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No Early Hospital Discharge: Stay In Until You Get The Proper Diagnosis

May 27, 2014

It’s hard to think of a time when you might feel as clueless as you do in a hospital emergency room.

If you’re there, you’re already anxious, even if you know exactly the problem. Between the usual managed chaos in the ER, doctors in charge of multiple patients in varying degrees of urgency, and your own time constraints, you might not get a clear idea of what your (or your loved one’s) medical condition is.

Or think about life in a nursing home: caring for hundreds of residents at the same time each with different medical conditions. Or an urgent-care facility, where dozens of patients arrive in various stages of alarm, see different medical professionals, ranging from physician assistants to nurse practitioners to MDs, and leave under their own volition.

Let’s be perfectly honest: your doctor is more knowledgeable of medicine than you will ever be.  He or she has studied the human body and its various reactions for a decade or more, through thousands of variations in classrooms, hospital rooms, and real-life emergencies.

But doctors often guess at what ails you (or someone you care about)—granted, it’s a well-educated guess—and they can overlook things.

That’s why your input is vital. No one knows what you’re going through better than you, and no matter the circumstance, you need to make that clear to them. As a patient, or someone who cares about a patient, it’s your responsibility to get an accurate diagnosis of your condition, or to stay in that medical facility as long as you need to get one.

We’re not trying to assign blame to patients. We’re trying to help you take some control over your medical condition: control that could be the difference between a minor infection and a major one, or often the difference between life and death.

Let no one send you home by a discharge until you are completely aware of what’s happening, and exactly what course of treatment doctors are prescribing.
In short, don’t leave until you know exactly what’s going on with your body.

Here’s an example.

Ms. Green’s throat had been bothering her badly for a couple of days, and as a single mother of three children, she couldn’t stand to be laid up for more than a few hours.

She visited the emergency room with continuing pain on the right side of her throat. The pain was bad enough she was having trouble sleeping and swallowing. On top of that, she’d run a fever, complete with sweats and chills.

She saw a physician assistant (PA), who tested her for strep throat and diagnosed her with viral pharyngitis. The attending physician signed off the care, but neither examined nor interacted with the patient. The PA instructed her to come back if symptoms worsened.

And symptoms worsened, and Ms. Green returned to the ER. The notes on her condition were harrowing: she was “hysterical” and rated her pain as a “10” on the pain scale. Her blood pressure increased and her vital signs were swinging wildly in one direction and then the other.

The right side of her throat and one of her tonsils had started to swell, and her symptoms worsened and failed to improve after her first ER visit. She saw another PA, who tested for mononucleosis. When the test came back negative, the PA ordered no more diagnostic tests and didn’t prescribe antibiotics. Rather, she prescribed more pain medication and preached patience, although the pain was debilitating and Vicodin had no effect.

Again, the attending physician signed off the care but didn’t examine Ms. Green, and the PA sent her home again.

One day later, Ms. Green returned to the ER, where the doctors discovered a massive viral infection had destroyed both tonsils, her uvula, and muscles in her neck. She spent the next 45 days in the hospital—some on a mechanical ventilator to breathe—and doctors needed to remove parts of her face, neck, and palate.

What could Ms. Green have done differently?

Not a lot. Again, Ms. Green isn’t to blame for what happened, but there are things you can do to help protect yourself in a similar situation.

Get an MD’s opinion, no matter what: There’s a reason physician assistants and nurse practitioners aren’t doctors: they’re not as well-trained or well-educated, so don’t allow them to be the last word on your medical condition. Make sure the supervising physician agrees.  A second, more educated and experienced set of eyes may catch what the first set missed, especially if you’re making multiple visits to the ER or other medical facility.

Though we want to be polite to the people taking care of us, it’s perfectly OK to ask for another opinion, especially if the first caregiver doesn’t give you a clear answer.

At no point in either of her first two visits did Ms. Green ask to speak to the supervising physician.

Ask for extra clarification or tests: Yes, tests can be expensive. Any time in a hospital is expensive: it usually costs at least $100 just to talk to a doctor, and that’s before any hospital stay. Think of the alternative, though.  Anything that can clear the picture is good.
If you’re in so much pain or in such a debilitating state you cannot function, don’t leave. It’s that simple.

Here’s another example.

Mrs. Verde was going in for minor, elective knee surgery. She was 67, but in good shape. She did not normally take narcotic medication, but the anesthesiologist and the outpatient surgery facility gave her a high dose for anesthesia and after for pain management.

