East Bay Headache Support Group
MARCH 2000 MEETING

TOPIC:  “MAXIMIZING YOUR VISIT TO THE EMERGENCY ROOM”

Have you ever had a headache so bad that you sought relief at the hospital’s Emergency Room?  Many of us have, and have not always had satisfactory results.  For its March 14, 2000 meeting, the East Bay Headache Support Group invited Dr. Stuart B. Shikora to talk about what to expect when you arrive at an Emergency Room with the complaint of severe head pain.  What treatment options are available to you, and what can you do prior to the visit to maximize your chances of finding quick relief for your pain?  These and other questions were explored during Dr. Shikora’s presentation in the Ball Auditorium at John Muir Medical Center.

Dr. Shikora practices Emergency Medicine at Mt. Diablo Medical Center in Concord and Kaiser Medical Center in Walnut Creek.  He trained at Hahnemann Medical College in Philadelphia, and is board certified in both Internal Medicine and Emergency Medicine.  Dr. Shikora’s practice of Emergency Medicine covers 24 years, during which he served as Chairman of the Emergency Department and President of the Medical Staff at Mt. Diablo Medical Center. 

Dr. Shikora began his presentation by stating that he and members of his family suffer from headaches.

What can we expect of a visit to the ER, and how can we prepare?  He said it is important for us to understand the four priorities of an Emergency Room, in order of importance:

1)      To preserve life

2)      To preserve limb

3)      To relieve suffering

4)      To promote health

Dr. Shikora said that most of the patients he’s treated in the Emergency Room have had headaches before; and in his experience, three common reasons headache sufferers come to the Emergency Room for treatment are:  the patients either ran out of their medication, or lost their medication, or past medications didn’t work and they wanted to try something else.

Information the Emergency Room personnel will need from the headache patient:

 ·      Who is your physician?  Have you called him/her?  Are they expecting to hear from us?

 ·      What is the diagnosis of your headache condition?  Migraines?  Cluster?

 ·      What medications are you taking, including OTC (over-the-counter) or nutricueticals (supplements, herbs)?  Are you taking aspirin, or Coumadin or Warfarin (blood thinners)?

 ·      What other conditions do you have?  High blood pressure?  Coronary artery disease?  Diabetes Mellitus?  Asthma or chronic obstructive pulmonary disease?  Do you have seizures?

 ·      What allergies do you have?

 ·      Have you bumped your head within the past few weeks?  Trauma?

 ·      What measures have worked for you before?  At home, or in the Emergency Room?

 ·      How does this episode compare to others in terms of intensity, quality, location, duration?  Is this the worst headache of your life?  Or, have you ever had a headache like this before?

 Probably the most aggravating part of going to the Emergency Room for treatment is that you have to give your medical history, sometimes more than once.  A nurse will first ask about your condition as she tries to perform triage on the patients waiting to be seen by Emergency Room doctors.  She/he must ask questions to try to determine which patients are in need of the most urgent care (see list of priorities above) and which patients can wait without further compromising their life or health.

 Following are things you can do to ease the process of being treated in the Emergency Room:

 ·      Bring someone to drive you home.  The medication to relieve your headache might not be given until they see you have someone to drive you.  Narcotics can’t be given to someone who will be driving.

 ·      Bring a letter from your physician regarding the types and names of medications recommended for you to have.

 ·      Bring dark glasses for your comfort.

 ·      Bring a book or soothing music.

 ·      Have your physician call in advance if possible; however, if your physician cannot be reached, don’t bother to have the on call or covering physician contact the Emergency Room, as he doesn’t know anything about your history.  The covering doctor can’t prescribe over the phone, but your personal physician can.

 Dr. Stein, advisor to the East Bay Headache Support Group and a member of the audience, made the comment that many HMO’s require the patient to call his doctor (or covering doctor) first, before heading to the Emergency Room.  Dr. Shikora replied that the federal government says this doesn’t make sense, and that new legislation is now in effect—if you (a reasonable person) think it is an emergency, then the HMO has to cover it.  The law now says that treatment (relief) of pain in the ER is included.  He said, however, that in places (maybe rural) you may come across organizations that don’t know the law.

 ·      Don’t demand medications by name or amount.

 Dr. Shikora passed out wallet-sized cards used to list information helpful to Emergency Room personnel in the event you need to be treated in the ER.  He emphasized that everyone should fill out the card and carry it with him at all times, especially when travelling.  Information such as your doctor’s name and phone number, diagnosis, conditions such as high blood pressure, asthma, circulation problems, allergies, past traumas; and medications taken (prescription, OTC, and nutraceuticals), should be included on the card.   He stressed that the card needs to be revised every time your medications change, even every month if necessary.  A sample is shown on the last page.

