The Wait In The Emergency Department….

 

I just got back from the hospital.  My wife was admitted with acute appendicitis and is scheduled for an appendectomy in the morning. That sounds like a routine occurrence.  There are after all about a quarter of a million appendectomies done in the US every year.  I had a complicated case myself at age 18 with a perforated appendix, sepsis, and a weeklong stay in the hospital with a drain in my side. It was one of the sickest episodes in my life – even after the appendix was removed, I could barely talk with my friends who came to visit due to the pain and intense malaise – but mostly the malaise - an intense feeling like you have the flu but many times worse.

The problem started at about 2PM today when she noticed some nausea and abdominal pain.  She thought it started after drinking some coffee at her health club along with a protein drink.  Over the next hour she became intensely nauseated and started to get increasing pain.  She asked me to examine her and she had tenderness with some slight rebound tenderness in the right lower quadrant but no abdominal wall rigidity.  I suggested we go to the emergency department to get assessed for appendicitis.  She declined because she knew the process would take hours.  She preferred Urgent Care – but I reminded her it was the place of no urgent lab results and over penetrated x-rays.  There was nothing urgent about any of the Urgent Cares we had been to in our health plan.  I finally convinced her that the ED was the only place where things get done and I was worried that she had an acute abdomen that would only get worse. 

That is exactly what happened over the next two hours – increasing pain and nausea.  She was eventually vomiting continuously and in severe pain.  So, we headed down to the ED and got there at about 7:10 PM.  The check-in was excruciating slow.  An RN asked her about 50 questions while she could barely sit in the chair.  She kept saying that she had to lay down.  The nurse finally said – “I wish we had a bed to offer you but we don’t.  You can lay down over there on the waiting room chairs.”  The chairs she referred to were in the triage area.  My wife laid across two normal sized chairs and covered herself with a blanket we brought from home.  We were interrupted by a nurse who took her down the hallway gave her medication for nausea (Zofran) and pain (hydromorphone).  She came back to those chairs but we were eventually asked to go to the general waiting area.  I took this picture of her laying across a larger bench style chair that was too short for her to lay flat.  The blanket is our own.

By 3 hours she was finally given a bed in the ED low acuity area and more Zofran and hydromorphone.  That stopped working a lot sooner.  She was sent for a CT scan of the abdomen at the 3 ½ hour mark.  That was preceded by a visit by an ED resident and later the attending physician. We got the final CT result about 1 ½ hours later when I went out to report she was continuing to get worse and the medications did not seem to be doing anything.  The Zofran was changed to Compazine and more hydromorphone was given.  Eventually a new ED physician came in and explained that surgeons had been called and that an appendectomy would probably be recommended.

At that point it was after midnight and I discussed me going home after I had said my piece with the surgeons.  I had two specific concerns about antibiotic coverage.  My wife was out of it by then but whispered: “Just behave yourself.”  When you have been married as long as we have - that snappy repartee develops.

On the long drive home, I had time to reflect on a number of things.  First, I was an intern at this hospital in 1982 and at that time we had a trauma wing and a non-acute wing.  Interns would rotate from one side to the other every other night.  The attendings on each side wanted to get people in and out as quickly as possible and they emphasized that point to us.  There were no bottlenecks and people were triaged based on acuity.  There was a sign there tonight saying that was still the rule.  Of the 30 or so people in the ED waiting room are, there was possibly 2 other people as ill as she was.  They were all laying on waiting room chairs.  Second, the pace was leisurely with a lot of down time. I still don’t understand why it takes 6 hours to get a diagnosis of acute appendicitis when I could do it as an intern in 15 or 20 minutes without a CT scan (we were told the CT scan results took 30 minutes to get back.)  Third, if EDs are that inefficient why not offload some of the front-end work to Urgent Cares.  That would entail making an Urgent Care urgent – a place where you can get a rapid assessment and the necessary tests and (hopefully) get directly admitted to a hospital and treated.  Fourth, the bottleneck suggests to me that beds are being rationed at some point.  We were in the second busiest ED in the Twin Cities. At some point – ED demand has been well defined and it should be accommodated.  Fifth, the place is run down. When I was there the argument could be made that it was worse, but this is a brand-new addition to the front of a brand-new addition to an old hospital.  It had the gestalt of a bus depot. People were milling about coughing and sneezing around the people laying on chairs waiting to get a bed.  Not a good look for either patient satisfaction or infection control.

