Monday, February 26, 2018

ER Nurses Guide to the Universe

I pretty much live in triage since I almost always work 3-11, a shift that attracts newer ER nurses as opposed to the dayshift dinosaurs.  There is a mandatory triage course but it requires AT LEAST two years of working independently in our ER, AND demonstrating the ability to consistently make good decisions.

Also an ability to separate the the truly sick from the truly non-sick, regardless of how much the patients/family members whine or demand a bed "right now", because their mother's brother in law is king of the hospital.  There is a lot of that kind of thing, name dropping and what-not.  Threatening to call your own doctor or chief of surgery has no bearing on the wait time if there is not an urgent need of care. And guess what?  I'm the gatekeeper, literally the one who decides how quickly you need to be seen.  As one of my favorite doctors says, every ER visit is relative.  It may be your worst illness or injury EVER (for YOU), but it may not be the worst thing in the ER AT THAT MOMENT. Needing to pick the kids up at the bus does not fast track the visit.

Sadly, there are those that will  employ underhanded means to get themselves to the head of the line.  High drama, embellishing symptoms, and outright lying to move up the visit food chain more quickly.  These are not the squeaky wheels who demand, scream, and threaten bodily harm, but the truth benders for whatever personal gain they might derive.  It's never a good idea.  It could compromise your care, perhaps even your life.  Or someone else's life, come to that.  So as a public service, may I suggest you not lie to your triage nurse.  Just don't.

Some top reasons for lying:

Don't lie if you have medical issues but choose not to take your prescribed meds.  Yes, we will think you are a dumb ass, but if you are supposed to be on medication for your diabetes or hypertension, we will not waste valuable time and resources trying to figure it out.  We can just go to the damage control and/or treatment phase.  Cutting to the chase is always best, and allow us to move on to the next patient who needs help.

Don't lie about whether or not you've been drinking, or how much.  We automatically at least  double the amount you tell us, for example, if you say 2 beers, we know it's probably a six pack.  If we smell alcohol and you say you have not been drinking, we know your BAL is 260 at least.  If you say you don't drink heavily every day like we suspect, because you have the look of someone who drinks every day, we will be waiting for you to withdraw.  Hope you don't have a seizure.

Don't lie about your opioid use.  You've been here before.  We used Narcan on you yesterday.  Those track marks on your arm are not "years old".  Your antecubital MRSA "spider bite"  is a dead giveaway.

If your pain doctor has fired you for lying, we know.

"I just fell on it."    C'mon.

There are far too many ER visits due to laziness.  Especially for people who aren't paying for it, but that's another whole issue.

Don't come to the ER because you didn't bother to contact your doctor for a refill of meds you use each and every day and tell us you "couldn't contact your doctor, been calling for days and my call has not been answered".

Please don't come because you "didn't have time" to call your pediatrician for a condition that your child has had all day or all weekend, such as an earache or sore throat, and it is now 9 PM.  Or got sent home from school at noon with a stomach ache, had lunch and a play date, and after dinner has a stomach ache.  Also consider that to us, a "high fever" of 100 is not a high fever.  If you haven't bothered to take the temperature because you are too lazy to buy a 1.00 thermometer and the child "feels warm" and you still didn't give any Tylenol, you will be waiting a long time.  Your child was not "lethargic" when he was jumping off the chairs in the waiting area.  He still isn't as he tears apart the triage office.  His "difficulty breathing" is real, though.  His nose is full of snot because you couldn't be bothered to wipe it away as you whiled away your time in the waiting area on your cell phone.

Your doctor is a douche if he told you "just go to the ER and tell them you need an MRI".  You won't get it, I promise, although it is not my responsibility to tell you that in triage.  You will have to wait a couple of hours and hear it from the provider.  It's above my pay grade.

It is really not cool to come to the ER if you are pregnant and say you are having vaginal bleeding so you can get a million dollar workup and picture of your baby.  Please go to the $1.00 store and purchase yourself a pregnancy test, and demonstrate some level of responsibility before you and your baby daddy sign up for all the freebies on the State Sponsored Breeding Program.


Nobody wants to believe they have a serious medical issues.    Heart attack.  Cancer.  Don't lie about how long you have had the symptoms.   Your significant  other knows and will rat you out.  Don't waste time that way.

If your doctor has put you on medication for your blood pressure, congestive heart failure and diabetes, please don't stop taking your medication.  You were already sick, the meds didn't make you sick.  None of these issues is going to get magically better.  In fact, you will get worse and probably die since you have refused to be admitted or follow a reasonable plan of care.

Here is a thought, on the issue of denial.  This is your son's third visit to the ER since the beginning of his pee wee sports program (usually football).  Might be a head bang, might be a leg or arm injury. Your kid is 12 and weighs about 50 pounds, his diagnosis is going to be "Not Suited for Contact Sports".  Think about it, and please  let him do something else, I beg you.  He is going to get killed and he knows it, he's trying to save his own life.

