5 lessons from a trip to the emergency department

Patients deserve on-call services from their doctors, with prompt and courteous responses.

There have been numerous times in my career when I had to refer a patient to a local hospital emergency department (ED). Sometimes it was for a truly emergent medical condition, and sometimes it was simply because of an inability to find a local specialty provider on the patient’s insurance panel to refer to when urgent, nonophthalmic care was indicated.

My previous experience as a patient in the ED was limited to 1 visit, decades ago, when I injured my ankle during a high school basketball game. My most recent ED visit, and what preceded and followed it, reinforced several important lessons practitioners can use to improve the care we provide patients.

The story

In the aftermath of a major hurricane that tore through my area, 1 of our offices was forced to close for 2 weeks and the other 2 offices for 1 week. We spent quite a while without power. As a result of being busy cleaning up debris at home and helping family, friends, and neighbors do the same, I hadn’t shaved for a week.

Once power was restored and patient care resumed, I picked up a razor and subsequently developed an in-grown hair on my jawline from using an old blade on my fairly thick beard. This led to an infection, which I tried to drain and heal with an antibiotic ointment. Its growth ceased but it wasn’t resolving quickly enough for my taste. Thank goodness we were still having to wear masks in clinic, so I was able to conceal it from patients.

Treatment

I decided to schedule an appointment at my dermatologist’s office during their normal half-day clinic the next Saturday morning. However, I had to see a new doctor in the group practice. She examined me and felt the abscess needed to be drained and cultured because I’d previously had a confirmed methicillin-resistant Staphylococcus aureus (MRSA) infection. She then performed the procedure.

I was prescribed oral Bactrim(sulfamethoxazole and trimethoprim) double strength (DS), oral rifampin, and topical mupirocin ointment. I was also instructed to clean the wound with hydrogen peroxide, reapply wound dressings, and, as a precaution against potential MRSA colonization, apply the ointment nasally twice a day and shower with Hibiclens antiseptic skin cleanser.

The medications

The prescriptions were sent to my pharmacy and I was escorted to check out. The medications and instructions had not been provided in writing and were relayed hurriedly. Had I not been a health care provider, I could easily have misinterpreted or forgotten them.

Assuming the instructions would be in my electronic health record (EHR), I left to get the prescriptions filled, but by the time the medications were ready, it was 1 pm. I had not eaten since breakfast earlier that morning but had taken Bactrim DS to treat the prior MRSA infection successfully and without issue. However, I had never taken rifampin, and my only familiarity with it was from optometry school as a tuberculosis drug. Curious, I searched online and found that some infectious disease experts recommend it in conjunction with Bactrim DS for MRSA infections. The problem was this: the rifampin is to be taken on an empty stomach, at least 1 hour before a meal or 3 hours after. Wanting to get started as soon as possible, I took the Bactrim DS and the rifampin, along with some ibuprofen, all at once. Since the anesthetic had worn off from the procedure, I decided to skip lunch and fell asleep on the couch watching a football game on TV.

Adverse effects

When I awakened an hour or so later and got up to throw the football in the back yard with my son, I found my arm and back were a little sore. After 15 minutes, I began to feel weak and nauseous. So I went inside and lay back down, which is when the severe chills hit.

I researched the medications I had taken at PubMed.gov and looked at US Food and Drug Administration (FDA) clinical trials. Every symptom I had was a known potential adverse effect. So I called the dermatology clinic’s after-hours number to inform them and ask for directions moving forward. Should I resume the Bactrim DS alone? Try both medications again after eating, since I had now been 7 hours without food? Or switch to something different?

The physician who had treated me called me back very quickly, and I described the course of events and my symptoms to her. I also shared my thoughts that these were adverse effects and/or a reaction to the prescribed medications. However, before I even finished, the doctor insisted I go to the emergency department immediately to ensure I was not developing sepsis. This caught me by surprise, and I tried to convince her of what I had found online, but she insisted.

To the ED

Very reluctantly (since we were still near the peak of the COVID-19 Delta variant surge in my area), I had my wife take me to the ED. As we waited, the nausea increased and I vomited in the bathroom but immediately felt quite a bit better. When I was finally called back, I was seen by the ED nurse, then the ED nurse practitioner, and then the attending ED physician, repeating my case history each time and stating that I was there due to the dermatologist’s suspicion of sepsis.

After monitoring my vitals and performing multiple laboratory tests, the staff agreed my symptoms must have been from the antibiotics. They prescribed ondansetron (Zofran) for nausea and discharged me. However, it was now 10 pm, I was $800 lighter in the wallet because my deductible had not been met, and no nearby pharmacy was still open. So we went home and I made it through the night. The next morning, still weak and not having consumed anything other than a few crackers and some electrolyte sports drinks, I decided not to take the rifampin, but did take another Bactrim DS while my wife waited for the local pharmacy to open and fill the Zofran. I then accessed my dermatology EHR to verify the doctor’s instructions for wound treatment and dressing, only to find the instructions were not there. I had to go by memory.

The nausea and weakness persisted throughout Sunday, and I did receive a voicemail from the dermatologist calling to check on me. Thankfully, by Monday I was getting my energy back and feeling somewhat normal again. My usual dermatologist substituted doxycycline as my oral antibiotic, and everything healed within a week without further difficulty.

Lessons learned

This series of events drove home several key takeaways:

• Clearly communicating advice to patients, especially when there are multiple medications and instructions, is vital to successful outcomes. And they are best reinforced in writing.
• Patients deserve on-call services from their doctors, with prompt and courteous responses. Although I may not have been thrilled with the advice I received, kudos to the dermatologist for calling me back so quickly and not acting as though I was interrupting her day. Every clinic I have worked in since my residency has offered on-call services—it is a huge practice builder, as well as the right thing to do. Most EDs do not have the equipment or eye care providers available to do so.
• Listening to patients can assist our clinical decision-making. The input I offered into the etiology of my symptoms seemed to be largely dismissed by the dermatologist, even though I had found clinical case studies and FDA trials demonstrating the exact adverse effects I was experiencing. We should not be dismissive of patient suggestions, as they may have researched their symptoms ahead of time
• The ED, although sometimes necessary, is inefficient and costly. We should not shy away from referring patients when necessary, but not everyone can easily afford the costs. Therefore, we shouldn’t rely on it because it is easier than caring for our patients ourselves or because we failed to do our homework on which cases really need to be sent to the ED.
• Calling to check on patients means a lot. Getting a phone call the following day from the dermatologist went a long way toward showing she cared about me as a person.

Although I lost several hours of my time and several hundred dollars from my wallet as a result of this trip to the ED, at least my patients will benefit from the good, the bad, and the ugly of what I experienced (and hopefully you will, too).