Migraines From an ER Doctor’s Perspective

I became interested in guest blogging for Migraine.com after reading a few insightful articles about migraineurs' perceptions and feelings about the ER and ER staff.

As an emergency room physician I was surprised and saddened to hear that many migraine patients feel that they are treated like drug-seekers in the ER setting. I hope to express some ideas throughout this post to improve communication between migraineurs and staff in the ER setting.

As an ER physician I will be the first to admit that “migraine headache” is not a chief complaint that most ER doctors climb over each other to evaluate. On the other hand, I find much gratification in treating migraines in general because there are so many treatment options and the success rate with migraine patients in our ER is very high. I do not perceive the chief complaint of “headache” or “migraine” as a drug-seeking type complaint. In fact, at least in the upper Midwest, I would say it is highly unusual to find a board-certified ER physician who attaches that stigma to migraine patients in general. Perceived or real indifference, on the other hand, particularly given our collective personality flaws as ER doctors, is much more likely to be encountered by a suffering headache patient.

In the ER, our approach to all patients (not just migraines and other headaches), is very straightforward. Unlike most other clinical settings, we do not work from the most likely diagnosis to the least likely diagnosis. We give priority to threats to life and limb. Our first task is to triage all patients/complaints into those problems which are life threatening and those which aren’t. It is absolutely vital that this be the case during a busy ER shift where there can potentially be several life-endangered patients at once. Most physicians in the ER will triage someone literally within seconds of entering the room and the treatment and evaluation plan for most complaints is completely established within most physician groups based on clinical studies and community practice standards. Headache as a collective problem is usually quite easy to triage. In general, the historical features and presentation of an unfortunate patient with an acute life-threatening headache (such as an intracranial hemorrhage or meningitis) is much different than recurrent non-life threatening headache (migraine, tension, and cluster headaches for example). That being said it is a universal (or it should be) that you will be given the benefit of the doubt. If there is question as to which general category you, as the patient, occupy, you will be given the more extensive workup (CT scans, lumbar puncture, MRI etc). Some unusual migraines with associated neurological symptoms will often be worked up again and again for possible CVA (stroke).

Often a physician who is pressed for time may give you, the patient, far too little time based on the initial assessment. If your clinical appearance is better than the patient in the room next to you, the other patient has to be prioritized. This can obviously be interpreted as an intentional slight by any patient (how else should a patient take this when they feel terrible, sitting in the ER and the doctor zooms through in a minute or two?). It is our job to express this to you as best we can, and hope there is some understanding. The vast majority of the time patients understand this.

What are the patients’ rights in the ER?
Legally-speaking, all patients who present to the ER are entitled to a “medical screening exam”. I believe that patients are also entitled to respect, relief from suffering, and compassion. My priorities when patients come to the ER are

  1. evaluation and treatment of life-threatening and long-term disabling medical problems
  2. provide relief of suffering to the patient
  3. counsel and listen to the patient and family
  4. make an effort to make a specific diagnosis in non-life threatening situations.

You will notice that an exact diagnosis comes toward the end of the list. Often an exact diagnosis in the non-life-threatening cases is beyond our scope in the ER. Many patients are frustrated to leave the ER without an exact diagnosis, but we often just don’t have the time or expertise to iron-out exactly what variant of migraine headache or non-specific abdominal pain, or rash etc. a patient is experiencing. It is definitely not because we don’t care, but this approach is necessary based on time and resource limitations.

What are ER Staff rights?
It is our job to empathize with patients, so why am I expressing the ER staff’s rights? My main goal with the article is to help you get fast, effective treatment in the ER. I think it is absolutely vital for ER nurses, techs and doctors to be treated with respect. This is common sense for most, but I cannot believe how badly we are often treated by patients. We know you are uncomfortable and we truly want you to feel better.

I believe ER staff is also entitled to honesty. Lies and omissions can kill people in the ER. This is the one time that I will prematurely end my treatment for a patient. If I have cleared the patient medically, and the patient lies to me, I will often ask the patient to leave the ER. Ten out of ten pain is difficult for most people to experience in a lifetime. The closest I have come was in a taser study and I maybe hit eight out of ten pain. I understand this is completely subjective. If you are truly experiencing the worst pain imaginable, by all means tell ER staff, but a realistic appraisal of your pain is very important. My bias is that 8 or 9 on a scale of 10 is much more believable that full 10/10 pain.

Continue Reading - Part 2: ER Strategies for Migraine Relief

Dr. Kyle Kingsley is board certified with the American Board of Emergency Medicine and a member of the American Headache Society. He currently practices emergency medicine in multiple hospitals in the Midwest. His interests include his two young children, health/fitness, triathlons, and Eastern medicine, particularly when it is applied to chronic health issues including chronic headache conditions. Dr. Kingsley studied acupuncture and alternative medicine in Cuba in 2003. He also presented his unpublished study “Acupressure in the Treatment of Benign Headache” at the Society for Academic Emergency Medicine annual meeting in 2005.

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