All things considered it is an ongoing suboptimal experience. Nausea and pain were tolerated far too long with little follow up on the initial results.  It highlighted to me the need for an advocate when you go into a hospital these days – not just to prevent major problems but also to troubleshoot around routine decisions like: “Should I press this call light because not only does the medicine not seem to be working but I feel a lot worse.” Or “Maybe you should ask that doctor again if they have the CT results – it has been an hour.”   And of course, if you know additional history as an advocate that is valuable information.

Were there bright spots?  Both the ED and surgical residents had a great interpersonal style.  They gathered all the relevant information, were personable, and the surgery resident did a great job with the informed consent for the surgery. That’s about it.  It took 5 hours to get to the two physicians who could do something and then another hour to do it.  I told the surgeon I was in the same ED as an intern and then went into psychiatry.  She said that her experience on psychiatry was “heartbreaking” and she thanked me for my service.  Not the first time that has happened.

That is all I know at this point other than the fact that my heart rate was up the entire time I was part of this process – probably by 30 or 40 beats per minute.  I got home at about 1:45 AM and got about 4 hours of sleep.  A call to her nurse this morning for an update resulted in me finding out that she is still in the ED at 9 AM.  She is now getting IV fluids, antibiotics, anti-nausea medication, and pain medication. Her surgery is not scheduled until 3:45 PM today.  The nurse reassures me that she will be in a hospital bed after the surgery and may be able to go home the same day.

This is state of the art health care in the US.  After 40 years of micromanaged health care by managed care organizations we have a system that is less efficient and patient centered than the one I was trained in back in the 1980s. The only real innovation has been the use of CT scanning for the diagnosis and that was scientific innovation rather than business management.  Despite all the patient satisfaction surveys we have a system that no patient should be satisfied with.

 

George Dawson, MD, DFAPA 

Update 1:  My wife had surgery today approximately 23 hours after presenting to the emergency department with acute abdominal pain.  It occurred at about 6:15 PM.  I have highlighted what happened over the first 24 hours in the timeline below. I have not filled in the medications yet – but she was taking an anti-nausea medication (Zofran or compazine) and pain medication typically hydromorphone or oxycodone.  She was getting IV fluids at a rate of 50 ml/hour and at one point became hypotensive and the rate was increased. 

The surgeon discussed the results of the surgery with me. The appendix had perforated and as a result they had to clean the area to clear away that debris.  The procedure was maintained as a laparoscopic appendectomy despite the area of infection.  The surgeon quoted a 20% abscess formation rate with this complication.  We discussed the importance of the right antibiotic combination to prevent infection and secondary infection of a recent hip arthroplasty.  The surgeon emphasized that despite previous statement – my wife would not be going home because she continued to need IV antibiotics and oral antibiotics at the time of discharge.  When I left the hospital, my wife was alert and had some continued nausea and abdominal pain.  She was in good spirts and the nurses were discussing how she would start the night out with frequent monitoring and how that would taper off into the next day.

The issue of antibiotic coverage for a hip or knee arthroplasty is somewhat controversial in terms of antibiotic coverage. Most sources suggest a first- or second-generation cephalosporin and metronidazole.  I will put the medications on the timeline if I can convince the nurses to print out a copy of the MAR (Medication Administration Record). Hoping that discharge is imminent if there are no complications tonight.

