Can an ER doctor order an MRI or does that order need to come from your family physician or specialist?

Did you share with Osorareo?

I’d go back to the ER. Most hospitals have CT and MRI equipment. If nothing else they for sure could do a CT scan. I went to the ER a few months ago for gallbladder pain ( I didn’t know what it was at the time ) and they did a CT scan on the spot and then my doctor had me do an abdominal MRI as a follow up.

The ER can definitely get an MRI done. Not every one has one on site though, so sometimes it’s still referred out to a specialist. A quick call to the nearest facility would be able to tell you if they have one, or where the nearest is.

CT has already been done.

That’s what folks without primary care do: go to the ER. Definitely go.

The other option is urgent care, but if his symptoms are worse, then go to the ER.

Edit:: urgent care is the in-between option, and an urgent care doc can also order an MRI.

Some good advice I read once:

Ask people who can’t help you, “what would you do in my situation?”

Call the ER people and ask that. Include all your medical and financial concerns. They deal with these situations every day.

@jaytkay I’m not calling the ER today since it’s Sunday but it’s on my list for tomorrow morning. I know Fluther has doctors as users so I figured it wouldn’t hurt to ask. The users here can help me in many ways and maybe offer some suggestions I would not have thought of. We’ve been getting the runaround by many medical personnel.

ER docs will only do what is an emergency. They generally will not order tests that require long term follow up.

@jonsblond

Understood.

Good luck.

I have said for many years that I’m really healthy, but dealing with insurance makes me sick.

That’s what I needed to know @osoraro. I’m considering taking him to a larger hospital ER an hour away but Jon thinks he’ll be sent home again with the same orders. It will be a wasted trip.

At the hospital I work in, the hospitalist (doctor that works only for the hospital) has to see each patient in the ER and determine whether the patient is admitted or released. The hospitalist is the one to order more tests and/or a consult with specialists.
I think Jon should return to the ER.

I am not a doctor nor do I have health care experience.

I guess I should back up a little. It’s recognized in health care that people have the right to pain management, so if he is in pain, then you should take him to an urgent care for the pain issues or the ER if urgent care isn’t available.

If he’s at risk for organ failure, some kind of permanent loss of body function or death, then without question he should go to the ER.

The ER’s job is to “treat and stabilize,” so they will generally provide whatever treatment is necessary to stabilize someone’s condition.

Here’s a summary:

Hospitals have three main obligations under EMTALA:

Any individual who comes and requests must receive a medical screening examination to determine whether an emergency medical condition exists. Examination and treatment cannot be delayed to inquire about methods of payment or insurance coverage. Emergency departments also must post signs that notify patients and visitors of their rights to a medical screening examination and treatment.

If an emergency medical condition exists, treatment must be provided until the emergency medical condition is resolved or stabilized. If the hospital does not have the capability to treat the emergency medical condition, an “appropriate” transfer of the patient to another hospital must be done in accordance with the EMTALA provisions.

Hospitals with specialized capabilities are obligated to accept transfers from hospitals who lack the capability to treat unstable emergency medial conditions.

If the original ER docs thought it warranted, they would have had Jon admitted to the hospital (e.g. the med/surg or intensive care departments) which would have provided him with more immediate testing, possibly including the MRI, but they seemed to think it could wait.

I have used a walk-in clinic doctor as a referring physician in the past. Basically, I walked in, explained that I didn’t have a primary and this situation needed to happen. She told me that it was not unusual to do this.

I live in Canada, but a walk-in clinic would have been my suggestion, too. That’s what one does here (whether public or private) when one needs a prescription, referral, etc. and doesn’t have a GP.

I didn’t consider a walk-in but that is a great suggestion. I’ve had an x-ray ordered this way before.

Our walk-in is affiliated with the hospital he went to. I’ve had a PET scan at this hospital in a mobile unit that came once a week. I wonder if it’s the same for an MRI? It’s a small hospital.

Certainly ER doctors can order an MRI, but you may be fighting hospital policy.