 To prepare for an Emergency Room visit, Dr. Shikora listed things that might happen when you visit complaining of a headache, such as:

 ·      A physical examination.  Some don’t think that one is necessary, but the law says a patient must have a physical exam before a doctor can prescribe medication.  The doctor will look at your eyes (some doctors will use a blue or green light), check your reflexes, and check your lungs and blood pressure.  And if you are asked to undress to complete the physical, do so.

 ·      An injection of medication, maybe several.

 ·      A prescription for medications.

 ·      A CT (computerized tomography) scan may be necessary if this headache is substantially different or worse than your other headaches.

 ·      Sometimes a chest x-ray is taken.

 ·      A lumbar puncture (spinal tap).  Dr. Shikora asked if any in the audience had had this test and two people responded, “yes.”  He explained that it is an infrequent test, usually preceded by a CT scan.

 ·      You might be asked for permission to call your doctor or other hospitals.

 ·      Be certain to tell the Emergency Room doctor about previous tests you have had, such as a CT scan, spinal tap, MRI (magnetic resonance imaging), etc.

 Then Dr. Shikora gave us an example of the questions he asks when treating a headache patient in the Emergency Room.  He asks his patients if they have identified any medications that work and any that don’t work for them.  He emphasized that one should never demand narcotics, especially large doses.  Dr. Shikora said that some patients have asked for as much as 200 mg of Demerol, whereas the usual dosage is 50 to 100 mg.

 Dr. Shikora has encountered patients who are adamant about trying some medication new to them and he tells them he wants to make certain that, “before you leave you will be free of pain.”

 Questions and Answers

 Dr. Shikora asked for questions from the audience, and began with asking what fears we may have about visiting the ER. 

 Q.  Dr. Stein said that patients understand the ER has to prioritize, but that headache patients may end up waiting three hours or more.  He asked Dr. Shikora to comment.

 A.  Dr. Shikora answered that there is a prejudice among ER personnel that minimizes headaches.  Some of the personnel may have a hard time understanding the headache patient who is incapacitated, when they themselves may be experiencing headaches and yet still are able to work.  He said that pain is an individual experience—one may be able to function while experiencing pain and another one may not.  And since headaches are not a visible illness, it’s hard for another person to understand your pain.  Dr. Shikora went on to say that some ER patients will pretend to have a seizure just to get to the head of the line.

 He told us, “When you see the triage nurse, try to present your case reasonably.  Explain how this headache is worse, or different than the others.”  He explained that ER personnel get scammed all of the time by people who are just there for narcotics; and added, “If you know that Imitrex works for you and you just ask for Imitrex, you will be treated better than if you demand narcotics.”

 Dr. Shikora thinks that one half hour is a reasonable time to wait in the Emergency Room prior to treatment.  If you have to wait longer, he thinks it’s not inappropriate for the headache patient to go back to the nurse and explain his condition, or have his personal physician call the ER.

 Q.  Dr. Shikora was asked, “If you had a choice between going to the ER or an urgent care facility, which would be preferable?”

 A.  He responded that if this headache is out of the ordinary, or different from your regular headaches, you should go to the ER (as it could be a stroke).  But the urgent care facility is good for a severe headache.  He said it would be good to check out the urgent care facility first, and ask what medications they would administer.  But they will be suspicious of you if you just call up and ask if they have Demerol.  Better yet, he suggested that you have your doctor call the urgent care physician.  That’s where a letter of introduction from your doctor is very helpful.

 Q.  Dr. Shikora was asked to list the questions he usually asks as he’s attempting to treat a headache patient in the ER:

 A. What are you taking now?

      •    What has worked to relieve your headaches before? 
      •    Then Dr. Shikora recites a litany of pills and the available injectable medications             (average dose of an injectable is 75 mg).

      •    He will then usually give an anti-nauseant.  He advises the patient to take the anti        nauseant first, and then take the headache pills.

       •   Then Dr. Shikora may try giving the patient Phenergan or Compazine (available in            pills and suppositories).

 Dr. Shikora asked Dr. Stein about the new Imitrex-like products on the market (all tablets).  Dr. Stein said we now have Zomig, Maxalt, and Amerge available by prescription.

