Impending Emergency

Cancer patients end up in the Emergency Department.

Fact of life, can't be helped. Two big reasons:

• Cancers are deadly and have a whole boatload of complications
• Cancer treatments are deadly and have a whole boatload of complications

There's a little-mentioned third reason, though. It's called scheduling.

Cancer centers and hospitals stay booked solid. As mentioned here, a third to half of us will have cancer at some point in our lifetime. Expect that ratio to increase as average life expectancy does, and as treatments for heart disease get better. It's more of a question of when, not if.

Since the infusion centers, CyberKnife centers, outpatient clinics, surgery departments, and interventional radiologists are usually packed full a couple of weeks out, a patient in need of attention must often be admitted to the hospital to get treatment if something urgent, but not necessarily an emergency comes up. The means of admission? A 4-12 hour stay in the ED ( Dr. WhiteCoat says, "Don’t call it the “emergency room” or the “ER” to my face, in the comments, or anywhere else. Period. It is the emergency department." )  is the point of entry for such things. Sometimes this is while they double check what has already been reported, and sometimes to try and figure out if something else is going on with the patient.

Say the patient has a history of cancer- or chemo-related anemia and their doctor or doctors are having them get CBCs on a weekly basis. They'll keep an eye on white and red blood cell counts as well as hemoglobin/hematocrit, in addition to other things. Red blood cells and hemoglobin are mostly about oxygen transport (the glowing E.T. finger sensor) and you'll usually want an SpO₂ percentage over 92. The white blood cells and neutrophils are about the patient's ability to fight infection. Anyhow, if those numbers drop lower than they should, the patient will get scheduled for a transfusion (RBCs/hemoglobin) or a Neulasta injection (WBCs/Neutropenia). Usually they'll get scheduled a few days out, because cancer center scheduling revolves around uncertainty and missed appointments. Oncologists carry great weight and they can sometimes talk the nurse coordinators or clinical managers into wedging a patient into the schedule. This is why a patient must 1) be completely honest with their oncologist and 2) never, ever, ever be a no-show for an appointment at the clinic/hospital/infusion center, etc. (reschedule instead.) 

Despite an oncologist's pull, and despite fitting a patient into a schedule, sometimes the symptoms will get the better of them and they will deteriorate enough (shortness of breath or excessive fatigue, for instance) that the patient can't wait. You (patient or caretaker) must keep track of the symptoms, the trends, and make the hard decision to get to the ED. Just do it.

Wren's labs came back on Tuesday showing a low hemoglobin (7.9). Wednesday, she was clearly getting more and more fatigued. Her oncologist scheduled her for the first available transfusion at the infusion center on Saturday. By Thursday morning it was clear that she was still trending downward from a fatigue and shortness of breath standpoint, and we were at the ED just before noon on Thursday, by which time her hemoglobin had dropped to 6.1. A normal range for hemoglobin is somewhere between 11 and 15. If we'd waited until Saturday, the trip would've been in an ambulance, not the car.

She's still here, Friday evening, and there's a strong likelihood she'll be here through the weekend.

Caretakers and patients, keep that in mind. It is cheaper to pay for the ED visit than the ambulance transport or a funeral.

Keep track of the condition. Watch for new symptoms and worsening of old ones. Don't wait on the schedule if a symptom's downward trend is alarming. Call the on-call oncologist, let them know what's going on, and get your ass to the ED.