Just to expound on my prior answer, who is going to follow up on the MRI results? Who is going to order surgery/PT/ortho/neurosurgery/ referral or whatever? It’s not the ER doctor’s job to do that—it’s a primary doctor.

If Jon came into the ER saying, for instance, “I can’t move, I’m paralyzed, or my pain is disabling” then he could have gotten an MRI, been admitted, and had emergency surgery or whatever. That’s really the only situation an ER doctor will generally order a test like that. It’s not tha they’re being jerks or anything.

My dad is a retired ER doc. Absolutely they can do MRI, CT, CT with contrast, X-rays – -they can order anything they deem important.

However, if Jon is stable (but still having symptoms) I can see why they sent him home.
They are telling him to find a Neurologist and/or Internist. This is the correct next step. No one in the ER can do anything but admit him—and he’ll STILL need a neurology work up.

Best to pick the best possible Neurologist (or Internist if there is more than one thing going on – because they’ll coordinate care between multiple specialists) and then see him/her. You’ll then want to go to the Hospital where THEY have admitting rights. (Not all doctors treat at all hospitals. Usually they have just one or two they are affiliated with.)

Ask around locally. Even call a few doctors and ask who THEY would pick.
If your area has a list of “Best Doctors” (ours does in a magazine released every year) see if you can get an appt. there. When you call stress that it is URGENT and that you’ve already been to the ER. Do NOT let them push your appt. out X number of months. It can be tough to be an advocate—but the squeaky wheel gets the oil as they say… Push hard for an immediate referral or visit.

They should be able to do the MRI in the hospital, as part of the ER visit. That’s way quicker than going home, calling a doctor, going to see him (generally a few weeks to get an appointment), and then he writes the MRI prescription and that takes some time to get. Outside of the ER, you’re looking at possibly 3–4 weeks from start to finish (at least around here that’s what it takes).

ER cares that the person doesn’t die on their watch or within a short time after discharging the patient. An ER doctor certainly can order an MRI, but they would only do it if they felt the test was necessary to address an acute emergency at that moment. If the CT is thought to have ruled out anything life threatening in the moment or ruled out further inpatient hospital treatment that is justified at the time you are there, then you’re sent home to follow up with a doctor.

All that crap the conservatives (some conservatives) say about people can always go to an ER and get treatment is half baked. I won’t continue on that tangent though.

I would call the doctor’s office Monday that you have the appointment for and say his symptoms are worsening and he has been to the ER twice already and if possible can they see him today or tomorrow. Push them to squeeze you in.

Has his records been forwarded to the doctor already? You can make sure the doctor has everything he needs from the hospital when you call.

Hopefully they feel that his dizziness and pain justifies the MRI. I would think if someone is dizzy, they’re at risk of falling and doing a grave injury to themselves, so they should see that as something to try to diagnose asap.

Was his CT with contrast?

I just realized you might be going to see an internist or GP. This problem sounds like a do not pass go, go directly to a specialist. Will your insurance allow you to go to a neurologist directly?

@JLeslie Most specialist will not see a patient without a referral.

—a little history about the first visit to the ER—-

Ten days ago Jon was working and getting ready to leave for the day. It was Friday and he was looking forward to the weekend. Out of nowhere he dropped to one knee. He felt like he was going to pass out. His fingers went numb and he felt a strange tightness and cold sensation on the right side of his face. He thought he was having a stroke. These episodes came on every five minutes. A co-worker called 911. He was taken to the hospital. When I arrived the EMT told me that Jon came close to cardiac arrest on the way to the hospital. His heart rate dropped every five minutes during each episode, with each episode lasting for 30 seconds. It was very similar to contractions.

A CT scan without contrast was done and nothing significant showed up so they focused on the heart. They called a specialist an hour away and sent Jon by ambulance to that hospital. He was admitted to cardiology for 12 hour evaluation. He was released after 18 hours. He was stable during his stay and did not have any bad episodes.

I understand why the ER focused on his heart, but I wish they would have also done an MRI during the first visit. We could be ten days in to getting him on the road to recovery, but instead he’s suffering and using up vacation days that are dwindling fast.