 The antibiotic issue in appendicitis is also controversial.  There is a debate about just how good a purely medical/antibiotic approach to appendicitis is.  For example, there is a high recurrence rate of symptoms after treatment with just antibiotics.  There is some uncertainty about whether the risk for perforation is reduced and there is currently a protocol to study that problem.  It seems fairly straightforward if you consider that a partial mechanism is that the infection causes circulatory compromise and this leads to tissue damage including necrosis and leakage of the appendix contents.  The CT imaging may also be predictive.  The first surgery resident suggested that if a pattern of obstruction was visible there would more likely be perforation and disseminated infection.  My wife’s CT scan had that pattern and she did sustain a perforation.       

Update 2:  My wife was discharged today (11/15/2024).  Nobody explained the rationale – but I am speculating it was because her blood pressure stabilized (she was hypotensive), she did not have a fever, and her physicians thought the current level of pain and nausea that she has will resolve in the next week.  She was discharged with 4 doses of a cephalosporin and 4 doses of metronidazole after receiving an undetermined amount of antibiotic.  I say undetermined because she requested a printout of the medications administered (MAR) and were told they would not give it to us.  Instead, we should go down to medical records and sign a release to get this printout.  That made no sense to me but I have encountered this resistance at this hospital before that included having to pay for a third party to send me many irrelevant records from my own treatment.  I would think that the world’s most expensive electronic health record would have no difficulty with this task.  We were given an incomplete discharge instruction sheet instead that highlighted some of the problems with this EHR – not the least of which is reconciling the discharge medications.

We were told that follow up will be with my wife’s primary care physician.  No mention of the 20% chance of an intrabdominal abscess or what to do about that.  Just instructions on how to inspect and care for the laparoscopy incisions. My wife also has a 6-week-old arthroplasty of the right hip. I emphasized the need for antibiotic prophylaxis to prevent infection of that hip to the surgical team.  Her orthopedic surgeons advised her not to get any dental work done for 6 months (it is 80% healed at 3 months) and in terms of bacterial exposure a perforated appendix is probably as problematic as dental work.  I will need to confirm with orthopedics about whether a longer course of antibiotics is needed.

She is currently ambulatory, in good spirits, and has pain, and nausea.  No nausea medications were given on discharge. A limited amount of oxycodone was given for pain at half the dose she was taking in the hospital (10 mg). The bulk of the pain treatment was a combination of ibuprofen, acetaminophen, and methocarbamol.  This polypharmacy approach to postop pain seems common these days.  I will be assisting her with the medications and helping her monitor her condition.  I will also be researching the antibiotic issue and trying to get in touch with her orthopedics team.

Supplementary 3: I am adding this note on the third day after discharge (post-op day #5).  It appears that my wife has made significant progress today with a marked reduction in pain and improvement in other gastrointestinal symptoms.  She did have a temperature of 99.5 F last night but none today.  She continues to take several pain medications, a medication for muscle spasm, and a medication for gastroesophageal reflux.  I messaged her orthopedic surgeon about the antibiotic prophylaxis to ask if he thought it was adequate to prevent infection of the hip prosthesis and he did. She has a follow up with him next week but none with general surgery.  Her discharge paperwork clearly states: "We recommend that all non-essential contact with health care facilities be avoided."  Apparently that includes discharge follow up appointments.

Supplementary - more on malaise - I use the term frequently on this blog and often interchangeably with "flu-like illness".  It probably correlates with systemic inflammatory components released during infection like cytokines.  Watching my wife go through this course of appendicitis - I was reminded of what I went through 50 years ago.  At that time I became acutely ill in a period of hours, met my primary care physician in the ED, and he took my appendix out and placed a drain in my side in a period of 2 hours.  I was in the hospital for the next week.  I can recall an intense sick feeling that was not associated with pain or nausea.  It was so intense - it was the only time in my life that I did not care if I lived or died.  I just wanted it to stop.  Friends visited and I could barely talk with them.  This is my understanding of malaise at the severest level.