A Headache is not an emergency

applesxoranges, BSN, RN · Jun 27, 2016

Here's my take. The ERs are busy. Sometimes you have to wait. I don't care why you choose to come in but it doesn't mean you can get everything you want when you want it. I also will not give you a sandwich and pop if you come in every day. It sucks when there is no staff. It sucks when there are no rooms open. However, ******** at me will only irritate me but won't magically open up a room. It'll just give me a headache.

floridaRN38 · Jun 29, 2016

Food for thought...a few months ago I had a healthy 25 year old with no history come in for a headache...acting very dramatic about it, etc etc. Doc put in for a head CT and some morphine. After the morphine she was knocked out in her room, snoring and all, vitals holding up ok. One of the times I make rounds she's not snoring anymore - because she stopped breathing! Didn't make it.
After that, I stopped being so dismissive.

I had a similar situation in the ED. Young healthy. No medical history. Came in said she had a "headache". Next thing i know I find her in the bathroom puking. I called the doc in right away Because I had a gut feeling about it. CT scan showed a large bleed. So u never know when it comes to a headache

wowohwow · Jul 4, 2016

Very good point (this and others; I always nod whole reading your posts, lol). When I am discharging patients who were unsure if they were actually having an emergency and who are then apologizing at discharge after a negative workup for "wasting the ER's time," I tell patients that if they are having a problem with brain/heart/lungs/eyeballs, don't hesitate â€” come see us. Acute abdominal pain is a tricky one, too â€” especially in women who have all these special pieces and parts.

I have diverticulosis and I know when I have acute abdominal pain I need to get to the ER for a CT scan. I found out last year and my GI doctor told me that if I had pain on my left side I needed a CT scan.

Well, had no clue as to what kind of pain he was talking about until my first attack of diverticulitis earlier this year. BAD pain. REAL BAD PAIN. I woke up in the morning and it was so bad I felt I was going to pass out. It was horrible and I ain't joking. I went to the ER and had diarrhea a few times but the doctor totally dismissed me and never ordered a CT scan and they even got my symptoms wrong even though I stated I had diverticulosis and had BAD pain in my lower left side. Sent me home.

In March I wound up in the ER again in bad pain. I went out for breakfast and started to feel wonky and then at Walmart I almost passed out again. But it passed and since I feel stupid for going to the ER and wasting their time after so many bad experiences I let it go but when I started to feel bad later that day I decided to go. Saw the same doctor in triage and basically told him off. He said that maybe I should see another doctor and I said yes. Luckily she listened to me about my symptoms and that I had diverticulosis and ordered a CT scan. Had antibiotics for 2 weeks and haven't had a flare up since.

So even abdominal pain can be serious without it having to be due to our "special pieces and parts". And to the people who get upset because people come to the ER for "just a headache". I would not let your disdain show towards them because if they are like me next time they won't go because of how they were made to feel and it might wind up being something really serious.

Editorial Team / Moderator · Jul 4, 2016

So even abdominal pain can be serious without it having to be due to our "special pieces and parts".

My point was simply that female innards lend themselves to more differentials. I have seen a lot of potentially surgical abdomens ruled out in favor of ovarian cysts (which can be surgical, yes, but seemingly less often).

Diverticulitis can be awful â€” my mom has had a few bouts over the last couple of years. She got to the point where she'd call her primary doc at symptom onset and he'd put her on abx with strong return precautions to come back or get seen in the ED if anything got worse. She's like a pro at it now, poor thing! I am glad you're better.

wowohwow · Jul 4, 2016

My point was simply that female innards lend themselves to more differentials. I have seen a lot of potentially surgical abdomens ruled out in favor of ovarian cysts (which can be surgical, yes, but seemingly less often).

My point was that when a woman goes to the ER with abdominal pain they automatically assume it is some kind of "woman problem". That was what happened to me back in the early 90's when I had a huge bleeding duodenal ulcer. Had so many pelvic exams before someone finally figured out my pain had nothing to do with my ovaries and uterus. They shouldn't automatically assume that when a woman comes to the ER with abdominal pain.

How does your Mom know when it starts? My symptoms both times were bad pain. Other than that I was basically okay.

Editorial Team / Moderator · Jul 4, 2016

My point was that when a woman goes to the ER with abdominal pain they automatically assume it is some kind of "woman problem".

Not in my ER, nor any of the 5 in which I have worked in the last decade â€” it never gets narrowed down like that without the appropriate exams and tests. Not sure what ERs you have visited (or do you work in the ER?), but I am sorry if that was your treatment.

How does your Mom know when it starts? My symptoms both times were bad pain. Other than that I was basically okay.

Crampy pain on her left side. It's the same every time.

wowohwow · Jul 4, 2016

Not in my ER, nor any of the 5 in which I have worked in the last decade â€” it never gets narrowed down like that without the appropriate exams and tests. Not sure what ERs you have visited (or do you work in the ER?), but I am sorry if that was your treatment.
Crampy pain on her left side. It's the same every time.

