MEDICAL emergencies are, by their very nature, unexpected. People dread the middle of the night phone call, the early morning rush to the nearest hospital, and the anxious vigil outside the emergency room. Will my _______(fill in blank yourself) be all right?

However we might try to prepare for such a situation, putting money aside for a rainy day, emergency numbers by the telephone, a packed overnight bag, etc., we will never know what to expect. It is likely that you, or someone you love, may need admission to a hospital at one time or another. Today’s hospitals and the rites of admission can be confusing and frightening for someone not familiar with how the system works.

The admission process
The reasons for consulting at an Emergency Room are as numerous as the people who consult. Patients are notorious for coming in for the most minor complaints, “Doctor, I’ve had a 38 C fever for the last 3 days and can’t go to sleep.” You’re the weary resident on call, its 2 am and you just sat down to dinner. On the other hand, the blood and gore of high trauma, and the life and death seesaw of a patient whose heart has stopped beating, rouses the emergency room, and everyone working in it, to throbbing life.
 
Whatever the reason, anyone may seek help at a hospital’s Emergency Department.

Modern day chariot
If you are feeling ill, it is sensible to ask someone, family, friends and co-workers to bring you to the hospital.

Although I do know of someone who took a bullet in the shoulder during a carnapping and still managed to drive himself to the nearest hospital, these heroics put not only yourself, but also others, in danger.   

If you are home alone, you may call emergency services, or ask someone to call the appropriate number for an ambulance. It is best to go by ambulance if:            

•    Your physical condition is serious and might worsen very quickly  

•    You cannot get to the hospital quickly or safely by other means. Consider distance and local traffic conditions.

•    You have serious, chronic past medical problems

•    If more than one person needs an ambulance

Some conditions that might require ambulance conduction include:
•    Loss of consciousness
•    Chest pain
•    Difficulty breathing
•    Palpitations (rapid or irregular heart beat)
•    Weakness or dizziness
•    Heavy bleeding
•    Confusion or agitation
•    Trauma, unless minor
•    Moderate to severe pain
•    Moderate to severe headache
•    Problems with vision, speech or muscle strength
•    Inability to walk
•    High fever

Some hospitals will pick up patients from their homes or offices or chronic care facilities like nursing homes, especially if the patient’s physician arranges it and has reserved a room. The cost will appear in your hospital bill. An alternative arrangement is through companies with ambulances (and doctors) for hire, whose main duties are mainly to pick up and drop off.

In panic mode, instinct will direct you (or those taking you) to the nearest hospital. The best hospital though, is the hospital where your doctor practices. Why? Because your doctor knows you best, and has a good understanding of your past medical history and health care needs.

Under circumstances beyond your control, you might end up in a hospital other than your doctor’s especially if you are out of town or away from the area where you live or work. After initial evaluation and treatment by the emergency room physicians, if your condition is stable, you may request transfer to your regular hospital.

If you even have the time, or presence of mind to pack anything, take with you a list of medications you are taking (the list should include the following, the name (trade or generic names) of your medicine, the dose and frequency of intake), and results of any recent diagnostic examinations (blood tests, ECG, CXR) that you may have had in the last few months. It is prudent to keep all this vital information in a clearly labeled file, so that if you are not able to give your history yourself, family members may show your records to the ER physicians and speed along the medical assessment. There is nothing more frustrating to a physician than having a clueless informant for a potentially seriously ill patient.

It would be helpful to also have identification and an insurance card if any, an accurate outline of your medical history, a list of your allergies, medical problems, your doctor’s name and number and any personal items you may need. But do not delay going to the hospital if you need immediate care, someone can always go retrieve what you need.

The hospital twilight zone
In the emergency room, you can expect a triage nurse to receive the patient, whether ambulatory, in a wheelchair or gurney, and make an instant assessment of the patient’s condition and direct you to a specific section of the emergency room (medical, surgical, pediatric, obstetrics).

Most tertiary care emergency rooms are a beehive of activity. Aside from the nurses, the house staff, residents, interns, nursing aides, laboratory, respiratory, cardiology and x-ray technicians, and if necessary, a priest, converge in the ER when a red alert status is raised.

A resident on duty (ROD), from the appropriate service, will interview and examine the patient. He may give initial interventions (medication or laboratory testing) and the patient is observed in the ER or a holding area until the condition improves enough so he is sent home, a laboratory result is available, and a decision to admit is made.

