5 lessons I learned from a trip to the ER

There have been numerous times in my career when I’ve had to refer a patient to a local hospital emergency department (ED).

Sometimes it was for a truly emergent medical condition, while other times it was simply because of an inability to find a local specialty provider on a patient’s insurance panel to refer to for urgent, non-ophthalmic care.

Previously, my only firsthand experience as a patient in the ED was limited to a single visit decades ago, when I injured my ankle during a high school basketball game.

Just recently, however, my second encounter, including what preceded and what followed it, drove home several important lessons that can improve the care we provide our patients.

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The story
In the aftermath of a major hurricane that tore through south Louisiana, our offices were forced to close for several weeks. We spent almost a week without power at home (and almost two weeks at one of our offices).

As a result of being busy with hurricane cleanup 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 was scheduled to resume, I finally picked up a razor again, but subsequently developed an in-grown hair on my jawline after unknowingly using an old blade that had dulled.

A cyst subsequently developed and began enlarging, which I tried to drain and treat with an antibiotic ointment. While it stabilized, the abscess wasn’t resolving quickly enough for my taste (thank goodness we were still having to wear masks in clinic at the time, so I was able to conceal it from patients, at least!).

Treatment
I scheduled an appointment at my dermatologist’s office during their normal half-day clinic the next Saturday morning.

However, my doctor was out that day, so I was examined by another doctor in the practice I’d not seen before.

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She examined me and decided to drain and culture the abscess because of a previous methicillin-resistant Staphylococcus aureus (MRSA) soft tissue infection I’d had.

After performing the procedure, she prescribed oral Bactrim DS (sulfamethoxazole and trimethoprim, double strength), 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 (I wasn’t the last appointment of the day, but I was the last patient in clinic as a result of the procedure being done).

Had I not been a health care provider, it would have been easy to misunderstand or even not remember all of the instructions.

Assuming everything would be in my electronic health record (EHR), I paid my co-pay and left to get the prescriptions filled. Having successfully taken Bactrim DS to treat the prior MRSA infection without issue, I was familiar with it.

However, I had never taken rifampin, and all I could recall about it from optometry school was its indication for tuberculosis.

Curious, I searched online and found that some infectious disease experts recommend it in conjunction with Bactrim DS for MRSA infections.

The only caveat is that it was to be taken on an empty stomach, at least 1 hour before a meal or 3 hours after, and by the time the medications were ready at the pharmacy, it was 1 pm.

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I had not eaten since breakfast early that morning, so wanting to get started as soon as possible, I skipped lunch and took the rifampin with the Bactrim DS, along with some ibuprofen (since the anesthetic had worn off from the procedure and it was aching).

I laid back on the living room sofa to rest and watch a college football game, but then fell asleep.

Adverse effects
Upon awakening an hour or so later, my son asked me to throw the football with him in the back yard, which I did, but noticed 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 severe chills started.

I pulled up PubMed.gov on my phone and also searched published clinical trial data from the US Food and Drug Administration (FDA) for information on the medications I had taken that day.

Every symptom I was experiencing was a known potential adverse effect, so I called the dermatology clinic’s after-hours number to let them know and to ask for suggestions moving forward.

Should I resume the Bactrim DS alone since I’d not had problems with it in the past? Or try both medications again after eating, since I had now been 7 hours without food? Or switch to something totally different?

The physician who had treated me was on call and called me back very quickly. After describing the course of events and my symptoms, I also shared my thoughts that these were adverse effects and/or a reaction to the prescribed medications.

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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 just 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 then 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 concern with 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 (my deductible had not been met), and no nearby pharmacy was 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 so we could fill the Zofran.

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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, and in a weakened state at that.

The nausea and weakness persisted throughout Sunday, and I did receive a voicemail from the dermatologist calling to check on me.

By Monday I was still weak but getting my energy back and feeling somewhat normal again. I called my usual dermatologist, who substituted doxycycline for the rifampin and Bactrim DS, and thankfully everything healed within a week without further complications.

Lessons learned

This series of events drove home several key takeaways:

• Clearly communicating our instructions to patients, especially when there are multiple medications involved, is vital to successful outcomes. They are best reinforced in writing, as well.
• Patients deserve on-call services from their doctors who provide specialty care (like eye care providers), with a prompt and courteous response. 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, which has been a huge practice builder, not to mention it affords the best eye care to patients, since most EDs and urgent care clinics do not have diagnostic eye care equipment or eye care providers readily available.
• 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 be careful not to dismiss patient suggestions, as they may have researched their own symptoms ahead of time
• The ED, although a vital part of the health care system, can be inefficient and costly. We should not shy away from referring patients when appropriate, but we should also remember the time involved and the costs incurred can be a significant burden for patients. Therefore, we shouldn’t overly rely on the ED simply because it is easier than caring for our patients ourselves or because we’ve not done our homework to determine which cases really need to be referred there.
• Calling to check on patients after hours means a lot. Getting a phone call the following day from the dermatologist was unexpected and reinforced that she cared about me as a person, and made me much more willing to overlook the other issues.

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

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