What's funny is that I get that kind of pain right before I have a bowel movement and once I go the crampy pain is gone till the next time.

Stress also seems to make it bad. I hate it.

A&Ox6, MSN, RN · Jul 4, 2016

As a migraine sufferer, I too take issue with the title of this thread. I have had migraines that caused me to temporarily lose vision, migraines that caused syncope, migraine that seemed like a hallucination as well as other status migrainosus.

However, due to the current attitude towards young females with migraines, it took many years for chiari I malformation to be diagnosed. I also have had psych consults called when I came in for left sided paresis and syncope. Only after I was psychiatrically cleared was any bloodwork and imaging done.

The interesting thing is that my migraines respond only to infusions of magnesium and dexamethasone. I cannot take any opioid due to anaphylaxis, I have to be careful about APAP because of liver functions related to overmedication as a teen by a doctor, and I can't take too much NSAIDs due to multiple bleeding ulcers.

I am lucky that I have not had a migraine emergency in almost a year, but I think it is very important to remember what a headache could be:

Meningitis

Cerebellar Herniation(chiari)

Concussion (delayed symptoms)

Stroke

Hematoma

Sinus Infection

Hemorrhage

Trigeminal Neuralgia

Opthalmic issues

Roy Fokker, BSN, RN · Jul 5, 2016

The vag discharge/yeast infection could go to a GYN Clinic or Fast Track area if your hospital had one.

There is no "GYN Clinic" (I've worked dozens of hospitals and hospital systems over many years; I've never come across a GYN Clinic in a Hospital and much less an ER setting.) Triage dictates you treat the sickest patients first (unless in a disaster situation) - waiting room would've been appropriate anyway since I had no open beds.

Regardless, do you think it appropriate for her to call 911 and utilize an ambulance for her chief complaint?

We never sent chest pains to the waiting room, especially if they were 80 y.o. grannies such as you described.

1. Never mentioned anything about '80 y.o. grannies' with chest pain being sent to the waiting room. My post specifically states "The ones who occupy a stretcher in the ED with their chronic, non-emergent complaint - while 80 year old gramma lies in withering pain in the waiting room!"

2. We don't send 80 year old grandmas with chest pain to the waiting room either - especially with abnormal EKGs. We just add onto the burden of the ER nurse already dealing with 4-5 patients with a new, potentially critical patient. Because y'know.. that's safe practice.... and all that...

The stretchers have wheels and they can be moved out of the room with non-emrgent patients on them so you can then put the CP Grannies in

Well aware of that, thanks!

I also mentioned that the problem is : "would you like the nurse taking care of your Father or Grandmother, to also be responsible for 5 other patients? Or would you prefer that the nurse be able to hand off her patient load momentarily so that s/he can pay undivided attention to your loved one in their hour of crisis?"

Problem ain't 'bed availability'; it is almost always "staff availability!" You can put all the beds you want, but unless you have a nurse to cover it - it is useless!!

That's what we did anyway, back in the Dark Ages.

Were your "patient populations" and "Chief complaints" the same from your time as they are today? What was the morbidity and mortality of your decade as compared to say the present decade? Did you have to deal with Press Ganey and JCAHO? What was the ratio of admits - med/surg, Tele, ICU? The patients who get admitted to ICU today and lived, would they have survived 'back in the Dark Ages?'

Because this just smells of what I experienced when I was in the Army - "You know, back in the Day when the Army was ARMY; we never did ...."

As already addressed, headaches can indeed be serious.

Both my Mother and her Sister suffer from horrific migraines and headaches. My best friend was almost hospitalised because of intractable pain from migraines. His wife takes a bucket of medication everyday to try and avoid a flare-up of her debilitating migraines. I've ordered a stat head CT by protocol on a young male patient who came in with c/o "headache" against the judgement of the charge nurse and the attending ER doc who didn't think the patient was "that sick" - who ended up being a bleed from a ruptured AVM.

So yeah, I know that "headaches can be serious!"

Some migraines require a strong opioid to "reset" the pain cycle.

"Opioids

There are numerous disadvantages to the use of opioids in the treatment of migraine, and they typically should not be used as first-line therapy. First, opioids are not as effective in the treatment of acute migraine as other agents, such as dihydroergotamine (DHE),²² ketorolac,²² butyrophenones, and the phenothiazines with more side effects.⁸^,²³^â€“²⁴ In a study comparing treatment with chlorpromazine and meperidine, chlorpromazine was more effective and patients receiving meperidine were more likely to need rescue medication.⁸ Opioids may also render acute migraine medications, such as triptans, less effective²⁴ and may impair the effectiveness of migraine preventives.

