Thursday, February 28, 2013

Violence In The ER

Maybe it's just me. Perhaps I've only worked in terrible places with terrible people. But I don't think so.
Maybe it's just that I'm a big, bad former Marine, and when one's only tool is a hammer, all their problems look like nails. Except I'm average sized, with a middle-aged donut (despite my brain's insistence that I'm still young), thus not really physically intimidating to anyone except perhaps Warwick Davis, a hobbit, or my cat. So in looking back at my anything-but-extraordinary career in the ER, I'm frankly rather astounded at what a throw-down knockdown hog-wrassling time it's been.

I've been spit on and at, punched, kicked, slapped, choked, hit in the head, clawed, gouged, bitten, urinated on, pelted with any number of objects and body fluids, dog-piled, injured to the point of temporary disability twice, one of which was potentially permanent and career-ending (and thankfully fully recovered from), assaulted, battered, and of course verbally abused, cursed at and threatened almost daily.

I've broken up fights, disarmed lunatics, and made at least as many tackles in my career lifetime as Dick Butkus did in any one year he played, and no disrespect to Mr. Butkus, but I did mine while wearing less pads and no helmet.

I've seen co-workers stalked, threatened with death, punched in the eyes, nose, mouth, and throat, had their heads yanked back by the hair, bitten so hard they had teeth marks a week later, had faces scratched, legs and knees twisted, need ice packs, Ace wraps, and stitches, been kicked in the groin, and had IV poles, power cords, chairs, instrument trays, canes, shoes, full and empty urinals and bedpans, and just about anything else you could imagine wielded, swung, or thrown at them, time after dozens of times.

Total number of patients or visitors arrested for assault or battery, let alone actually charged with violence against us, or prosecuted for same, in all that time: zero.

Is it just me, or is there something more than a little f*****d up with that ratio?

Police have bullet-resistant vests, pepper spray, tasers, batons, and guns. And numerous other cops one radio call away.

If we're really, really lucky, the hospital, one time in a thousand, might file a restraining order against somebody, once they've gone apeshit enough to get charged and booked into jail anywhere else in society. And hand to God, had anything like this happened to me at home, I'd have been well within commonsense rights and responses to have blown a few heads off.

So Houston, WTF?
Saying this is a problem is like saying the explosion of Mt. St. Helens was unsettling. It's telling the astronauts on the last Challenger ride that things would be a little bumpy.

Whose fault is this?

Society in general, for thinking that walking into the ER is carte blanche for doing what the jacktards with Ph.Ds, and too many with Nursing Ph.Ds, call "acting out".
What the police call it when it happens anywhere else is aggravated assault and mayhem, so let's quite pussyfooting around and using psychobabble happytalk instead of precise clinical language. Five year olds "act out". Adults are being criminally violent.

Hospital management, from relief charge nurses to CEOs and every worthless waste of skin and oxygen thief in between, for collectively and reflexively shrugging, and adopting the "Tough Shit, You Knew The Job Was Tough When You Took It" philosophy, which is a remarkably callous, spineless, gutless, and self-serving crock of a well-known substance when employee safety (not to mention the safety of everyone else in the hospital) is what's at stake. Coal miners in Appalachia get more respect from management than staff workers do in hospitals. In the words of one former military commander, "F*** You. Strong message follows." Those penny-pinching short-sighted bastards have never had anyone's backs except their own buttcheeks, mainly because that's where they store their heads on this issue, 365 days a year, plus an extra day during leap years. I'm remarkably well-read, and I've got pretty comprehensive recollection of my nursing school days, and I can't seem to recall reading in either the state penal code nor any textbook of nursing that the job of healthcare workers is to get the shit kicked out of them, literally, day in and day out until they either quit, retire, or die, yet I've seen and experienced that is the reality.

The police, for taking a "So what do you want US to do?" attitude, as if suddenly the laws of the city and state magically don't apply inside a hospital like they do at Fred's Bar & Grill.
(For the record, Officer, I want you to do to them what you would if it had been a "brother officer" they'd kicked, punched, spit on, or tried to choke out. Because if you don't, Hear Me God, I'm going to treat you like them, every time you and your brethren in blue enter my ER. Think about that long and hard when you just can't feel me about cuffing Mister Douchebag and filling out those nasty reports.) 
And a lot of that is because of the city and district attorneys who are too gutless and chickenshit to prosecute, in their entire careers, one case of violence against health care workers anywhere I've lived, worked, driven by or flown over since I Australian rappelled out of the womb on the end of an umbilical cord. As Casey Stengel said time after time, "You could look it up."

And lastly - not mostly, not substantially, not firstly, but certainly lastly - us.
Those of us who put up with being treated like punching bags, as though getting jacked up is some mark of special blessing, machismo, or street cred. Or because we didn't know any better, or because supposedly older and wiser colleagues told us, explicitly or implicitly "That's just the way it is." As Bruce Hornsby's song should have taught you, "Aw, but don't you believe it."

It's bullshit, boys and girls.
For the love of Jesus, Buddha, or the Flying Spaghetti Monster, stop acting like the dumbass battered wives and girlfriends you diss and scream at, strap a 2x4 to your spines, and stop putting up with being whomped on like it was some freshman hazing or dumbass rite of passage.

It's assault, battery, mayhem, and attempted murder.
Swear out the complaints, press the charges, and if necessary make the citizen's arrests required, and don't take no for an answer, or tolerate getting undermined by higher-ups.
When you feed the pigeons, you get more pigeons, and more pigeon crap. When you appease the bullies, you encourage more bullying. (And yes, you worthless wankers, I mean every one of you in a supervisory position who doesn't kick abusive people out the door on their fat whining asses, in 100% of cases, with zero tolerance, with security and if necessary a police escort.)

Or someday when one or fourteen of your co-workers, God forbid, finally gets a window blown in them by somebody with a 'tude and a firearm, because of all the times you didn't stand up and scream "ENOUGH!", it's going to be too goddamned late to tell yourself, or their families and kids, that you're really sorry you couldn't find the will, the wisdom, or the sense given to the dumbest jackass on the planet, with any number of legs, to act to end things before they went that far.

I'm not expecting to speed-dial 9-1-1 for every insaniac. That's what Geodon, Ativan, Haldol, hard restraints, and big security guards are for. And I get that both those on booze, PCP, meth, and those stricken with Alzheimers' or otherwise altered may be a handful.
Those are patients, and we'll deal with them.

But the ones who are AOX4 and just aggressive, hostile @$$holes, including spouses, parents, family, and friends in about a 10:1 ratio to the actual patient seeking care, need to be confronted with a simple common-sense standard: you attack those trying to help, you leave in handcuffs, and you never get to come back to us again.

I want the law in 50 states and every U.S. territory to be blessedly simple, straightforward, and unconfusing:
any threatened assault or actual battery on anyone in healthcare, from an EMT at the side of the freeway to so much as a custodial person at a hospital or a clerk in the doctor's office, is a straight out-and-out non-negotiable felony, and with the same mandatory 24 hour no-bail no-release jail time as spousal abuse. From Bangor to Guam, from the Bering Sea to the Canal Zone. And yes, that goes for drunks and drugheads. If we can charge them for manslaughter behind the wheel, we can damn skippy charge them for felony battery in the hospital or ambulance, and the quickest way to take the fun out of things is for The Man to deliver the smackdown.
And any continued verbal abuse or threat of violence whatsoever gets you kicked out so fast it takes your clothes a minute to catch up to your sphincter when you get ejected, and you get a restraining order filed the next morning in perpetuity.
To hell with "Three Strikes", let's try the "One Strike" policy, and see how it works. And post it in big red letters on signs right next to the cutesy "Patients Rights" plaques, at every entrance to every hospital:
"Any assault, battery, or threat of same by anyone against any employee here, for any reason, will result in immediate arrest and prosecution. Any verbal abuse will result in immediate and permanent ejection from the premises. There will be no exceptions under any circumstances and no second chances."