The ROD at the ER, or the private physician on staff at the hospital decides if a patient needs admission. In case your patient does not have a physician in the hospital, the ROD will assign one from a roster of rotating physicians.

Alternatively, your personal doctor (family member, co-worker, neighbor) may have a doctor at that hospital and may recommend admission under his care.

Vital questions
Your physician will recommend admission for ‘admissible cases.” In medical parlance, these are patients who have medical problems that could be serious, have other chronic medical problems that might complicate or cause the current problem to get worse, who have abnormal physical exam, unstable vital signs—temperature, heart rate, blood pressure, oxygen concentration and abnormal laboratory tests like ECGs, lab work, and x-rays.

At the ER, the physician will already have a working diagnosis or impression of what is wrong with you. Some conditions do not require admission and you will be sent home as an outpatient (someone treated at the hospital but not admitted as a patient) with medication and follow-up instructions.

It is also entirely possible that the request for admission come from the patient themselves, especially if they have health insurance. One running joke in the admitting conference is, “How many patients with card-itis did you admit last night?” alluding to the patients who were admitted just so they could make the most of their insurance premiums.

Questions you might want to ask if you require admission to a hospital are:
•    Why do I need admission?
•    What is wrong with me? What is my diagnosis?
•    If the doctor does not know, what are the possible things I might have?
•    How long might I need to be admitted?
•    Will my insurance pay for the admission?
•    What workup or treatments will I need?
•    Are there any risks to my admission?
•    What are the risks if I don’t agree to be admitted?
•    Are there any other options?
•    Did you contact my physician already?

In some cases, patients (or their relatives) will refuse admission, despite a physician’s advice. For many patients, the bottom line is economics, inconvenience (no patient watcher) or they don’t understand why admission is necessary. People who are mentally competent may refuse admission, whatever the reason, but before you decide, make sure to get adequate information. You may be putting yourself at significant risk of death or disability by not following the admitting doctor’s advice.

If you refuse admission, you will most likely be asked to sign out against medical advice (AMA).

Please admit to room of choice
Once the patient’s family agrees to admission, a relative will bring a slip with the patient’s name, age, sex, physician and working diagnosis to the admitting section. Although most patients are free to select their own rooms, under some special circumstances, assignments will correspond to the level of care the patient requires.

A patient with a highly infectious disease will be sent to an isolation ward. Clean cases (patients who do not have an infection) will not be put in the same ward as patients with an infectious disease.

For instance, the intensive care unit (ICU) beds are reserved for the sickest people, those who require close nursing supervision, or those who require a ventilator to help them breathe.

Most private hospitals practice socialized medicine. Patients should be aware that charges for physician services, laboratory procedures, medicine, and operating room fees will depend on the “room rate,” or how much your room costs per day. Government or teaching hospitals waive only the physician fees. You will still pay a certain percent of the bill for laboratories, medication and procedures. No charity hospital is entirely free.

Refer accordingly
In the majority of cases, your private doctor will write orders for your care, or confer with the ROD. Orders will include the frequency of monitoring of your heart rate, blood pressure and temperature, feedings and meals (NPO is nothing by mouth, general liquids is just water and tea), intravenous fluids, laboratory tests, medication and other special instructions like catheter or nasogastric tube insertion.

As much as possible, the patient (or a family member) should be involved in any decisions that affect his care. Discuss with your doctor any planned treatments including medications, invasive procedures and surgery. Ask how effective the treatment usually is, what side effects if any and how severe they will be.

Ask about the cost of the treatment, if there are any alternative treatments and for how long you need treatment after discharge. Ask for a second opinion if you have concerns.

Your physician will visit you at least once daily, and more frequently if necessary. He receives continuous updates on your clinical status, any new problems or abnormal laboratory results as they arise and calls in new orders. The house staff: the residents, interns and medical students, nurses and paramedical personnel also provide supportive care.

Discharged improved
Once a patient’s condition improves, your physician will plan for discharge. In some cases, special home care, oxygen, hospital bed, nurses, nebulizers or suction machines may need to be available before the patient goes home. Clear instructions with regard to what medications to take, and for how long will be discussed prior to discharge. Other issues such as how soon before a patient can go back to work, any limitations or partial disabilities and follow up schedules should also be clear before leaving the hospital.

Although a hospital emergency admission can be traumatic for the patient and his family, knowing what to expect (even in theory) will help cushion the experience.