatments for the condition I was there for. Neither was fully effective while I was there, but I was discharged with a prescription for another medication to take if the ER treatments didn't work within the next 6 hours or so.

When I read the after visit summary, I noticed that the CNP had missed a finding on the CT scan -- I had a hernia -- which which was probably a contributory or precipitating cause of the problems that sent me to the ER. Oh. I suspected the hernia, and I pointed out the odd swelling and pain in my groin, but it was not recognized by me or anyone else for what it was at the time. The CNP said it was "gas". And I saw on the CT scan report that there was considerable build up of "gas." But missing a hernia with obvious symptoms (I realized later) was odd. 

The treatments that were administered in the ER did work effectively the next day at home, so that part of the problem was taken care of, thankfully. The hernia has not been addressed yet, though the swelling and pain are not as severe.

It seems to me, I've had this condition before -- a hernia, that is -- and after several weeks, it self-repaired. We'll see. It's not fun, but it's bearable. Primarily it limits my movement. 

What I can say about the overall experience in the ER this time is that it was worlds better than any ER I've been in (for myself or on behalf of others). Even though part of my problem was missed by the staff, or perhaps not missed but dismissed as not that important, I was treated with consideration and respect, was given needed medications and treatment, was tested and imaged to a fare-thee-well, and discharged with explicit instructions and medication prescriptions with orders to return promptly to the ER if none of it worked.

Well, it did work, and I'm grateful.

Now to deal with the hernia... 🤪

Meanwhile: Medical Update

Today's results are... ambiguous.

Pulmonologist says X-rays show marked improvement, however... there are signs of scarring. He's concerned as well that the pneumonia is not completely cleared up, so he's put me on another ten day antibiotics course. He says it could take yet another 10 days beyond that to kill it, given the way he (and I) believe I acquired it [Note to self: do not aspirate stomach contents!] But on the other hand he says there is no sign from smears and blood tests that I have TB, and he doesn't suspect it at all. He wanted another blood test and a chest X-ray in a month.

So this afternoon, I see the infectious disease specialist for the first time. He's quite bemused by the whole affair which tends to lighten the mood somewhat. He says there is no sign -- at all -- that I have TB, but he can't rule it out completely because the skin test was never "officially read." Yes, he says, I clearly have pneumonia, and yes, it is responding to treatment though it is stubborn as heck. Instead of waiting a month for another X-ray, he says that I should have one as soon as I complete the next course of antibiotics, then come back to see him and "we can discuss progress."

Naturally, the antibiotics that were ordered this morning are not ready at the pharmacy, so I may not be able to start taking them until tomorrow. The pharmacy is "behind." Yes, well. This is Kaiser, and anyone who uses them has their own horror stories. Not having a prescription ready is hardly the worst that can happen or has happened there.

Overall, truth to tell, I'm pretty pleased with outpatient care of my condition. It's a bit chaotic to be sure but manageable nonetheless.

For the time being, the IIED suit that I was preparing to take to my favorite plaintiff's attorney is on hold.... heh heh heh.

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Note: While I may seem to be cavalier about all this, in fact I know it's nothing to make light of. Even if my healthcare coverage is through Kaiser Permanente, and it may not be the best, at least I have health care coverage, and if I choose to use an alternative urgent care or med clinic, I can afford to do so. That's not the case for many tens of millions of Americans. So I'm lucky compared to many. While I may not be happy at the way I was treated -- and not treated -- at the Kaiser ER a couple of weeks ago, I have seen with my own eyes ERs that do much worse, that cannot handle the crush of patients at all and that seem to thrive on neglecting patients rather than treating them.

There is something deeply wrong with the practice of heath care in America. It goes back many decades, and nothing that's been proposed to date is capable of really reaching, let alone dealing with, the underlying problem. Our heath care system is not set up to deal with patients as people/individuals. It's set up primarily to serve the interests of industry. Hospitals, doctors, administrators, nurses all are served first and foremost. Patients are, for the most part, an afterthought if that. Our health care system, in other words, is upside down, and it has been that way for decades. It's a sad thing to witness and experience, but it's really all we've got -- if we're lucky enough to have access to it apart from whatever happens in the ER.

I resist hospital care because I've seen again and again, and I've personally experienced, how truly appalling it can be for the patient. I know too much of what goes on, how neglect is built in to the hospital care system, and how recovery is essentially impossible in a hospital setting. I don't mind outpatient and clinic care because I have seen and personally experienced how it can be -- but isn't always -- better for the patient to obtain necessary healthcare as an outpatient. Mistakes can be and are made no matter what, but outpatient care is more oriented toward the patient -- even if treatment takes longer and is more complicated to obtain.

But the crying shame is that so many people don't have access to anything but the ER. And they will be lucky to get through that alive and not immediately bankrupted.