It's ridiculous that flight attendants serving Diet Cokes are given more protection from obnoxious businessmen under the law than the doctor, nurse, or tech working to save a life in the ER or at an accident scene working with drunks, drug addicts, certified lunatics, and world-class violent jerks, but they are.

None of us should have to lift weights and work for a martial arts black belt, or seriously consider wearing shin guards and knee pads, a cup, and possibly even a bulletproof vest under our scrubs just to do our jobs. Or to soberly weigh whether we'd rather carry pepper spray, a taser, or even a pistol hidden on our persons, breaking ethics, hospital policy, and possibly even state law, in preference to being one of the half-dozen pictures in the paper when some sub-human ghoul decides hospitals are the new place to go on a shooting rampage with no one who can shoot back.

There's a way to reverse things before it goes that far. (And if we don't, it's going to go that far, mark my words and note the date.)

It's far past time to stop mollycoddling the f*cktards, and start applying a little tough love. Generally, by giving them steel bracelets, and a 24 hour time out at the Graybar Motel, until the day comes when you're more likely to see icebergs off Miami Beach than hear about a healthcare worker getting roughed up.

Can I get an "Amen"?
And how many of the yapping pointyheads constantly carping about "getting nursing the respect it deserves" will help make such a policy reality, and how many will instead stare blankly like you've just grown another head, cough, shrug, and move on to studying the latest JCAHO Happygas, rather than saddle up for this fight?
Watch closely, and look and see who your real friends are when your own safety is under discussion, ladies and gentlemen.

Wednesday, February 27, 2013

Can I Get That In Writing?

"You guys are The. Worst. E.R. I've. Ever. Been. To!
If you aren't going to let me in to see a doctor right now,

Oh, by sweet Florence Nightengale's underpants, if I had only stipulated that I get paid $1 cash bonus every time Patient Crankypants pulled that withering nugget out of their diaper and flung it at me, I could have paid for trips to Maui to sit on the beach and ooze into the sands out of the proceeds annually since the day I graduated school.

(I should mention that I was ordered to remove the sticker on my badge I made with
as my last name, after some sharp-eyed House Super figured out what it meant. In case you aren't gifted at word problems, I'll give you a hint: "Don't Let The Door Hit You..." should get you started. You can probably work out the rest for yourselves.)

Hey, I'm all for choice in healthcare. Please, feel free to exercise yours by going somewhere else. Particularly any one of the 20 hospitals you passed on your way here, all of them with longer wait times, fewer beds and staff members, and lower ratings in virtualy every meaningful metric measured by human minds. If you thought your tantrum was going to reduce my coworkers or I into quivering blobs of tears, or rub our noses in the shame of the willful departure of someone healthy enough to shriek out the door, down the corridor, out the lobby exit, and all the way to their parked car, and get us to fling ourselves at your ankles to bodily restrain you from departing before we'd had a chance to fix whatever's ailing you, let me spew some of the Golden Warmth of Truth from my bladder right onto your pointy little entitled heads.

It. Isn't. Going. To. Happen.

Sorry if that reduces to tatters your master plan for getting all the turkey sandwiches and juice you could demand while you wait for the CT scan of your weekly abdominal pain, and enough blankets to shelter a tribe of Inuits on the tundra north of the Arctic Circle, plus enough sympathy from your friends and relatives over your tragic plight to redeem your broken childhood, and a never-ending fountain of opiates to make life's slings and arrows bearable, and all delivered to you on bended knee by your personal butlers and maids of the white-tiled linoleum palace you see as your private hotel, which we all call the ER we work in.

But see, it's like this:
even if you go, that only leaves 145,999 of your friends and neighbors, of the 400 people daily and nightly who literally darken our doorstep, who I'll have to fall back on to provide me with something to do, professional and personal satisfaction, and the resultant paychecks.

In fact, if someone stormed out in a huff every 15 minutes, 24/7/365, I'd be forced to console myself with the fact that we'd go from being one of the busiest ERs in the country, to only one of the Top 100. O, the shame, the ignominy of it all! 
And since most of you are paying for your visit, when you do at all, with money taken out of my paycheck to pay for it, frankly, my back's been hurting for a while just from carrying you all for so long, so you going away isn't killing me, and in all likelihood, you either.

May I suggest further that you take advantage of all the electronic gadgetry you tote around, and further decry our horrible insensitivity on Yelp, Twitter, and the local Restaurant Guide, and tell all the other whiny crybabies of your tribe out there that we suck harder than a thirsty elephant, and give service lower than whale droppings in the Marianas Trench.
If perhaps you could also tell the jacktards from Press Ganey that as well, maybe you could single-handedly induce the dipwads who pay for your shenanigans to stop reimbursing us for folks like you, and force us into the shame of only seeing people who actually retired from or still work at actual jobs to afford the healthcare they consume, pretty much like happened from the dawn of time until 2009, or perhaps even speed the demise of relying on how you feel about your hospital experience, rather than such worthless metrics as how many people we see, how many of them survive and improve, and how few of them get sicker, get infections from us, or have the gall to die under, let alone as a result of, our actual care. Because what could all THAT matter when compared to the unimaginable platinum and diamond-encrusted magnitude of your pwecious feeeeeewings?

And as you leave, could I possibly be allowed to reveal to you, that when everyone from your first pre-school teacher, to the principal who handed you your social promotion diploma, told you every day in every way that you were the Most Special Snowflake The Universe Ever Created, that they were lying their fool @$$#$ off, right through their teeth?

And thanks for choosing Callous Bastard Hospital for your healthcare needs today.

Sadly, despite the promise in your little hissyfit, we know that you'll be back again another time with the predictability of the tides.

Tuesday, February 26, 2013

Groucho Marx Lives

We get into this job for the action and the trauma drama, but stay for the personalities and the comedy.

One night I'm sitting in my second home triaging patients, when one of our newer docs, jaded but not burned, whom I'll call Doc House, calls up front.

"What's this "foreign body ingestion" who signed in?"

"Oh, him...he swallows stuff all the time."

"How's he look?"

"Very stable. He's watching TV in the waiting room."

"Okay, what did he swallow tonight?"

"Lemme check the chart... He swallowed 3 quarters."

"3/4s of what?"

"Not three quarters OF something. He swallowed 75 cents."

"Gotcha. Call me if there's any change." <Click!>

Ba doomp. Tip your waitresses. Try the veal. I'll be here all week. Thanks for taking some of your time and spending it livening up my night, Doc.

Later on, I get shifted to the express zone for minor injuries and stoopid $#!^, and get to discharge The Swallower of Capistrano, whose abdominal x-ray reveals that he's got the makings of a small hardware store jangling around in his stomach. Airport security would probably pull him in for secondary screening every time when he sets off the metal detectors. Except he probably can't get to the airport, because he swallows his car keys.

But Doc House hasn't finished playing with this one yet. Handwritten note on top of the discharge instructions says:

"Attention Charge Nurse:
Please provide Mr. Capistrano with a taxi voucher to get home.
Do NOT give him bus tokens under any circumstances.
He'll eat us out of house and home!
 - Doc House

p.s. Feel free to give him directions to any of the 5 ERs closer to his residence than ours."

Monday, February 25, 2013

You Rock

Besides the expected doctors, nurses, and techs, the ER needs/wants/demands/begs and pleads for the support of numerous other departments and services in the hospital, and mostly we get it.

