An Ounce of Prevention...

    My pager went off - again. It was CCU - again. "Hi Susan - it’s Alice." "We’ve got another one. This guy’s bad." "On my way."

    "Another one" meant, in medical jargon, another chest pain/rule out MI. Translated, another patient having chest pain, on whom we were performing the tests which would either rule out or rule in a heart attack. "Another one", to me, a case manager, meant another person traveling from somewhere else who might need a lot of social services and insurance intervention. "This guy’s bad" meant "get down here NOW."

    They always called me for these patients. In addition to being a critical care nurse and a nurse case manager, they knew I was a full time RV’er. I went through my mental check list on the way down in the elevator. How far away from home were they? Where are they staying? What kind of rig do they have? Is the person traveling alone? If not, can the other person drive it? Will they have their medical records with them? Will they know what medications they are on? Is their insurance an HMO? What kind of social and emotional support might be available for a frightened spouse? Is there family? If so, how far away?

    I walked into CCU. Susan pointed to room 5. "Doctor wants to know where he can send him." Code cart outside the door - not what I wanted to see. I stopped and pulled a face sheet from the chart. Patient was 56, male, from Michigan. Wife listed as next of kin. Insurance was a Michigan HMO. I glanced at the monitor - didn’t need to run a strip to see the ST elevation - probable heart attack in progress.

    I walked into the room. Looked at the IV stand. Nitroglycerin drip, heparin, maintenance IV. Looked at the patient. Pale, frightened, oxygen under his nose. Looked at the bedside table where the nurse was taking her information - noted the lidocaine and atropine syringes near her hand. Looked at the monitor - blood pressure in the 80’s. Finally looked at the chair by the window. Pretty woman about my age, scared to death and doing a good job of hiding it.

    I introduced myself. "Hi, my name’s Alice, I’m a nurse case manager. I understand you’re traveling from Michigan?" Little by little I got my information - most of it bad news. No, he didn’t have his medical records with him. He had never had any problems before. He wasn’t on any medications. They had just gotten in last night - staying at a local commercial park - were on their way to Oregon to see their daughter who had just had a baby - had been driving 10 hour days in their fifth wheel. "You know how men are - they never want to stop." Did she know the name of their primary care provider? Did she have his number? Yes, no. What town is he in? What is his first name? Do you have any friends or family locally or in the state? No. Can you drive the fifth wheel? "Oh no, I’m afraid of it - it’s so big. Jerry always does the driving."

    Into my standard explanation. Jerry has had a heart attack. The good news is he had classic symptoms - crushing chest pain, cold sweat, nausea - and they called 911 and got him to the ER. We "clot-busted" him - thereby preventing permanent heart damage - we hope. The bad news is, we are a small rural hospital. For further diagnostics and treatment, we need to get him to a metro area. Her eves widen. "Don’t worry", I say. "You’re not in this alone. I do this all the time. Let me talk to your insurance company and find out exactly what we need to do; then we’ll call your daughter. Jerry’s going to be just fine. When was the last time YOU ate or slept?"

    Check with doctor. Yup, big inferior MI (heart attack affecting the back wall of the heart). Yes, he needs to go out - helicopter if possible. "Can I send him where I want?" Probably not - let me call his insurance. "Make it snappy - I don’t like the looks of this." Neither do I.

    Ten minutes in voice mail hell. Finally a live human being. No, they don’t contract with the doctor’s comfort zone. (Hospital and associated physicians which he works with all the time, knows, and trusts.) "We only contract with two hospitals in your area. I can fax you a list of physicians in our system." OK, now please. I have an unstable patient here who needs treatment. By the way - I need authorization for air transport. "That will have to come from the PCP." (Primary care physician.) Can you give me his number please - I’ll put him in touch with our physician here. Out to the fax - here it comes. Thank goodness - I recognize three cardiologists. Now if one of them just practices out of one of the approved hospitals. More phone calls - we are in luck. All three physicians are on staff at one hospital. Names, numbers of PCP and cardiologists to doctor at desk. Quick explanation - talk to the PCP first please, so I can set up the chopper - need his OK. Let me know when you have an accepting doc - I’ll call for a bed meanwhile.

    Back to the wife. Patient is asleep - read sedated. Unfortunately, she’s not. "I’m working on a transfer - I’ll let you know how soon. Can you drive the pickup?" She can. "Is the trailer unhooked?" No. I’ll deal with that later.

    OK. PCP says do what we need to. Doctors have spoken, agree. Bed available in CCU, cath lab alerted; they are expecting him. Chopper en route. Primary focus: patient is cared for. What are my remaining problems?

    How do I get spouse 150 miles south to join her husband? Should he need surgery, how will they get back to Michigan? What happens to the rig while she is waiting for him to get out of the hospital? Can we find a driver to take her and the rig south to be near him? Can they afford one? Do they have any insurance which might cover that? HOW COULD THIS HAVE BEEN AVOIDED?

    Well, let’s forget the fact that the patient is male, over fifty, a smoker, and about 30 pounds overweight. He can’t make lifestyle changes in time for a trip, and he’s stuck with his genes and gender. But one thing jumped out at me when talking with his wife. They had been doing 10 hour days with very few stops. Bingo. When you sit for long hours, blood pools in the lower extremities. Pooled blood likes to clot. This man had numerous risk factors for heart disease - meaning he probably had significant narrowing of his coronary arteries, even though he had, as yet, no heart history. So he sat for hours on end and created tiny clots in his legs, which broke loose when he started moving around. One of them got stuck in his right coronary artery, closing off blood flow to part of the back wall of his heart. It could just have easily ended up in his brain, causing a stroke; or in his lung, causing a pulmonary embolus; or stayed in his leg, causing a thrombophlebitis. Any of the above will get you a trip to the ER and an introduction to the limitations of your insurance. Not to mention panicking your spouse or significant other, stranding you and your rig thousands of miles from home; thoroughly inconveniencing your friends and/or family; and probably costing you big bucks.

    What can you do, besides never leaving home again? Well, for starters, STOP every two hours (at least) and stretch. Get out, walk around. Get a dog. He will force you to stop.

    Next, either make sure your travel partner can handle the rig or buy insurance which will get him/her and the rig back home. It does exist; it costs about $250 a year, and you can find ads for it in the Escapees publication and probably in the Good Sam stuff as well.

    Third, make a folder. In it, put the name and number of your primary care physician, if you have an HMO for health insurance and the names and numbers of family members. Include a copy of your medical history, if you have a medical history; and a list of your medications, if you take any. If you have any questions about what your insurance covers away from home, CHECK IT OUT. If you will be on the road a lot and your insurance only covers you within a 30 mile radius of your home, you might want to shop around. Read the fine print in your roadside assistance policy. Some of them cover some or all of medical emergency stuff.

    Lastly, this man was lucky. He’s alive and back in Michigan. His wife produced a son-in law who flew out and drove them and the rig back. They were both lucky in that our small rural hospital has a case management program with all too much experience in just this sort of problem. Many do not. And what if he had died just because he was in a hurry to get to Oregon?

    So don’t let long hours behind the wheel turn into long days in the hospital - or worse. Use your head - stop and rest and exercise - enjoy your trip. Plan for the unexpected - even the unthinkable. Have a backup plan. Life being what it is, if you plan for it, it will probably never happen.