Health Care Update

Spent a good deal of the morning being worked up and lectured by my primary physician and a resident. They still "suspect" I have TB and claim the skin test I demanded from the ER isn't "valid" because it wasn't "officially read." In fact, it was my primary physician's office that said -- on Monday -- it didn't need to be "officially read." Needless to say, I had some choice comments about doctors who think they're gods and can't be bothered following the simplest procedures.

The lecture had to do with the fact that TB is a public health issue -- which I was pretty sure of -- and that if I continued to refuse treatment (which I never have done), they would be forced to report me to the County PHS and have them follow up. By law. Etc. Etc. So I explained, again, that I was not refusing treatment, I was refusing hospitalization, and that my experience in the ER had been deplorable, yadda yadda. This does get old after a while. He wasn't there, he knows nothing. Too bad, so sad. CYA.

Well, things seemed to settle down, and the physician actually calmly and coherently -- and (I think) truthfully -- explained that he didn't know and couldn't tell what was wrong with me, but he suspected pneumonia (since I was responding to antibiotics) on top of another condition which, given my history of smoking and asbestos exposure, was quite possibly cancer. There was a clearly anomalous mass in my lung -- which could be cancer, TB, or simple pneumonia. But the blood I keeepcoughing up was a sign of something serious, but what, he couldn't be sure. I gave them a sample for culture. They want two more.

He scheduled me for a pulmonary specialist this afternoon and an infectious disease specialist in a week. Clearly, the TB diagnosis is low priority.

There will be a number of tests more, including a likely biopsy.

It's a strange sensation at this point. I am really angry at their continued inappropriate suspicion that I have tuberculosis, when I haven't even been exposed to it -- according to the very obvious negative results of the skin test, which was never "officially read" because the doctor's office staff assured me it didn't have to be. How dare they threaten me over it. How dare they?

On the other hand, I'm rather sanguine over the potential of a cancer diagnosis. It wouldn't really be that much of a surprise. Not something I want, to be sure, but if that's what the gods will, then that's it.

So, more update after I see the pulmonary guy.

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That went well. Surprisingly, given what I've been through to this point. The pulmonologist was not alarmed in the least, said as far as he could tell, what I had was incipient emphysema -- from past smoking -- and "simple" pneumonia. The blood I'd been coughing up is most likely a consequence of the pneumonia and nothing more. He said the CT scan showed that all the airways were open. He said the other doctors probably couldn't tell because they weren't trained to read lung scans the way he was and their alarm was probably overdone. He was annoyed that my primary physician didn't bother to read the TB skin test within 48 - 72 hours of administering. But he accepted my description of negative results (no reddening, irritation or bumps). Since he does not suspect TB in any case, he isn't too worried about it. I may have to get another test, however, when I see the infectious disease specialist next week. I need to provide two more sputum samples (good luck!), but there is no rush. I'm scheduled for a chest x-ray next Wednesday. The chest guy thinks it will be pretty clear. If it isn't, I'll be scheduled for additional followup, but if it is, then that's pretty much it.

What a difference from what I'd been through earlier. Doing the necessary exams and tests as an outpatient may take a little more time, but it's been my experience that outpatient medical services are usually better for the patient than in-hospital service. Too much can go wrong in the hospital for one thing, and for another, issues tend to be treated as crises, all the time. The patient is nothing but an object under the circumstances, and that severely affects the ability to recover. Recovery may be completely impossible in the hospital.

A week or so more, and this episode should be resolved. I'm hoping.

Recovery Update

So far, so good, though it's a rougher course this time.

Antibiotics are working, as they have in the past, but the course of recovery is not as smooth as I might like. No sign of blood in the lungs has shown up since I went to the ER, but nothing at all has come up since then, either. UPDATE (02/09/11, 11:00am): A small amount of blood has just come up. Sigh. The TB skin test is negative. I'll do outpatient follow up with doctor on Friday, a few days before the antibiotics run out.

Thinking back, I'm pretty sure how I got pneumonia in the first place: aspirating stomach contents. When it happened, I convinced myself that I hadn't breathed in what had been coming up, but I was wrong. It was a very strange experience to say the least. Anyway, the first attempt at recovery seemed to work, but the pneumonia came back, worse than before, and now I'm going through another course of antibiotics.

There may be some other issues as well. I haven't discussed it with doctors, but I should. For about 2½ years, maybe three, I was working in an asbestos saturated environment -- unbeknownst to me at the time. I breathed in asbestos dust every day, sometimes quite a lot of it, and only years later did I find out what I was breathing and how dangerous it was. I haven't smoked for about fifteen years, but I smoked heavily before that. So that may be a contributing factor (I have discussed my previous smoking habit with physicians.)

First things first: take care of the pneumonia (please!), then deal with the potential other problems.

New Mexico? Not This Week (end)

Clearly Ché has messed where one doesn't mess, and he's not going to New Mexico this weekend.