I don’t know because I don’t live in the us, but this happened to me at an empty train platform in the hills. Ambulance, hospital, they did Mri with contrast. I was there overnight. Good luck to you both.

And a ct scan.

All the best. Really and truly hope things smooth out soon. I wish you courage and strength.

@chyna I think it depends on the doctor and the specialty. I have seen oncologists, endocrinologists, ENT’s, and dermatologists without a referral. I go directly to specialists more often than not. Some do require referrals, I don’t dispute that, but not always.

The ER doctor might be able to do the referral. The GP can order the MRI, but I really doubt this will be solved without a specialist, @osoraro can comment on whether he would be likely to refer this to a specialist or not. If so, more money spent by the insurance, more spent in copays, and more spent by everyone in premium payments.

I just hope that if they do go to the GP and the MRI shows something that needs to be treated and evaluated by a specialist, that the GP just does the referral at that time and doesn’t make them come in for the follow up appointment just to tell them they need to see another doctor. The waste of time and money and gas to get back to the GP’s office is frustrating to me and will be to the blonds. They don’t have a relationship with their family doctor that they might appreciate the hand holding and someone coordinating their care.

@jonsblond Who suggested the MRI? Do they think it will likely show something? Or, is it to rule out things?

I had Guillain Barre Syndrome about 7 years ago. I went to the ER, got a CAT scan of my head, was kept in the hospital, got further assessment, and stayed in the hospital for almost a month. Just an example of what they can do when they’re smart enough.

Another thing: not all insurance plans require a referral to see a specialist. With mine, for example, if I feel a need to see a dermatologist or neurologist or whatever, I just go.

@jca They admitted you. That’s the major difference here, I’m pretty sure Jon is being discharged from the ER. It might be because of insurance coverage, that wouldn’t surprise me. Or, it might be the ER doctor didn’t think he was in immediate danger. Sometimes the hospital goes too far the other direction (too often) gets you in a hospital bed on a floor and then the hospitalist calls all her doctor friends she can justify in the specialties to come visit the patient and start billing.

Sometimes doctors require referrals having nothing to do with insurance. Each doctor is different. I have the same experience as you overall, I just call up and make an appointment.

@jonsblond: @JLeslie is spot on on two points. First, a hospital’s experiences with a patient’s insurance carrier no doubt is a major determining factor in the quality of care provided. Simply put, patients whose insurance is known to be easy to receive full (or very nearly full) reimbursement will receive much better care than those who do not.

Second, ER doctors are experienced in making snap decisions in life or death situations where seconds count. When this type of decision making carries over to less emergent cases, seemingly minor, yet important, details do get overlooked, leading to situations like the one posted here. Plus, I suspect the time of day and day of the week subconsciously affect the doc’s decision making processes.

The fact remains, however, that a patient (or close relatives) remains his (or her) own best advocate when it comes to health care. The challenge becomes one of striking a balance between being forcefully assertive (in a diplomatic way) and being seen as overly aggressive or demanding. Where that balance lies is a question I have yet to find the answer to.

And, yes, literally pounding on desks in the ER is, on occasion, the only way to get the attention of the doctor and the nursing staff.

Sometimes it is not better care, sometimes it is extra unnecessary care. I had a shitload of tests done at the ER after an accident that I am very very upset about. Very. I can’t emphasize it enough. If I had had no insurance I feel pretty sure they would not have all been done. Once inpatient I had what I believe to be an unnecessary visit from a neurologist, ok I’ll say the first visit might have been justifiable, and an unnecessary MRI. I also feel I could have been relieved of my most debilitating symptom if they had just had the ENT come to see me before the neurologist, or if the ER doctor had been trained in the Epley maneuver to relieve my vertigo, which some ER doctors are. Not to mention the X-ray tech had to take two hits of radiation, because he had to hold me in position.

Anyway, the upshot is the money does influence things in many ways. Unfortunately.

@JLeslie: Yes good point. The times I’ve been in the hospital (Guillain Barre and weight loss surgery), students come to the bedside, ask how are you doing today, a one or two minute visit, and then bill the insurance company.