Some of them are average, some are horrible (I promise, I'll get to you another time), and some absolutely shine.

In this last case, the bunch of folks I've almost always had the best experience with has been radiology. Every last blooming one of them, from x-ray, to CT, to ultrasound.

I haven't gone soft, and there's been an occasional stinker or two, but so seldom as to be noteworthy when it happens. And I wish a couple of them could remember that when they bring somebody back, they can plug in all the wires they disconnected to take them away. But that's small potatoes in the long run.

I've had x-ray techs wait patiently for me to finish a tough stick and lab draw without a peep, tell me about a patient who needed more attention, and save me/the docs/the unit secretaries from ordering or getting the wrong x-rays, on the wrong body part(s), on the wrong patient more times than I can remember.

I've had CT techs who should be wearing the ER equivalent of a chestful of attaboy medals for the most phenomenal service and support I've ever seen. And save a life or two, above and beyond the call of duty.

And ultrasound techs who were so good they whisked my patients away, brought them back, and had the results sitting on the doc's desk before I checked on when they were going to take my patient, and long before Doc Crabbypants started whining about it.

They've expedited care on children, and adults who act like children, gotten in the game without getting in the way, they've caught little old ladies before they fell, and helped dogpile the homicidal whackjobs who tried to attack us, gotten every picture and scan we needed, no matter how difficult, and did it all without pissing and moaning, mostly just a simple shrug, and usually a smile.

Take a bow, boys and girls, because you and what you bring to the party are the biggest difference between all medicine before Pierre and Marie Curie, and after.
And you really, really deserve a gold medal.

Sunday, February 24, 2013


Almost certainly, the local ED has some type of personnel who assist the licensed staff, whether they are paramedics, EMTs, CNAs, or generic emergency techs of some sort.

In the main, these come in two types, and three grades.

Type I is someone who's doing the job while planning or actually undertaking advanced schooling and work to gain licensure as a nurse, physician's assistant, doctor, etc. Bravo to them.

Type II is doing the job with no plans to upgrade at any forseable date. Bravo to them as well.

The three grades, found in both Type I  and Type II, are as follows:

Grade A exceeds all your expectations. They're everywhere, and have usually already accomplished what you asked them to do before you thought of it, because they not only anticipated the requests of you, the docs, and the PAs, but have the initiative and intelligence to carry those anticipated requests out without waiting for you. They are a joy to work with (and occasionally, to work for, regardless of their level of certification and your own, whether you admit this is the case or not), and they consistently force me to step up my game just to keep up with them. They are worth their weight in gold, and if I were King, that's also what they'd be paid.

Grade C gets the job done. As fast as the world craps on me, they keep up with the pace, and do the tasks they're capable of, until either we're caught up, or at least we've reached shift change by the skin of our teeth. Both this grade and Grade A techs make taking care of patients in a busy ED possible, and without them, too much important stuff simply wouldn't get done.

We need you, and we really appreciate you, every single day you're on the job.
You are helping save lives, which is kind of the entire point.

Grade F techs are those who consistently fail to meet any expectation, no matter how low you place the bar. You wonder how they arrived for their shift and in clothes most days, and for the egregious examples, you're less than upset when they simply don't show up at all. (Bonus points if your co-workers have chipped into the pot to pay them to stay home. I've been there and seen this.) You can't find them most of the time, and when you can they can't be asked, nudged, encouraged, begged, shamed, or threatened to help you do your job nor do their own jobs with any bait whatsoever, including actually handing them blank employment applications during their shift for McDonald's and Burger King restaurants, (with the proviso that to date, management has refused my offer to try using a whip and a loaded pistol, despite my frequent and sincere offers/requests/threats). You'd like to beat them with large pieces of lumber, if only for the sheer satisfaction, and when they're assigned to another nurse/section/zone - or, Praise Sweet Jesu! announce their imminent departure/retirement/terminal diagnosis - you do the Happy Dance. Sometimes right in front of them.

If you are, or think you are, a Grade F tech of the Type I variety, seriously consider your intended career choice. Before you kill someone at work, or someone at work kills you.

If you are a Grade F tech of the Type II variety, the Japanese method of ritual suicide, by performing a transverse abdominal incision with 2 feet of razor-sharpened sword steel, is heartily encouraged. Look it up on the internet, and try it at home. Please. Or else simply report to the state's labor website, and sign up for your 99 weeks of taxpayer-financed douchebaggery, thus saving your own life, and those of innumerable patients you won't hazard daily simply by showing up for work.

And though it's sad to say, I've worked with both Types of techs, and the real-world distribution of grades is about exactly 30/40/30, regardless of any variables including schedule, shift, pay scale, or the supposed applicant screening efforts of whatever short-bus f*cktards Human Resources allegedly employs to try to fill vacancies, when they can be bothered to do so at all.

I seriously think we'd be better off if we just went down to the docks and press-ganged random recruits and chained them to gurneys until they learned the rudiments. We couldn't do any worse than some of the incomparable flaming hemorrhoids they've hired to date, and it's only the good techs that make the horrible ones bearable at all. (Along with random REM-sleep fantasies of their ritual crucifixion while burning alive, for the really horrible ones.)

Tuesday, February 19, 2013

Dr. Sherlock Holmes

Round about midnight, the paramedics deliver a senior citizen suffering from "general weakness." No surprise.
Her resting pulse is 40. Big surprise.
Oh, and no, she doesn't regularly run marathons or bike in the Tour De France.

As I and my co-workers get her hooked up, IV'ed, and labs drawn, 12-lead EKG done, etc., ER Doc starts pawing through the pillowcase of meds the paramedics have helpfully scooped off the nightstand and delivered along with the somewhat lethargic grandmother on the gurney.

So when the husband arrives a couple of minutes later, Doc does a quick interview with him, since he's much more with it than his other half.

When he comes out of the room, Doc hands me one of the bottles, and says "Send one of these tabs to the pharmacy to identify the medication stat."
I have a tech run it down right then, and call the PharmD. on duty, and give him a heads-up and the 20 second run-down on the patient.

My patient is stable, just in profound bradycardia. As long as we don't try to get her up and walk her around, no worries for the moment.

Doc warns to get a dopamine drip ready, which I do, but her pressure stays stable in the low normal range, so we hold off for now.

Within a few minutes of my tech's return, pharmacist calls back, and when the doc picks up I stay on the other extension.

"The med is verapamil, 240 mg."

Except the fresh Wrong-Aid Pharmacy label on the bottle says it's 40mg.
The geniuses at the local drugstore have had grandma unknowingly dosing herself with a 6-day dose of her BP med every 24 hours for the last week, and her calcium channel has been really blocked. Like another couple of days and she might've not woken up one night.

So I give the nice lady a really annoying NG tube, which fortunately spares her the nasty taste of the charcoal I'm going to pump down it, and the ER doc admits her to ICU.

Medically speaking, I almost never recommend that anyone should consider a lawsuit, but in briefly explaining the situation to Nice Little Old Man, I suggest to him that in all likelihood some legal advice wouldn't go amiss, and that their everyday pharmacy should expect to be picking up the tab for tonight's little pharmaceutical misadventure.

And that they might want to think about getting their prescriptions filled somewhere else, at least for awhile.

So I ask what the husband said, and Doc tells me hubby was absolutely certain none of the wife's meds had changed anytime recently except the one bottle (out of about twenty in the case), and he'd pointed it out to us.

Nice going to both docs. Sherlock frickin' Holmes in action.

Doctor                 1
Death                  0

Monday, February 18, 2013

Endangered species?