Oh no. As I was putting the finishing touches on my packing and such last evening, I started coughing up blood, and I spent the rest of the evening until well into the early morning hours in the emergency room of my semi-convenient Kaiser Permanente hospital.

I got there 6:15pm or so, was given a face-mask by the reception desk, was ushered into the triage nurse promptly, was then shown a "positive pressure" room in which to disrobe and await (a few minutes I was told) treatment. I waited two hours before anybody came at all, a nurse who read back what I'd told the triage nurse, only they both got it wrong. After correcting the record, the nurse went away. I saw no one else for another hour or so, when the first physician arrived, did a cursory inspection, ordered up a chest x-ray and blood work. Said if the chest x-ray was inconclusive, they'd do a CT Scan for positive diagnosis. Soon enough, he showed me the chest x-ray, and behold: there was a mass in the upper right quadrant of my lungs. He could not tell what it was; I was taken for the CT Scan, protesting loudly about my allergy to the dye. Doc says, "No dye! No dye!" And when I get to the scanner, the operator asks if I am allergic to anything; I tell him what happened the last (and only) time I was CT scanned, and he cheerfully says, "I guess we shouldn't give you any dye, hm?" We agree. The scan is done fairly quickly and I am transported back to the "positive pressure" emergency treatment room. "The doctor will bring you the results shortly." And I wait. For hours and hours.

Finally, long about midnight, a doctor I've never seen before bustles in, introduces himself, says, "We're admitting you for observation...." I tell him I'm not good in hospitals, and the preferable course is to "observe" and "treat" as an outpatient. He says he's concerned about the blood I'd coughed up. He was worried I had burst a pulmonary blood vessel, and it would be best if I stayed overnight at least. I could leave "early in the morning." Remember it is already long about midnight. They were concerned that I might not have pneumonia after all, but it may actually be TB (because, he said, I'd been making all these trips back and forth to New Mexico -- he was the first one to get that right, all the others had said "Mexico), or even cancer.

I told him that all the observation and tests he wanted for me could be done as an outpatient, that I really didn't want to stay. He said the blood I coughed up was the main issue, and it wasn't "safe" for me to go home without them doing some more observation and tests in the hospital. After discussing it further, I said -- reluctantly -- OK.

An hour later, a new nurse arrived to do BP and such. She said they were getting a "special room" ready for me; she didn't know how long it would take. Almost an hour after that, Admissions arrived with paperwork. By this time, I had decided I wasn't going to stay, no matter what, and told her that I was refusing hospitalization. She wasn't too flustered, but said of course I would have to discuss it with the nurse and the doctor.

Yes, well. More time went by, the nurse came back, and I explained I didn't want to stay, all the observations and test could be done as an outpatient. Half an hour later, another doctor arrived who apologized for the wait. I'd already been in the ER for close to eight hours. I explained again that I wanted to go home, all the to-ing and fro-ing in the ER, and the interminable waits without resolution of my condition and without getting me a hospital room, either, convinced me there was no point in staying. If this was a sign of the kind of treatment I would receive as an inpatient, I would much rather stay an outpatient.

He at least told me that their real concern was that I might have TB, and they wanted to be sure. Do a skin test, etc. I said, "You know, you could have done that hours ago. You could have done most of the tests and observations you say you want to do now hours ago while I was waiting for any kind of treatment at all." He apologized again. I told him again I was not refusing treatment, I was refusing hospitalization. He assured me that "treatment" included hospitalization. We went around again, and finally he agreed I could go home, with antibiotics and a specimen cup in case I hawk up another bloody hairball, and that, yes, they could do the majority of the tests they wanted to do while I was in the ER or as an outpatient.

More time passes, someone comes and does a TB skin test, someone comes with "against advice" paperwork, someone comes to do semi-final discharge. One more step, then get some meds at the pharmacy, and I'm free! Free at last! Got home around 4:00am.

Sigh. There will be some outpatient followup, to be sure, and I have agreed that if I hawk up a "lot" more blood, I will return to the ER pronto.

I realize they were just doing their jobs as it were, following an elaborate protocol, and that there was a shift change half way through my ER stay, meaning that the new staff had no idea what was going on and had to get themselves up to speed before they could address any patient in the ER, let alone someone as cranky and perhaps foolhardy as me. I know that's how hospitals operate these days. I've spent enough time in ERs and hospitals the last few years shepherding patients through the intricacies, delays, miscommunications, treatments and so on. It didn't used to be like this, believe it or not.

In my case, the protocols they were following had to do with suspected TB, which they wouldn't even test for until I made a stink. If the skin test turns out positive, you bet I'll bee-line it back. But at this point, I think they were overdoing it, in an excess of caution. In the end the last doctor I saw admitted that the chance that I had picked up TB was actually very slight, that I probably had a particularly stubborn case of pneumonia. They just wanted to be sure, that's all. And I only really fault them for following protocols rather than paying attention to the patient.

So. We'll see. No trip to the frozen East Mountains, though. Not this weekend