 Dr. Shikora took a poll of the audience to see how many had tried Imitrex in the nasal spray form, and two persons said they had.  He thinks this is the best way to administer the medication, as it gets into the bloodstream faster than taking a pill, but you don’t feel the side effects quite as rapidly or as strong as when the medication is injected.

 Dr. Shikora cautioned the audience about the practice of sharing Imitrex with friends and visitors.  He said, “Unless your friend has already had previous experience with Imitrex, or one of the other Imitrex-like medications, this can be a very dangerous practice.”  This type of medication can bring on severe intracranial hemorrhage (stroke) or a myocardial infarction (heart attack).  Dr. Shikora asked Dr. Stein how he administers Imitrex for the first time to a patient, and Dr. Stein answered that he used to hook up each new Imitrex patient to a monitor, but he’s more relaxed now because he’s found few problems with toleration of the medication.

 Other protocols (treatments) that can be used for severe migraine:  Depakote and Inapsine can be given intravenously, or Toradol intramuscularly, in the Emergency Room, but they take more time than a shot of Demerol and Vistaril.  Two members of the audience said they had received infusions of Compazine or DHE in the ER.

 Dr. Shikora said that now patients are observed for at least 25 minutes after administration of a medication before they are allowed to leave the Emergency Room.

 Q.  One audience member asked Dr. Shikora about ergot.

 A.  Dr. Shikora immediately asked if the questioner was a Kaiser patient.  Kaiser tends to push ergotamine as it only costs them one penny each, whereas Imitrex is very expensive. (Editor’s Note:  The last time I asked my pharmacy for the retail price of Imitrex, the pills were $9.00 each.)  Dr. Shikora added that it is important to remember that if you take ergotamine, you cannot have Imitrex within 24 hours.

 Dr. Shikora always tells his ER patients, “I make sure you are feeling better before you leave.”  He then commented that urgent care facilities haven’t done very well in the suburban setting, so the urgent care physician usually runs a family practice on the side.

 He said, “You survive headaches—they have a lifetime of their own, but they do go away.”  He has the hardest time dealing with the family of a headache patient in the ER, especially the husband.  He tries to tell the husband that life doesn’t go on for his wife, it’s on hold.  The family needs to be engaged, to help out, and the family or spouse shouldn’t yell at the patient.  He added that our society doesn’t value family members who take time off from work to be the caretaker of a headache patient.

 To sum up his talk on “Maximizing Your Visit To The Emergency Room,” Dr. Shikora said:

 ·      Have a plan of action.  Know who to call to take care of the kids, and plan to have someone available to drive you home.

 ·      If you suffer from headaches more than once per month, or once per week, see your physician about taking preventive medications.

 ·      Avoid your headache triggers if you know them.

 ·      Carry a letter from your doctor explaining your diagnosis, especially if your speech is impaired during a migraine (known as a complicated migraine).  If you slur your words while experiencing a severe headache, the ER personnel could mistake your condition for a stroke and might try to aggressively treat you with thrombylitic medications.

 ·      If you are a cardiac patient, carry a copy of your EKG, especially if it is abnormal.

 Dr. Shikora explained the term “implied consent” to the group:  If you present yourself to a place where you need help, hospital personnel have permission to go through your wallet, purse, or other belongings for identifying data to assist them in treating you.

 He said that Kaiser has been very good at teaching their members to carry a pink card containing medical information.

 ·      Bring a list of the medications (prescription, over-the-counter, supplements, herbs, etc.) you take.  Dr. Shikora said some people just bring a whole bag of all the pills they take.  He said it’s very important that the pills are kept in their original containers so that it is easy to identify them.  “Don’t bring in loose pills—we can’t tell anymore by looking at them—they’re changing all the time.”  Even pharmacists make mistakes sometimes in identifying a pill just by its size or shape or color.

 Dr. Shikora said that as an Emergency Room physician, he can go to the computer at Kaiser and at Mt. Diablo to look up the medications taken by a particular patient, but he added that he doesn’t have access to the computer at John Muir.

 He relies on the patient or the caregiver for the necessary information he needs to properly treat a patient in the ER.  He said they do see three-, four-, and five-year-old children in the ER who are diagnosed with migraines.  One mother made up her own laminated card listing medical information for her young son, and made certain each parent and caregiver carried a copy.

 Dr. Shikora was thanked by the East Bay Headache Support Group for providing us with a wealth of information about what to expect when we must go to the Emergency Room seeking relief for a severe headache.

 The intention of the East Bay Headache Support Group is to provide information and resources.  It does not provide medical advice, which should be obtained directly from a physician.