Let Me Call It In For You

These days they have navigators for everything.  When we got lost back in the day, we used to consult a map, or lacking a map, we would pull in to the nearest “filling station” (what we used to call gas pumps) and ask for directions from the friendly young man who would appear to wash our windshield, check the oil and the tire pressures, and of course, pump the gas.  Not anymore. These days we type the address we are seeking into our smart phones, and a nice man with a somewhat generic British accent directs us to “turn left in 0.3 miles.”  No intervention—no human interaction required. Medicine has taken navigation one step further—now it is quite fashionable to have “cancer navigators”, usually registered nurses, who help a patient from the shocking time of diagnosis, to the myriad choices for treatment, to coping with survivorship.  But so far, I have never heard of emergency room navigators, and to the best of my knowledge, this is an area ripe for harvest.

In medical school, a great deal of time is spent teaching students to take a relevant history, called the “history of present illness.”  This would seem like a simple thing, but in reality it is quite complicated.  Each patient perceives and gives weight to a different aspect of her symptoms, and the events leading up to her appearance in the emergency room at 10 pm on a Saturday night.  What takes us four years to learn in medical school often eludes patients—the pertinent parts of the history and physical symptoms which may lead to an appropriate hospital admission, or conversely a waste of a good hospital bed, or even worse an inappropriate discharge resulting in the death of a patient.  The fact is, that if a patient cannot put together a concise cogent account of the events just prior to showing up in the ER, the attending physician is disadvantaged to the point of making a serious and sometimes grave error.

A case in point—a few weeks ago a good friend of mine in another state had a skin cancer removed from her neck.  A few days after her surgery, she was feeling poorly and noticed that the incision site was reddened and tender.  I urged her to go back to the surgeon, but he had been abrupt with her and she was more comfortable going to her primary care doctor.  The primary was not used to evaluating surgical wounds, but sensing my friend’s discomfort, she prescribed a course of antibiotics to cover typical skin infections such as staph and strep.  My friend began the medicine but that evening she experienced a bone shaking chill followed by a temperature spike, and her incision opened up, allowing drainage.  She called me, barely able to speak, and I directed her to go to her nearest emergency room at once.  I offered to “call it in for her”—to speak to the triage nurse or the ER doctor.  She said she would let me know where they were going.  But she did not.

When she appeared in the emergency room, she told the ER doctor that her chief symptom was a severe headache in the posterior occipital region. It was the worst headache she had ever had.  My friend ending up getting a noncontrast CT scan, which thank goodness was negative for a brain hemorrhage or stroke.  She was given Valium and Demerol and Compazine, and then Vicodin “to go” and was told she had a bad migraine headache.  As best I can tell, no one ever looked at the surgical incision on her neck.  My friend survived, but only because she continued to take the Bactrim DS, two tablets twice a day, that her primary care MD had prescribed empirically.  She did enjoy the Vicodin and the Valium.

The moral to this story is:  when you’re sick and your fever spikes to 103 and your doctor friend offers to “call it in for you”—that is, speak to the triage nurse or the emergency room doctor—take her up on it.  It might just be a migraine, or a tension headache, or a virus.  But it might be a life threatening disease or infection.  Doctors spend years learning to decipher symptoms and to dissect out the relevant parts of a history.  We speak the same language.  Let us help you.