One thing that's boggled my mind since kicking off this blog, is the absolute dearth of actual ER nursing blogs.

Or at least, blogs that survive.

Even the ones I linked to are generally anything but regularly contributed to.
Maybe nurses don't make good electronic diarists, or maybe most of the people who actually work in the ER are just too ripped up most days to put a few words together. I don't know. I can certainly confess to feeling too tired to do much besides eat, shower, feed the cat, and sleep after a string of tough shifts.

Everybody's blog list I've run across has any number of blogs with dead links, from people who quit, logged off, ran out of things to say, or just never had time to start.

As I said, I don't have the answer to this, and it's like trying to study the sound of the bell that doesn't ring.

On the other hand, self-expression has never been one of my weak points. My friends laugh when someone describes me as "quiet" because it generally proves they either don't know me, or haven't known me very long, because I've been told that I talk too much since the second week of kindergarten. Maybe they were on to something.

My reason for holding it in so long now was a simple lack of internet access. Obviously, that's been remedied. It's just that I expected to find scores of people scribbling away, given how many of us there are, and instead what I find, internet-wide, probably wouldn't fill up a city bus.

It's just peculiar. Not X-Files peculiar, but definitely a little bit unnerving.
I haven't seen this much trouble finding an ER nurse since the last Saturday night shift of a three-day weekend.

At any rate, while now and then I may go a couple of days without anything bubbling up, I'm not going anywhere anytime soon, as long as I'm breathing.

Sunday, February 17, 2013


Lately I've been pondering a lot about What Is Wrong With (U.S.) Healthcare.
Mainly because so much is.
And none of it is what the genius "experts" think is the problem.

Suffice it to say, about 1000 things, and you aren't going to get them all in one blog post.

Let's call this one Reason #42.
It's a quote I read from someone who has nothing to do with healthcare other than reading the stories of those who work in the field.

"Health care “reform” nowadays consists of people with seven-figure incomes hiring consultants with six-figure incomes to make recommendations on how to step up the pressure on people with five-figure incomes."

Amen, brother.

1) If you're working in healthcare and making seven figures, unless you do brain or heart surgery on multi-millionaires, you're a selfish @$$hole. Bear in mind, I'm pro-business, a registered Republican with a firm grasp on the fundamentals of capitalism, and I believe that Bill Gates deserves every penny he makes. But there is nothing, nothing whatsoever, on God's green earth, you could possibly ever do, short of invent a cure for cancer, that justifies getting paid 5-10 times more than the doctors, 20 times more than the nurses, and 30 times more than the techs working for you, who actually do the work. A least the top guys at Ford Motors invented the Mustang. But you didn't invent the CT scan, or surgery, or f*ck-all else that makes the medical carousel go around every day. You're paper-pushing flunkies who somehow conned some hospital's board of $#!^-for-brains jacktards into believing that you possessed some magical inexplicable power that required compensation beyond all rational explanation. The next time you hear about one of your custodial staff qualifying for food stamps, please go kill yourself.

2) If you're hiring consultants, you're also an out-of-touch dipshit who should be getting off your fat ass, and taking a day every week to roll up your sleeves and see how things tick in your hospital. Look closely, and notice that admirals don't "hire consultants" to tell them WTF goes on anywhere on an aircraft carrier. This is because they freaking know what's going on, and if they had any questions, they'd take a short walk and ask a couple of questions. And they'd damn sure know in about 60 seconds, because that's how running a large operation works, if you don't have your head shoved somewhere looking for colon problems from the inside.

3) If you are one of those "consultants" (the best definition for which is "someone with a clipboard and a briefcase 500 miles from home reporting on something they don't understand"), I can't begin to express how loathsome and worthless you are, except to point out that even used-car salesmen and politicians have some quantifiable utility, unlike yourselves, and they both score at the bottom of the esteem scales for the entire rest of the population. So either quit and get a real job, or let's just repeat the desire that you go kill yourselves. Take one for the team, and improve healthcare for everyone else by not jacking it over any worse than you've already done, by checking out of the gene pool with all due haste.

4) The people you're stepping up the pressure on aren't cylinder head gaskets, they're flesh and blood. Every time you crank up the ratchets to fatten your bonus portfolio, they get ulcers, high blood pressure, more colds, more flu, and heart attacks. That is, if they don't call off sick, quit, change jobs, or kill themselves. Every drop of their blood is on your hands. And every time you damage or destroy one, everyone else left behind has to strap on that much more extra work. If you're a patient, think about how this burgeoning stress load on your doctors, nurses, etc., affects the care you receive.

I'm certainly no Norma Rae. I've belonged to two unions in my life, and I resent the hell out of them, for their dues out of my pocket, and for what they don't accomplish, as well as the protection and crappy work ethic they promote by protecting the incompetent, the lazy, and the criminal.

Despite that, it's becoming crystal clear that if we're going to continue running hospitals in general, and ERs in particular, like an immigrant-staffed sweatshop in the early 1900s, the only thing that's going to put a kink in somebody's truss is them running full face into an employees' union, or unions, to give out the kick in the crotch most management so desperately needs, and deserves.

Either that, or I get to carry a baseball bat to work, and I get five free swings at targets of opportunity per shift. And to be sporting, I'll do it from in front, and I'll give them all the dodges they can manage.

Saturday, February 16, 2013

Yes. Yes, We Do.

Some people wonder if they can level with us, because they're worried we might, or absolutely certain that we are going to, laugh at them.

I could, of course, reassure you that everyone I work with is compassionate and professional, because no amount of money in salary makes it worth cleaning up both ends of you or sticking our hands inside your bloody guts to save your life, and yet we cheerfully do it, because we really are that compassionate and professional.

Some people will try to tell you that we're so compassionate and professional, we would never make light of ___________, because that'd be, y'know, wrong. And that we had our funny bones removed in nursing/medical school.

And if you believe that, just send me your credit card number and PIN, because I have a friend in Nigeria that needs a small investment to get $30,000,000 out of a bank there, which he'll split with us.

Look, you're in the ER because something happened (or you did it to yourself) and you can't fix it, or aren't sure it needs fixing, and even though you're afraid to tell us, you're more afraid of not getting it fixed. So you tell us.

And I absolutely promise, we won't laugh.

At least, not right now, or in front of you.

Because we're that professional, but we're not frickin' Vulcans. We see really crappy people, in crappy situations, and have crappy days, and sometimes - far more often than I'm happy with - if we didn't resort to occasional (and yes, a tad inappropriate if it was in your face) humor, we'd climb on an empty bed and start screaming hysterically, or just sobbing and sucking on our thumbs. So when you, and Fate, conspire to bring something snort-worthy and wave it right under our noses, you're damn skippy we're going to laugh. It's the garlic we wave to keep the soul-sucking vampires of depression out of our heads and make it to the end of another shift.

No, we aren't cracking jokes while we're doing CPR on the pulseless 97-year-old diabetic Alzheimer's patient with metastatic brain cancer whose guilty family has left him as a "full code". But what we do joke about does sometimes go beyond whatever tattered bounds of taste even the late late late night comic on Comedy Central would hesitate to cross.

