Psychosis is the Reason for the Season

The holidays are always a time to anticipate seeing more of those lost souls who Cannot Cope With Life. Like the bag on old St. Nick's sleigh, the ER's are filling up with with the depressed, the suicidal, the drug seekers, the alcoholics and the true psychotics. Now, before you get on your high horse, I have such individuals in my own family. They cannot cope with their lives either. They are the drug seekers, drug addicts, and other people who exist in a world that doesn't understand them and is sick of trying to help them because they are incapable of helping themselves. While this is sad, it just sucks the life out of ER staff to have to see these same people day, after day, after day. It is a waste of resources, really. The Scary Catholic Medical Center in Pseudocity where I occasionally moonlight (the crucifixes in every room creep me out a little, quite frankly) lets them sleep in the waiting room; they are allowed to sit and wait about 8 hours until they are sober or get bored and wander away. The genius is they have a warm place out of the weather, but the ER doesn't really have to take responsibility for them.

Icing

The first (of many) winter snowstorms in Frozen Tundra of NH always brings out the best and worst. The newly fallen snow covered treacherously hidden ice, causing many to go to ground. In the first 90 minutes of my shift in Tiny Satellite ER, local EMS delivered an ankle fracture and two shoulder fractures, a coccyx fracture, shoulder sprain, scalp lac and a variety of bumps and bruised egos. Naturally, it brings in someone for a med refill ("I know the pharmacy screwed up and didn't give me ALL the Ritalin I need, so now I've run out"), drug rash ("My three year old has had it for THREE DAYS, and it's much worse since our PCP saw it the last 2 days, what do you mean it's a two hour wait??"). It never fails to amuse and amaze that these people would take their lives (and their children's) in their hands, put on the galoshes and go out and drive around with the rest of the crazies here above the Arctic Circle.



The best was the Hover Mom: you know, standing in the doorway, asking for something every 5 minutes so you know she's concerned about her 9 year old who fell in the driveway and has a head bump. No LOC, but their PCP assured her that "a head injury would be a top priority and seen immediately" (um, your pediatrician is an idiot who lied to you, and he WAS seen immediately and appropriately triaged. I'm pretty sure he's not herniating). What posesses these PCP's to say make such blatently stupid statements and get everybody all riled up?



Anyway, after casting, splinting, slinging, stiching and icing all the boo-boos, it got very un-busy. I hesitate to use the Q word, because you never know when it will come back to bite you. And I have to work tomorrow, so I'll play it safe.

Meet Dr. Dewshe Bagghe

Since leaving Utopia ER, last year, I have come to accept that quality care (and quality ER docs) are a matter of perspective. One individual who should just hang it up I will refer to as Dr. Dewshe Bagghe. Cranky, sour, condescending, everything the experienced physician was, oh, say 35 years ago; which is about when he should have retired. He is just plain mean. Honestly, I feel sad for the patients who have the misfortune to have him for a doc. He actually said, not only in my presence but IN FRONT OF A PATIENT, "I hate this fucking job, it sucks". Nice. He hates me because I have a brain, 30 plus years of experience, and usually anticipate what he's going to do. If I get out a certain med, he won't want it. If I draw blood, he won't order any tests for awhile. If I order a cardiac workup, he'll cancel it. If I ask him for pain meds, he'll dance around the issue. He makes it the most unpleasant place to work. One night I had a sick 2 year old, a tough stick with a fever, vomiting, and a nervous mother who was used to getting her child's emergency care at Big Metropolitan Children's Hospital and not Regional Pseudocity Medical Center. A master of communication and a real team player, old Doc. Dewshe Bagghe told me to put a line in the child. OF COURSE he was going to order cultures and labs, he just neglected to tell me (or was waiting to give me enough line to hang myself with so he could confront me). And OF COURSE as I was drawing the blood anyway after a successful stick the Charge Blond comes barreling in to tell me to draw the bloods. Sorry, already on that. Ha!

I'm pretty sure the rest of the world has progressed to the point where this kind of behavior is not tolerated. I throw him under the bus whenever I can, though, so that's fun. When the patient's complain, I give them the name of my boss, the name and phone number of the administrator and encourage them to complain. Guess I will have to come up with something else though, because he's still there.

Supersize Me

The official start of the holiday season brings a week for caring for the morbidly obese. Now, I have no problem with people unless they refuse to take any responsibility for themselves, but I'm frankly getting tired of spending a lot of effort stepping around people's motorized scooters because they are so overweight they can't walk.

One guy (no scooter) weighing in at over 300 pounds presented with increased urination and insatiable thirst for about a week. To nobody's surprise his blood glucose was 620. I was kind of worried about this guy because all he could think about was going home to eat the cheesecake his wife had made. Sheesh! Guy, you are a walking heart attack and a stroke waiting to happen.

Supersized contestant number two was a woman weighing in at over 400 pounds who comes in by ambulance (EMS, you are my heroes) with an ankle injury one day after sustaining a fall in which she broke her proximal humerus. Truly, I don't know how this individual functions. She was clearly hygienically challenged. Her ankle was merely sprained, but a family member wanted her admitted. WTF! Don't you love how the family members are all over the patient in the ER, but when it comes down to taking care of the patient at home they trip over each other heading for the hills. I had PT do a safety evaluation and she failed because 1) the patient lives in a 2nd floor apartment, 2) the family had REMOVED THE BANNISTERS AND THROWN THEM AWAY TO GET FURNITURE UP THE STAIRS, which means, 3) she couldn't safely or QUICKLY leave the apartment in case of an emergency (!). Are you kidding? That woman had no prayer of leaving that apartment quickly for the last 10 years with 4 good limbs and wings. Yikes. The bottom line is that the patient gets admitted so someone else can take care of her. But the family drove her, I'm sure out of the goodness of their hearts.

The ER Waiting Room: Too Many Squeaky Wheels

It is at Triage that many of the problems dealing with the public begin.

Not understanding or caring that the ER is not Burger King where one may very well not have it their way, the triage process is of little importance to the patient who insists that his problem is worse than anyone else’s. The consequences of the “squeaky wheel” mentality on a waiting room full of frustrated, anxious, sick, and angry patients can best be described by envisioning the abandon ship scene in the movie, “Titanic”.

As the boats are filled with women and children (think of these as the really sick people), the men (people who are not as sick, have chronic conditions, and are well enough to sit in the waiting room for hours) are left on deck hoping for rescue and singing “Nearer my God to Thee” while the stewards put out more deck chairs. Much as these patients believe it, however, the ER waiting room will not sink; this means it is pointless to storm the triage nurse to explain how badly one needs to be seen as soon as possible (consider this clamoring for a spot on the stern of the ship). Eventually, there will be a boat for everyone, even it is takes 6 hours. If a patient is likely to require a kidney transplant by then,he/she will be seen sooner. Otherwise, the waiting area is a little like Disney World: just when you think you are getting in, there is another 2 hour wait before you actually get on the ride. Alas, there is no "baby swap", and sending your 7 year old to inquire for the fifth time in 20 minutes how much longer it will be just wont' fly. And it doesn't matter if you have another appointment, dinner reservations, a meeting with your parole officer (pimp, ex-boyfriend, drug dealer, your child's teacher, life coach). Remember, patience is a virtue.