How is Jon today?

Yesterday wasn’t so bad but he’s having another terrible day today. We have the blinds closed and he’s sitting on the couch with his eyes closed. That’s about all he can do right now. His mother and I were close to insisting that we take him to the ER an hour away but he refused whenever we brought it up. Then yesterday he told me that he considered it Sunday because he felt so bad, but he didn’t want to travel if they would just release him again. It’s ridiculous that he can’t be seen sooner. No one will help us.

You need an ER that’s in a big city, that is more likely to have the best doctors and most recent equipment.

Did they give him pain meds?

It’s definitely not a migraine right? I only ask because it’s on one side. It seems to me he describes it as nerve pain, not a headache, but I thought I would ask. I’m stressed out for him, I can’t imagine what it is like for you both.

He’s not experiencing pain. He describes it as pressure and dizziness and light and sound make it worse. He can hardly walk without feeling like he’s going to pass out. He has trouble remembering words and he’s had times when he smells things and has a weird taste in his mouth. The ER gave him antivert and it helped a little when he was still there, that’s why they released him because he was able to walk around once it kicked in, but now he says he’d hate to see what it would be like if he wasn’t taking it. He doesn’t know if it’s helping at all.

They talked about migraine, but this is extreme and a migraine wouldn’t make his heart rate drop like it did during his first episode.

Just awful. I have a feeling it could be several things. I don’t know for sure what though. Probably the hospital just ruled out aneurism, embolism, elevated cardiac enzymes and cardiac electrical problems.

Scary, @jonsblond – I hope he gets better soon. I’m sorry if you answered this already and I missed it, but did you decide where to go next?

He’s refused my suggestion to go to the ER at a better hospital 60 miles from here. He’s trying to wait it out until his doctor appointment Thursday morning. He agreed to go to the ER then if the doctor doesn’t send him first.

I think I would have refused too. I’m not saying it’s the right thing, just saying the ER hasn’t done anything worthwhile so far and it’s horrible having another doctor tell you nothing and do nothing.

Do you have a blood pressure cuff at home so you can see if his blood pressure is dipping dangerously low during these episodes? That could definitely cause vertigo and nearly passing out..

That’s a good idea @geeky_mama. I was just talking to him about this ten minutes ago.

He saw a doctor today and the doctor ordered an MRI. It’s scheduled for next Wednesday. The doctor mentioned it might be a strange virus but he really has no idea. 7 viles of blood were taken and he’s also ordered a holter monitor. Hopefully we’ll have an answer by the end of next week.

Yep, a holter monitor makes the best sense. That will track these episodes. It sure sounds like some potential symptoms of Bradycardia (slowing / stopping of the heart rate for short intervals)..but then again, a lot of other things can cause vertigo and near-passing out.

FWIW, my grandmother did have a similar virus at one point that kept her bedridden (when she was otherwise healthy as could be) – she had severe vertigo and would pass out if she attempted to get up. She complained of intense headaches and we just had to keep her in bed and attempt to get her to eat for about a week or two.

After that she was back to her regular vim & vigor—traveling and doing all that she loves.
So…not that my non-professional (and completely anecdotal) opinion counts for anything – but what you’re doctor is doing now is what I’d advocate for if I were in your shoes. Sounds like it’s headed in the right direction—and hope he feels MUCH better soon.

Update: Jon had a great day yesterday. The best since this all started. We thought he’d have another good day today, then an episode came out of nowhere. He feels terrible right now. We received the results of his blood work and the only thing that stood out was a vitamin D deficiency. They said it was very low. The MRI is still scheduled for tomorrow.

Thinking of him and sending prayers and green light to all of you!

Insurance would only let Jon have an MRI without contrast. They will do an MRI with contrast if something is found. (ugh. we are so unhappy with the state of medical insurance and health care right now.)

He was told that results could be in that evening (Wednesday). It’s Friday and we are waiting anxiously for the results while my husband sits and suffers. He’s been dealing with this for three weeks now with no definitive answers.

Maybe be the squeaky wheel and call and say it’s intolerable and can you get some answers right away. Just at least know if nothing turned up on the MRI.