One night - actually, so late it was early the next morning - an unfortunate man was brought into the trauma bay after being deprived of a goodly amount of his lower leg, amongst other and more critical complaints. A car is not a toy. It was grim and gruesome, partly because medicating his agonized moans hadn't gotten him to anywhere within shooting distance of bliss yet, which fact was audible to everyone within the department. It was even further grim and gruesome because all the supplies for starting IVs were kept in the trauma bay as well, and right next to them on the counter, delivered by the paramedics along with the patient, was a large tupperware pan, containing one tennis shoe, with a sock sticking out the top, then a section of calf sticking out of that, a bloody hunk of muscle above that, and finally half each of a bloody and broken tibia and fibia end poking out of that. Sitting on the other side of this ghastly table decoration was the young(er than me) trauma surgeon, deep in the midst of his pre-op notes to get the patient ready for imminent surgery, which almost certainly was not going to include the re-attachment of the battered and now extra appendage of Mr. Stumpy.

I don't know you, so maybe seeing severed limbs is part and parcel of your everyday, and you handle the sight with taciturn aplomb. I worked in the busiest and bloodiest ER on the planet then, and even to me, this was a bit out of the ordinary. And, being a movie fan, I stopped to process the I-can't-believe-I'm-seeing-this visual. As the surgeon turned to look at me across this flotsam of random anatomy, our eyes met for a second. I stared right into his face, and in my best Richard Dreyfuss tone of mock disgust and moral outrage, softly told him with utter solemnity that
"This is no boating accident!"
Then I immediately went back to rounding up the tubes and toys I came in to get.

And quick as lightning, trauma doc not only got the Jaws reference, he started to giggle. And couldn't stop for almost 5 minutes, even as he continued to write, and on the way out the door accompanying his latest charge to surgery. The patient, semi-delirious, and quite snowed in a haze of pain and opiates, never heard any of it. But I was quietly pretty damn happy that I'd lightened the load on a young doc's shoulders at 4 A.M. And didn't run screaming into the night myself, either.

Another place and time, a young father brought his toddler in for an unknown foreign body up a nostril. Come to find out, post removal, it was a big, BIG fat green table grape. Dad and doc marvelled at how on earth a three year old boy could have shoved a grape twice the size of the opening way up into his nose. But now, fixed up good as new, home they went.

Two hours later, dad came back, and signed himself in.
For a grape up his nose.

Thanks, ye Gods of Comedy.

Monday, February 11, 2013

Computerized charting

Computerized charting is here to stay, unfortunately.

Unfortunately, because it's all horse$#!^.

Y'see, when they tell us about it before the fact, we're led to imagine someone with the technical skills to take that multi-page paper chart we've used forever, and turn it into a similar electronic chart, with the ability to simply hit the bubbles/check the boxes, and let us enter typed text in the same manner we've charted with pens since quills and inkwells went out of fashion.

Because let's face it, FedEx and UPS track a $20 dollar package with a $5K electronic clipboard, that tells them all about that parcel, including precisely what it is and where it is, with a couple of mouseclicks on the internet, anywhere in the world. Whereas we've been taking care of $500K patients with $1 worth of paper and ink absolutely unchanged since Teddy Roosevelt was president, and functionally unchanged since scribes scratched out the Dead Sea Scrolls 2000 years ago. See if you notice anything upside down with that picture.

But then, wrench, meet monkey. The geniuses who buy this stuff consult all manner of people, from salesmen, to software designers, to computer geeks, and so on. The only people they don't talk to, manifestly, are any people who
a) actually care for actual patients, or
b) have any idea what's necessary.
Such as, just for wild examples, doctors, nurses, technicians, financial staff, etc. If we made movies the way these bozos create and purchase the software, it would be directed by Ray Charles, Stevie Wonder would be the cameraman, and Marlee Matlin would be holding the microphone.

The other lie is that we imagine that we'll be transitioning to state-of-the-art software and hardware.

Not just no. But OH HELL NO. That would cost, y'know, MONEY. So for the "bargain" price of a mere $40,000,000, my employer decided that we'd use MediTech. Google some pithy phrase like "MediTech sucks" and ponder the 17,000 pages that appear on Google, posted by everyone from doctors, to nurses, to actual IT professionals. But wait, there's more!

It's not only expensive as hell, and irredeemably atrocious to use, but by carefully bringing the system up online one department at a time, the day we go hosital-wide, it crashes the entire operating computer systems for every hospital in our system, in several states. That's overacheiving mediocrity on a world-class level, I'm here to tell you.

So then multiple hospitals are back, after months of preparation, onto paper charts for months on end, while the tech genuises try and figure out what the problem is. (Besides evidently, realizing that the chosen software is the problem.) Some people say you can't fix stupid. I say you should let me grab the right size hammer, and give me a crack at fixing it, and I think I could perform miracles.

And understand me, I'm 5-stars all for going to computer charting.
It's just that I suspect, with metaphysical certainty, that I could call up Bill Gates, or the guys at Apple, wave $40M in front of them, and in 90 days I'd have a state-of-the-art medical charting product that would work flawlessly on Windows or Apple platforms, interface with everything from smartphones to car-dash systems to the CT scanners, be accessible to everyone using the system even from the International Space Station, and be designed and updated regularly after exhaustive research and input by the end users, who would swoon in rapture when they viewed the first edition of the finished product. And, coincidentally, enable Microsoft/Apple/whoever to sell said software system to 40,000 other hospitals and facilities on the North American continent and rake in a random few billion dollars or so, year to year. But nooooooooooo.

But the chosen system has three things going for it:
1) It uses a proprietary set up that's compatible with absolutely nothing else.
2) It was designed 30 years ago, and painstaking updated so that it's now only 29 years out of date. For reference, 30 years ago, the height of high-tech screen displays was the drifting white square blipping around in the cutting edge computer game "Pong". I mean, seriously, Meditech would make the guys who flew the Apollo missions to the moon feel right at home. Except they're so old they're dying off.
3) And third, it was originally designed for, approved by, and placed on the Official List Of ObamaCare Compliant Electronic Charting Systems by...wait for it...
the U.S. Government!

So with all that going for it, what could possibly go wrong?!?

Somewhere, there are a couple MediTech salesmen laughing about putting their kids through college on the bonuses they got for unloading this monstrous piece of $#!^ on our hospital group. And there are any number of people in charge of purchasing it for us who should be carefully skinned with potato peelers and slowly lowered skinless into an enormous vat of rubbing alcohol, and their screams broadcast over the hospital paging system 24/7, as a warning to others. Weekly.

But some people are alive simply because it's illegal to kill them. That would include the sellers and purchasers of this monumental mountain of dung.

Instead, most of us, doctors, nurses, and assorted staff, are the ones doing the screaming, and have become fluent in profanity to an unbelievable degree, and the smarter ones - or at least, those better prepared - have installed a small square of closed-cell foam padding at the edge of the desk, so that the inevitable banging your head on the desk multiple times per shift doesn't result in a laceration requiring sutures to repair.

This is what you get when the government "helps" you.

"We had to pass the bill to see what's in it."
That level of asininity would tell you they had to eat the horseapple to see what was in it.
If only I could serve them all the crap sandwiches they so richly deserve.

Thursday, February 7, 2013

Poor Historian

If you ask for the rules of their job that they've learned by experience, every cop or attorney will usually tell you pretty straightforwardly (and really, you should ask people about their jobs, since they spend 1/3 of their lives doing them, and usually no one asks people, and you'll never get as much free education as asking someone to tell you what they're an expert at doing, but I digress...), and invariably one of the first things they'll tell you is the simplest one:

"Everyone lies."

It's not quite that bad with patients, but it's close.

I stopped counting after the 500th time I did a star-spangled full-fledged in depth assessment interview, and specifically asked all the relevant rule out questions, and had the patient confirm the critical answers, then took them to a treatment room, told the doc what the patient just said, then when the doc walks in and asks the same set of questions, gets the exact opposite answers. Sometimes while I'm standing there looking the same patient in the face.