In addition, opioids have the potential to promote chronic migraine²⁵ and probably medication overuse headache.²⁶^,²⁷ Using opioids as first-line therapy for acute migraine in the ED is associated with an increased risk of relapse and need for return to the ED.²⁸ Migraine patients with opioid dependence have more disability, depression, and anxiety issues when compared to those who had not with similar headache frequencies.²⁹

Despite these many disadvantages, opioids are still frequently given as first-line treatment of acute migraine in the emergency room,²^,²⁸ and this use is not at all understood.³⁰ Education about the proper role of opioids in headache management is an important component of neurological consultation in this setting.

It may be reasonable to consider opioid use for pregnant patients who are refractory to first-line migraine therapies such as fluids and antiemetics, as nonsteroidal anti-inflammatory drugs (NSAIDs) can only be used in certain trimesters of pregnancy, ergots are contraindicated, and in general triptans are contraindicated.³¹^,¹⁰⁴

"

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3737484/

"I am under the care of a neurologist, have been for 20+ years. When all of the prescription treatments my neurologists has given me fail and I am going blind and vomiting from the pain....YES I go to the ER at her request (after calling the on call neurologist for further instructions). If they tell me to go to the ER I go!"[/Quote]So the Specialist who deals with migraines/headaches sends you to the non-specialist, generalist in the ER with zero-to-no-training in handling chronic pain/headaches.
And if it is anything like around here, said specialist never bothers to call us and say "Hey, my patient J Doe is coming in for intractable migraine. This is the history. This is the treatment and meds we've tried. This is what I'd like done yadayada."
Just to be clear - I'm NOT accusing you or anyone else of anything. I'm merely stating the situation as is. Because this isn't limited to migraineurs - sickle cell, fibromyalgia, chronic back pain, RSD, neuralgia... you name it. ALL manner of chronic conditions are sent to the ED - the place least equipped to manage it appropriately.
Pain - especially chronic pain lacking any changes/acute presentations - is not an emergency.
cheers,

wowohwow · Jul 7, 2016

My sister has migraines and has been going the botox route at her neurologist. Not sure if they really work. I had a neighbor who said they did nothing for her.

Oh, and the local hospital puts migraine sufferers in the fast track when it is open.

A&Ox6, MSN, RN · Jul 7, 2016

[quote=

Just to be clear - I'm NOT accusing you or anyone else of anything. I'm merely stating the situation as is. Because this isn't limited to migraineurs - sickle cell, fibromyalgia, chronic back pain, RSD, neuralgia... you name it. ALL manner of chronic conditions are sent to the ED - the place least equipped to manage it appropriately.

Pain - especially chronic pain lacking any changes/acute presentations - is not an emergency.

cheers,

I appreciate your response, but I think there are some errors in what you are saying.

First of all, I work with children with sickle cell disease on a regular basis to help keep them out of the hospital. We focus on self management and the like. However, as pain can be a sign of VOC (vaso occlusive crisis), we do need our clients to get emergent care for this pain. While the hematologist should see the child at regular intervals and soon after an episode, it it's unrealistic to expect that they see the patient within the needed timeframe if this occurs at night or on weekends. My clients do tell me that they avoid emergency rooms, even in an emergency because they are often labeled as drug seeking or not requiring emergent care.

Going back to other chronic conditions. Every condition had signs of am emergency. As an example, I have chiari I malformation. I am well managed, and not yet a candidate for surgery. However, I know that if I experience certain symptoms such as severe headache with stiff neck, hemiparesis and new symptoms, it could be a sign of an acute herniation.

I understand that emergency nurses are stressed and often have too many patients too deal with. In a past job I was often floated to the emergency room. I just want to remind you that individuals with chronic conditions may or may not seem to need emergent care, but oftenthey are following a treatment plan. Also, remember that providers who see clients on an outpatient basis need to send individuals to emergency rooms because of the nature of office hours. Lastly, some clients go to am emergency room because they have poor health management.

Finally, I will agree that not everyone who goes to the emergency room needs to go, but please don't take it out on those with legitimate chronic diagnoses. Why should sickle cell and migraines be treated any differently than diabetes and hypertension. All for can be managed in an outpatient basis but may have specific symptoms that necessitate emergency room visits.

EDRNCCmom, MSN, RN · Jul 8, 2016

Let me just say that I have been following this thread and it has came to my mind as I work. Just yesterday, I had a patient come in via ambulance for a headache . . . she was a patient who truly deserved to call an ambulance to get to the ED. She had been vomiting for over 12 hours due to the headache and couldn't keep any medications down. She arrived actively vomiting, pale, diaphoretic. Needless to say, she got the whole work up - EKG, labs, urine, CTA of head and neck, and a whole cocktail of medications. When she left, she looked better than when she came in. I have to say that one of the nice things about being an ED nurse is being able to make those with severe headaches feel a lot better!!