Also on the issue of denial, your teen daughter had a mild allergic reaction to some antidepressant weeks ago.  Bringing her in for the last 3 nights at the same time with "difficulty breathing", and "it's happening again", with normal vital signs, fake gasping and wheezing to be treated by Ativan is not actually a breathing  problem, madam.  Your kid is probably having other issues as evidenced by the meds she's on.  She is having anxiety and no amount of you trying to make it a medical issue, and thus "easily treatable" is going to make it so.  Start counseling immediately.  And for god's sake, call the school.

You have an agenda

We are experts at determining who just wants narcotics.  Seriously.  There is no story we have not heard.  If you say your drugs were stolen we will expect that you have filed a police report.  Bringing a note from your doctor, copies of scans, and empty prescription bottles is laughable to us.  Bringing your kids with you is a rookie move.  Further, if your chief complaint is one of the Holy Trinity of pain complaints (back pain, dental pain, migraine) you are already suspect.  FYI, we are now RARELY prescribing narcotics for ANYTHING.  I'm sorry if your doctor told you to go to the ER.  Please put on your big boy pants and make an appointment.  And yes, dental care is EXPENSIVE , but you only get one set of permanent teeth.  Judging by the condition of yours you have not made it a priority, brushing and flossing being just soooooo tedious.

Work notes are handy to have when you have failed to go to work because you are sick.  Please understand that your work note will just say "seen in the ER today and OK to go to work", it will not explain why you have been out for a week.

One woman's chief complaint was "I'm really short of breath and I'm going to be homeless", and seeking a medical hotel admission which is basically someone to wait on her.  She then proceeded with concierge demands (sandwiches, juice, hot blankets, more pillows, phone charger).   She was kicked out eventually because there was no reason to admit her, although the social worker went to great lengths to help her with her situation.  The next day, she presented as suicidal in hopes of an inpatient psych admission.  Sorry, no beds for days.  What you will be getting is a 24 hour suicide  watch in the ER, paper plates, no food that cannot be eaten with your fingers as we don't allow utensils (so you aren't tempted to stab yourself in the jugular with a plastic fork).  Also, no TV, limited phone privileges, and a hard, uncomfortable ER cot.  Difference between a 4 star accommodation and a Motel 6.

Embellishment (to appear sicker, thus garnering a bed and hastening access)

An ambulance ride does not automatically guarantee you an immediate bed in the ER.

Don't call an ambulance if you don't need it.  This is the worst thing to do to your neighbors and community.  If your family members, all 15 of them, have preceded your arrival, please feel free to join them in the waiting room.  If your EMS providers patch in on the radio and tell us "well known to your facility", "normal vital signs", we will ask if you are appropriate for triage.  And out you go to join the queue.

Don't lie if you've been to another hospital and claim that you don't know why there are bruises on the arms and sticky residue from adhesive tape and monitor leads.  You didn't "just get blood drawn". That's three days worth at least, right there.  If you walk in on crutches that are about 10 years old and have tea towels on the arm pads, and claim that you "just got them",  your nonsense knee injury will be deemed bullshit and you will not be receiving the Percocet you claim is the only thing that works.

We have seen caregivers of every type and description bring their patients to the ER with everything from seizure to altered mental status to weakness to pulled out feeding tube.  Often these caregivers scarper at the first opportunity and are never seen again.  Some local nursing homes have been known to send a challenging patient or two to the ER on a Friday afternoon with "fever", which is non-existent on arrival.  When the patient is ready to back, they claim "their administration won't take the patient back because they are too disruptive/demented/violent".   We usually win the administrative sumo wrestling, our patient services rep is a more of a pit bull than your corporate clipboard.  The patient will return to your facility and you will have to deal with it on Monday, sorry.

Worst of all, DON'T EVER, EVER lie about chest pain.  If you are in the ER for chronic back pain, do not say you have chest pain to get seen quicker.  That is the ultimate dick move, and will not be treated kindly.  You will likely not die of the chronic back pain for which you have run out of pain meds, but somebody may while we attend to your nonsense.  And it will be well documented for your next visit for something potentially bad.

Karma.  It will get you.

Sunday, February 4, 2018

Dobby is free

In the midst of the busiest of busy days ever, this little germ pops into the ER for  evaluation of
"I can't feel my toes".

As this was a person in her late 20's, I was not concerned about anything truly serious until I saw that she was wearing a post op shoe. (AKA, Ugly Shoes: sizes small, medium and large).

"What happened to your foot?"

"Well I broke it a couple of weeks ago, and that is fine.  I was shoveling out my car from the snow, though, and now I can't feel my toes.  The officer who helped me thought I should get it checked".

She apparently did so in the last 20 minutes while wearing a sock and the post op shoe.  On one of the coldest days.

"I see.  Is your sock wet?"

"yes, I didn't have time to change it".

"Ah.  Well, here is a pair of dry hospital fuzzy socks and a warm blanket.  Take off the post op shoe and the wet sock.  It is about a 3 hour wait".


For the amusement of Fil, I documented the following:

"Ednurseasauras has given Emily a sock"