Dear Patients: Hi, I'm your nurse. Remember me from up front? Hey, maybe no one told you, but the doctors and I, we've been doing this for a number of years, I know their kids' names, what they snack on during a slow time, and how they like all their trays set up for a dozen different procedures and which labs they're going to want before they order them. That happens after a decade with the same bunch of folks, if you pay attention. So you should know that before, during, and after your visit, the doc and I talk about you. It's called communicating patient status, and it shouldn't be a shock to you that telling flaming whoppers, or changing your story, has a direct correlation on either your mental status, or your moral status. You're getting treated either way, but it's really up to you whether you get treated like someone with a sincere problem, or like someone with a sociopathic personality seeking attention, narcotics, or a kick out the door. So please, spare me the childish behavior.

And by the way, whenever I have reason to expect that this may come back to bite someone later, especially me, I cheerfully and explicitly chart exactly what your answers are, and the time, and the doctor does the same thing. So eventually, your insurance co., your lawyer, the hospital's lawyer, and if pushed far enough, a judge, jury, God, and everybody are going to know you waltzed in and lied your @$$ off to one or both of us.

We don't swear people in on a bible in triage, but maybe it might help.

Tuesday, February 5, 2013

Trust Your Gut

On this particular night, I was in triage, my home away from home.

Do this stuff long enough, and you realize that for no discernable reason, patients with the same chief complaint all show up on the same night. Some nights you get two main flavors, others it's just one.

On this one, it was one, and the one flavor of the night was chest pain.

Four hours into the night, and we'd already triaged eight legitimate chest pain patients. The last one, in fact, was a hot STEMI (ST Elevation Myocardial Infarction - a big fat heart attack in layman's terms) soon to be headed for the cath lab. Once I got him in the room and the fire drill of getting him ready to go began, I headed back to triage to start on the next patient.

Looking at the computer tracker, I saw that the newest sign in was a 40 y.o. M with abdominal pain, nausea/vomitting. Bummer, but nothing special during the height of flu season. I already had 15 pts. on deck waiting to get back, and 5 or 6 waiting to come in for vitals and a quick look, but a lot of them were overwhelmingly likely to be of the "you aren't dying any faster than the rest of the human race" complaints. So I decided to stick my head out the door and eyeball the new guy, who I was sure wouldn't be having a fun night, just to make sure he was okay.

I looked towards the front, and saw who it had to be, guy in his PJs, trashcan between his knees, and looking thoroughly miserable. But something about the look on his face made me say "Let's bring this one in for a closer look".

I walked out, grabbed his wheelchair handles, and told him I just wanted to talk for a minute, and check on him. His female entourage (fiancee, I later learned) was 39 weeks pregnant and ready to pop any day, but that was ancillary to everything at this point.

I piloted this guy inside the screening area, hooked him up to the vitals machine, and while it cooked, I ran through the 60 second OPQRST about his pain (epigastric) - {Perk!}, he'd been feeling miserable at home since shortly after dinner, hadn't been sick prior, no history/no meds/no allergies. His pulse is slightly tachy, but nothing radical, ditto for the BP, but then I've just watched him do a couple of gloriously painful dry heaves on the trip inside, and he's a little diaphoretic. Nothing inconsistent with the Food Court Two-Step, and he's probably just eaten something that his body wants out ASAP.

But he's 40. And his pain is epigastric. So it could be gut, or it could be cardiac. So even though the chest pain team is running like one-legged butt-kickers, including with the STEMI I just took them, I still page for an EKG, just to be safe, for me, for him, for the lawyers.

I get him on the table and prepped just as the harried EKG tech zips in with the "You've got a lot of nerve" look on his face, but this guy fits the profile, so I'm not abusing the privelege, and we run a 12-lead.

"Abnormal EKG".

No elevations, but it's funky, according to the $5K electronic chipset brain in the box.

So I roll the gurney he's on back to another open room with full monitoring, because it was empty 90 seconds ago when I took the STEMI to the room across from it.

As the nurse in that section looks at me, I do the clutching-my-chest pantomine for "chest pain". His jaw drops. "You've gotta be kidding me! Another one?"

"Sorry man, he's legit. I don't order them, I just deliver them."

I see the cardiologist on call has arrived to see his guy with the STEMI, and he AND the ER doc both look at the fresh 12-lead from my latest, which I hand them as I roll past to the room.

I hear the cardiologist, one of our finest, say to the ER doc as the both look over the 12-lead printout, "That looks okay, he's stable to wait. We'll be ready for the STEMI in about 5 minutes, as soon as my team's all in."

I'm thinking that's pretty spiffy, since it's only been about 20 minutes since the page went out. Even when we're getting beat up, we shine.

My partner has triage under control, and I know my co-worker's getting hammered, but them's the breaks. Another nurse is floating, and I ask her to grab an IV set-up, while the chest pain tech and I get this guy into the empty room with a quick swap of full gurney for the empty one already there, and I start hooking him to the room monitor.

The float nurse comes in with a ready-made draw kit, and grabs the guy's right arm, while I'm sticking EKG leads on and firing up the room monitor. The guy's talking to us, and his very pregnant girlfriend takes a seat at the foot of the bed. As the tourniquet's going on his arm to pop up a vein, I'm snapping the last of the 3-leads onto the patches. The other nurse calls the guy's name. Then again, loudly. I glance over and see he's clutching her hand as she's trying to stick the IV.

Just as I look back at the monitor, I see his eyes roll back in his head, and he goes from sinus rhythm to full-on bag-of-worms classic ventricular fibrillation. His girlfriend's screaming gets everyone's attention outside rather nicely.

"Code Blue Room 6!" I yell over the other nurse's back and out the door To Whom It May Concern. Then I drop the cannula I had prepped, and swap it for a bag valve mask at 15 liters. The crash cart and even more nurses are at the bedside before I've even finished dialing the liters up, and we stick the pads on him in maybe 20 seconds. His girlfriend looks for all the world like she's going to deliver right now, and I nod to the tech to gently move her out of the already too small room.

The ED doc bustles in as she goes out, the crash cart nurse has the defib charging, we're all clear, and we shock him.

No change. Still v-fib.

The doc says to up the charge as one of the other nurses is already spinning the dial, and in seconds we're ready again. "Clear!"

Zap Number Two...resolves into a beautiful sinus rhythm, and I'm happy to confirm between bag squeezes that he has both carotid and radial pulses just like both monitors show.

Meanwhile the other nurse finished getting the IV we wanted, and drawing a full rainbow of tubes for the labs he's going to need. Most everyone else goes back about their business elsewhere. With nothing else to do, I grabbed the Code Record, documented everything we did for the 65 seconds it lasted, and just as I and the other nurse are signing it, the patient pops back fully conscious and says, "What happened?!"

"Hey pardner, you left us for a little while. Glad you're back. But I think it's safe to say we're keeping you tonight."

Then I went to the inside wait area, and told a much-relieved lady her date was back around as I walked her back to his bedside.

I passed the zone nurse, told him we saved his patient for him to work up, no charge, then headed back to triage.

The guy had another shaky few minutes later, no codes though, but as he was waiting to go to the Cath Lab next, they hooked him up to a nitroglycerin drip. That's when it hit me, as I was passing his room coming and going with other patients from triage for the rest of the department.

He was pink. Slab of ham PINK.

This was remarkable, because while I hadn't consciously noticed it, when he'd arrived he was somewhere between white and gray, by comparison to how he looked at the moment. My frontal lobe hadn't caught it, but some part of my brain had, and that had to have been what caught my notice.

The zone nurse told me later, "I'll never question your triage calls again!"