His symptoms became worse the past two days and he developed a terrible headache. Tylenol and Ibuprofen didn’t touch the pain. We called his doc and they told him to go to the hospital. This was our third trip to the ER since Feb 13.

They had the results of the MRI. No lesions, tumors or abnormalities on his brain. They did find several cysts in his nasal cavity. The ER doctor didn’t think that was causing his symptoms. She said to follow up with his doc on Monday and the next step might be a spinal tap.

So now what? He sits around at home and waits for doc appointments and tests? What ever happened to admitting someone and finding out what’s wrong? He has run out of vacation days. There will be no paycheck in two weeks.

^ I’m so sorry. I told your story to someone arguing against socialised health care last week…shut them up.

@jonsblond He doesn’t have long term disability at work? That usually starts kicking in after a certain amount of sick days.

You say ibuprofen and Tylenol didn’t touch his pain, aren’t they prescribing him super duper pain killers?

@jonsblond – I’m really sorry you’re not getting any answers. Everything I type here seems really inadequate, so I’ll just leave it at that.

What I would do if my wife was in Jon’s spot
– request medical records from every office you’ve been to. Part of the problem is getting everyone all the information, so it’s best to have your own copy. When we did this, for some reason medical records are stuck in 1985, so they want to fax them, and act like you’re asking for government secrets, but it gives you some options. I’d get that process started. (payperfax.com gives you a fax number pretty cheap, and send you an email with the pages received)
– Find someone who’s interested in getting Jon better, beyond just making another appointment, maybe this is your existing doctor, you’ve got a better feel for that, maybe it’s a doctor in the big city nearby, but it’s time to get one person that’s going to follow through and know your situation.
– Explain to that person what this means to your family as honestly as possible without complaining. It makes a difference and they need to understand 4 days waiting on another appointment is 4 days without income and 4 days of watching your husband (and your kids father) in pain. They see sick people all day, and people tend to become puzzles or appointments and it’s hard to imagine their lives outside the office. They want to help people, and I think most people could imagine themselves or their partners in your situation, so let them know you need their help and you’d really appreciate some time and honest advice. It makes a difference.

You might be doing all of this already, and Jon’s lucky to have you with him. Please don’t take this as anything other than someone who wants to help.

I am all for having your own set of records, but each place is going to probably charge you $25+. Hopefully not, but just be warned. If the primary care doctor requests everything it gets sent to him for free and then you can pay him one fee for all the copies possibly.

Just an option to think of.

The MRI and CT can be copied on disks. The reports for those would be in the chart.

Have you freaked out yet and started demanding things? It’s best to be calm and firm, but sometimes calm means the doctors don’t think the person is in enough pain to warrant immediate action. It’s easy to be overlooked.

My advice is go to a different ER. I have a story that is too long and detailed but it involves me getting sent home from one ER, deteriorating at home for 3 days (as per the doctor’s instructions) and then being brought to another ER where they pursued a different angle and I ended up hospitalized for almost a month. So obviously, when you go to the ER you have been going to, they are looking at things one way and Jon’s case needs a different angle, a different set of eyes.

@jca I agree and that’s what we did yesterday. The ER physician didn’t think the cysts were the main culprit, but after I did a lot of research I disagree. I read numerous complaints from people with every symptom that Jon has and they all had sinus cysts. It took weeks or months of suffering before they finally found the right diagnosis. Most of these people were referred to a neurologist when they should have seen an ENT.

We are going to insist (or as our daughter said “incyst” she has her dad’s sense of humor) we explore that route before a neurologist. Antihistamine is easing his suffering some. They gave him some at the hospital last night and it seems to be helping.

I wonder if a steroid nose spray would help? That’s something I think your GP could prescribe if you have to see him again and if he agrees. I don’t no if it is a good suggestion or not, just putting 2 and 2 together. If it gives him relief maybe that is more information supporting the ENT route.

Follow your gut I think, go to ENT and have a back up appointment with neurology that you can always cancel. It will help cut waiting time to see a doctor if you have the appointment already set up.