Her surgery seemed successful, but she was drowsy and largely unresponsive after surgery. The anesthesiologist and orthopedic surgeon left specific instructions for post-op care: the nursing staff was supposed to monitor Mrs. Verde’s blood-oxygen level, and if it dropped below a certain point, they were supposed to notify the physicians.

The doctors also instructed the nurses to make sure Mrs. Verde’s was aware, alert, and responsive before she left, but with the painkillers they kept giving her, she couldn’t stay awake or respond clearly to questions.

Mrs. Verde failed to reach either of the physician benchmarks, and her blood-oxygen level dropped into the danger zone, but no one notified the physicians. The outpatient facility staff moved around closing down and cleaning up, as they were reaching the end of the scheduled business hours.

Mrs. Verde could not stay awake or dress herself. At no point did anyone give Mrs. Verde anything to counteract or neutralize the narcotics in her system. She couldn’t concentrate on or sign her discharge instructions, and the nurse told Mr. Verde to sign her out and drive her home.

Mr. Verde carried his wife into the house, changed her into pajamas, and put her to bed. He checked on her soon after, and found she’d stopped breathing. The paramedics tried to revive her, but she was gone.

What could Mr. Verde have done differently?

Again, not much. But if you’re in the position of having to take care of a loved after surgery, you can be clear on a few important things going in.

Get specifics. Make sure you know the terms of your loved one’s discharge beforehand. Ask questions of the surgeon. Know exactly which behaviors are signs of improvement and which may be cause for alarm. Be sure about all of the surgeon’s and anethesiologist’s recommendations and guidelines. Ask about the medications being used for sedatives and how they’d affect someone who does not regularly take narcotic medication. Forewarned is forearmed.

If those specifics don’t match up, don’t leave the facility. If the person you care about is dozing off or otherwise not ready to travel, don’t leave medical care. Everybody working in the facility is responsible for making sure all patients leave safely. It doesn’t matter whether the patient shows up at the start of the day or five minutes before closing—staff must stay as long as it takes.

If they insist on sending your loved one home, you insist they transfer the patient to another facility that can meet medical needs. Yes, ambulance rides and hospital stays are expensive, but the alternative can deadly.

Do not allow them to transfer a vulnerable loved one without your express consent, regardless of cost.
Kick, scream, and protest. Let them know you’ll contact police or an attorney if necessary. If your loved one is incapacitated or in a vegetative state, do not let the care providers transfer your loved one without your express consent.

Nursing home facilities are not equipped to handle emergency situations or patients with significant care needs, and transferring someone who needs round-the-clock care to a facility less equipped is a extremely dangerous.

Whatever you do, don’t get pushed out the door.
As we’ve mentioned here, medical facilities—whether they’re hospitals, urgent care facilities, or nursing homes—are staffed by well-trained, experienced professionals skilled in the arts of urgent and long-term care. Unfortunately, on occasion they overlook, ignore, or fail to notice vital details.

On those days, with just a little diligence, you can play a crucial role in your safety or the safety of someone you love.

The Consumer Bill of Rights and Responsibilities puts everything we’ve just mentioned in writing.

  • You have the right to accurate and easy-to-understand information about your health plan, health care professionals, and health care facilities. If you speak another language, have a physical or mental disability, or just don’t understand something, help should be given so you can make informed health care decisions.
  • You have the right to choose health care providers who give high-quality health care when you need it.
  • If you have severe pain, an injury, or sudden illness that makes you believe your health is in danger, you have the right to be screened and stabilized using emergency services. You should be able to use the services whenever and wherever you need them, even if they’re out of your insurance network, without needing to wait for authorization and with no financial penalty.

  • You have the right to be informed of treatment options and participate in decisions about your care. You have the right to ask about the pros and cons of any treatment, including no treatment at all. As long as you can make sound decisions, you have the right to refuse any test or treatment, even if it means you might have a bad health outcome. You can also legally choose someone to speak for you if you cannot make your own decisions.

  • You have a right to considerate, respectful care from your doctors, health plan representatives, and other health care providers that do not discriminate against you based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment.
  • You have the right to talk privately with health care providers and have your health care information protected. You also have the right to read and copy your medical record. You have the right to ask your doctor change your record if it’s not correct, not relevant, or not complete.

  • You have the right to a fair, fast, and objective review of any complaint against your health plan, doctors, hospitals, or other health care personnel. This includes complaints about waiting times, operating hours, or actions of health care personnel.
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