The patient, it later turned out, had a 95% posterior cardiac artery occlusion, with no ST elevations noted anywhere. If the fiancee hadn't pushed him into coming, he'd have died at home. And if I hadn't gotten him back to a room when I did, he'd have coded on the waiting room floor, with probably a much worse outcome.

His fiancee's pregnancy was the other shoe to a pending but not yet final divorce, which explained why the dude was having a heart attack. Look up divorce, marriage, and having a baby on the life stress scale, then combine the scores.

And learn to trust your gut even when you can't put your finger on why.

Of course, we got 3 more chest pains after that.

Sunday, February 3, 2013

When I Have No Idea What To Say

A long time ago, in a galaxy far, far away...

Orientation Day One, standing behind the Real Triage Nurse, looking at the line of 27 people at the beginning of my first shift as an ER nurse (Trainee, first class).

Absolutely beautiful 19 year old hispanic girl, and her great-looking significant other guyfriend come up to the window, and slide a piece of paper through a slot under the uberthick bullet-proof glass window, legacy of a whackjob who wandered in one day and started cranking off rounds.

It's a lab result printout. She wants to know what it means. My Spanish is good enough to figure that much out.

I look it over, and thankfully, but horribly, it's in English.

What it tersely announces, is that apparently her friend-boy has tested preliminarily positive on the ELISA test. Her boink buddy standing behind her has HIV.

She wants to know what the test means to us here in Big City Mega-Hospital. She's smiling, it's a sunny morning in late summer, the birds are singing. And the guy she's hooked up with has an incurable STD that he's probably also transmitted along to her without bothering to inform her.

How do you say "You've just been royally and supremely hosed in the lottery of life, and all the plans you have for the rest of your life will be overshadowed by the three letters HIV, until, in all probability, it kills you."?

Sure, there's a one in a gazillion chance the Western Blot will show this was a false positive. But it won't be. There's probably some tiny recess of my mind where I can hope that they always used condoms too. But they didn't. Friend-boy, probably very well aware of whatever risky behavior he undertook in the first place, doesn't want to look at her, me, or the paperwork. My Spanish is rusty, but I speak fluent body language, and his is screaming "I'd rather be anywhere else but here."

And there's tons of drug cocktails, and all kinds of other promising treatments, and they're doing tons of great research, so maybe someday...

Sh'yeah. As if.

I feel trapped behind the glass like some zoo animal. I want to scream at how unfair this is to her, me, and the universe. I wish I was 1/10th as fluent in Spanish as I was in English, as if even then I could begin to tell her, standing at the head of the line, what this all means to her, her relationship, her family, life, the universe, and everything.

I've got nothing. Absolutely nothing.

Nothing from 15 years of prehospital medical work, 8 years as an RN, 7 years of college, or 37 nursing textbooks. As if the entire cadre of instructors I've ever had, all lined up on my shoulders, could lean over and say, "We've got this." If aliens from Zoltar had landed with a Cloaking Device right behind me and sucked my brains out my ears silently and invisibly, one minute earlier, I could have felt no less able to come up with one coherrent course of response to answer the question she asked, the question on her face, in her mind, or behind those beautiful and tragically cursed eyes looking up at me as Someone Who Knows What To Tell You than the Infinity of Utter Nothing bubbling up in my head right that minute has left me.

So I heroically punt the ball as hard and far as I can away from me.

In my about to get tons better gabacho Spanglish, I tell her she needs to go across the street to Building 37, whose suitably non-descript name for bystanders is the equivalent of waving a lit road flare to anyone on staff, because it's the AIDS Clinic.

Good luck with the rest of your ruined life, chica. And I'm really sorry, so help me Florence Nightengale, for not having the wherewithal to do one single damned thing for you, say anything helpful, or do much besides feel like a butterfly pinned at the bottom of a kill jar.

Because my soul, in the first 30 seconds of this job, just died a little bit.

God Almighty, I woke up worried about my first day, and we talked about You helping me out on my drive in. Remember? Now I don't know if I'm going to make it to the end of my first hour, and there's still 58 minutes of that to go.

And the memory of that 2 minutes still makes it really hard to see.
Must be something in my eyes.

Saturday, February 2, 2013

Preparing For Your ER Visit

Let’s be serious: there are only two types of people—those that have been to the ER, and those that are going to go.

And since, by virtue of my hospital’s estimation of my skills, I (or someone very like me) is who you’re going to see first, I’d be seriously remiss if I didn’t give you a little coaching to make an unpleasant experience for you go a little easier. Pay no attention to the fact that it’ll also make my night a little smoother too.

I could give you a copy of my friend’s "120 Rules For The ER” but they’re funnier to those of us in the biz than they will be to you. So I’m just going to hit the highlights.

First, what to bring. (BTW, 10,000 of my colleagues agree on this, so don’t think you can pull one over on us. We’re pretty cliqueish about this stuff, and you won’t be the exception that proves the rule. Trust me.)
For the novices: triage comes from the French word triager, which means "to sort". It arose when, during WWI, they had to sort the casualties during 4 years of brutal trench warfare to decide which ones to see, and in what order. What follows is how we do that at the Emergency Department when you arrive. Pay attention please.

1. Why are you here?
No, not in a college philosophy class metaphysical sense, but rather ”Why are you darkening MY hospital doorstep right this minute? Especially if you arrive at 4 AM.
I don’t want to know the history of your internal organs, the strange things that went on since 1962, or the comments from the 5 non-medical people you talked to that finally chivvied you into coming. What I’m digging for, and usually none too subtlely, is an explanation in 10 words or less for why you’re in my assessment room chair this minute.

Good examples:
This crushing chest pain since 20 minutes ago.
The arm bone poking out of my lower arm after I fell.
This swelling in my throat since we ate the crab stew.

Bad examples:
I’ve had this headache for 14 years.
It’s Friday night at 2 AM, and I decided to detox from alcohol and drugs just now.
My arm hurts and I have this sore on my toe and I’m coughing and I’m tired all the time and once in 4th grade I think I might have had a stroke and…

Try to remember, it’s the Emergency Department, not the Because I'm Pushy And Felt Like Coming Now And I'm In A Hurry For My Date/Dinner/Airplane Flight Department. If there isn’t some pressing reason you’re here right frickin’ NOW that you or an immediately accompanying friend or relative can elucidate verbally and rapidly, no amount of college essay exam b.s. will conceal that fact from me. I will screen you, and send you back out to the Siberian Winter of the Waiting Room while I attend to more pressing concerns. I swear to God. You’ll get seen, but not until we’ve taken in all the more serious patients.

2. What medical conditions do you have?
We’re talking real, serious, known, pre-existing and diagnosed by someone with a medical LICENSE conditions, not the ones you saw in Cosmo and THINK you have.

Good examples:
Hypertension (or high blood pressure - English is fine if you don’t speak medicalese)
High cholesterol
They took out my (appendix, gall bladder, female plumbing, etc.) in year XXXX

Bad examples:
Inability to answer direct questions
“I think I had a heart attack once” (Either you did, or you didn’t; if you don’t know, you just lost 10 points with me as a personal historian.)

3.What medicines do you take?
Good answers:
Lasix, Plavix, Lovenox, Librium, etc.
furosemide, aspirin, amoxicillin, etc.

Tolerable answers:
blood pressure pills
heart pills
cholesterol pills

Really sucky "I'm a dumb@$$" answers:
A little white one
A big yellow one
Those two tiny ones

Know your medications, by name (Trade or generic name) and WHAT THEY’RE FOR, or understand why you’ll lose 10 points with me for being a bad historian and making my job more like being a vet helping mute animals than one helping people.
That's too hard? Then if all else fails, bring me the pill bottles. If necessary, in your/the patient's emptied pillowcase, just like the paramedics do. 

4. What are you allergic to?
I don’t care about cats and dogs—I’m not going to hand you anything to pet.
I want to know about food, and particularly, DRUG allergies.
Good answers:

Bad answers:
all antibiotics
all pain medicines
all pain medications except Demerol
that one that starts with “A”

And BTW, getting nauseated isn’t an ALLERGY, it’s a side-effect. Turning red, getting itchy, swollen all over or hives, or not being able to breathe is an ALLERGIC reaction. If you’re really allergic and you don’t know this, -5 points.

But how in heck can I remember all this stuff? I’m DYING here? It’s IN MY CHART! Etc. etc.
Thanks for asking.
A) I don’t expect you to memorize it, though it’ll impress me. And demonstrate your mental status is pretty good.
B) I don’t have your chart, and I can’t get it. I don’t ask these questions for my amusement, I ask them to save your life. Cut the crap and whining, and answer them please.
C) You’re reading this on a computer, so you have no excuse for not for not doing the following:
Put this info into a word processor file, and print out a copy before you need it. Update it when you need to, and always have a copy in your wallet or purse. Bring it with you to the ER.
If you don’t have a printer, I’ll accept an index card. And I promise, you’ll get 10 bonus points with me for being smart and prepared.
And don’t think you get an excuse for being on vacation, out of town on business, at DisneyWorld, blah blah blah. THIS INFO IS LIKE AMERICAN EXPRESS - DON’T LEAVE HOME WITHOUT IT.

If you’d like to also list your doctor or doctors’ name(s), their telephone numbers, and perhaps your blood type, knock yourself out.

And the same goes for all your kids, your wife’s father, or your crazy Uncle Tim if you take care of them or bring them to the doctor.

If you have this info on a sheet of paper, I’ll photocopy it, and learn enough about your medical history to make a far better and quicker decision on how serious your emergency is than if I first have to play “20 Questions” to puzzle it out. Work with me, and I’ll work with you, and we can get you in, seen, and hopefully treated or home a lot faster. That’s what you want too, right?

Things to tell us immediately, even before your name:
"I'm over 40 and I'm having new chest pain."
"I have a cardiac history and I'm having new chest pain."
"I/they are transplant patients."
"I/they are oncology patients with/without a fever."
(Nota bene that having chest pain for 6 days/weeks/months, having chest pain when you're 22 with no history, or having chest pain because you've been coughing for a couple of days ranks a lot lower on the urgency scale. We'll still probably do an EKG, but when we then plop you in the Pit Of Eternal Waiting, it's because you aren't dying any faster than 300 million other Americans, which we view as a GOOD thing. Act suitably happy over this news, and wait your turn.)

Things that absolutely don't work for you, or with me:
1. Telling me "I/He/She can't breathe!", unless you/he/she are either dark blue or grey with no chest movement, and thus actually not breathing; or else Speaking. In. One. Word. Sentences. Between. Gulps. Of. Air. This may come as a shock to you, but they cover the importance of breathing in nursing school pretty comprehensively. They also do a pretty good job of training us not to panic over b.s. histrionics. The latter really, really winds me up.
2. Getting huffy and pissed off back at me when I call you on your b.s. histrionics. That may work in your living room. It doesn't work in my waiting room.
3. Trying to intimidate me by standing, hovering, or waiting right in front of my window and giving me The Stare or the Stink Eye. Some patients need to go back next, or rapidly, and I ask them to wait right where I can keep an eye on them and find them right away when I get my next available room. If I didn't ask you to wait there, you're just annoying me. And potentially keeping me from seeing someone I wanted in my line of vision, which is the short route to getting Security to have you move along, while graduating yourself from "In Pain" to "Royal Pain" on my mental list. Tread carefully.
4. Raise your voice, create a scene, or tell me how to do my job. I didn't scream at you. If no one ever raised you to behave in public any better, believe me when I tell you my lessons won't be as tender as your mother or father's should have been. And I have seven years of college, a professional license, and 15+ years experience doing my job. Unless you have the equivalent or better, I'd back off and work with me if I were in your shoes. If you came in my door looking for help from qualified professionals, you'll get it, and rapidly. If you came in because you wanted to argue everything with everyone, tell us you're smarter than all of us, and generally be a flaming pain in everyone's backside to get your way, I hope you wore your sturdy jeans, because they're going to get a working out from the bottom of my foot in about a heartbeat, I promise. I can't emphasize my sincerity on this point enough. But do promise me you'll take the same approach with the court and judge when you get there, please.
5. Threatening me with lawsuits, physical violence, and calling down the curse of the Virgin on me, my co-workers, or the hospital. The total number of people I've inappropriately left in the waiting room, let alone who died, stands at zero, in over 15 years' worth of decision making. On the other hand, I've sent more than I can count out the door, and I don't have enough fingers to count the number of times they've gone in handcuffs. Even if some soft-hearted judge lets you beat the rap on assault/battery/making terroristic threats, your lawyer is either some barely competent Asst. Public Defender, or someone costing you $200/hr and up, whereas I'll likely be appearing on overtime pay. Shoot your mouth off or not, it's your nickel.
6. Threaten to leave, because "That'll show you!"
My response, in 100 out of 100 cases, will be DLTDHYITAOYWO.
(In case you didn't get that, it starts out "Don't Let the Door Hit You... You can work the rest out for yourself.)
7. Threaten to leave when you've been directed to return for either an infectious disease, or a condition requiring urgent care/admission for your minor child, and/or abuse has been reported or suspected. We have hospital security and the local PD on speed dial, and they can and WILL wrestle you to the floor, or cop knock your door at home, and drag you and/or your dependent child in for care, and not infrequently refer you to Child Protective Services if they think you're a danger to your kid. Please don't test me on this. We wouldn't have called you and told you that you needed to return if it wasn't really, really serious. Look around the waiting room. Do you really think we were hard up for something to do??
8. Ask to see my supervisor. Yes, you're entitled. Just as you're entitled to burn American flags at protests, according to the Supreme Court. Neither of which exercises will endear you to anyone you'd care to be "in" with. Firstly, because my supervisor is generally busy with higher priorities than your out-of-joint nose and ruffled feathers, and has had to deal with pushy @-holes in the waiting room a few million times too. Secondly, because the odds are, I trained him/her from when they were ER nurse larvae back in the day; and even if not, they assigned me to this spot because they know I'm not only qualified to do it, but damn good at it. And finally, because their default setting to having people escorted off the premises runs on a much shorter fuse than mine, most days. And by the way, the next time you succeed at getting your way by throwing a tantrum, and bump everyone else behind you into waiting another half hour for that bed you just weaseled, remember that someone'll be doing the same to you the next time you're in that ER.

For 100% of people, I operate on the Golden Rule in reverse: I treat them the way they treat me. In fact, frequently I treat them with buckets of compassion, diligence, and expertise - the way I'd want to be treated if it was me, or my child, or my relative in the waiting room - even when they're a total pain to everyone within 100 miles. But eventually, acting like something a child drops in its diaper, towards me or my co-workers, is going to get you the return treatment you deserve. I've trained Marines, cupcake, and put barking jackassical surgeons in their place, so believe me when I tell you that you don't want to test my rough side, and I'd rather not have to prove that fact to you either. Let's all be grown-ups, shall we?

And lastly, a few insights to my job for you to remember:

EVERYBODY on your side of the desk “doesn’t feel good.”
EVERYBODY on your side of the desk is “in pain.”
EVERYBODY on your side of the desk is “having an emergency.” The sign over the entrance might have tipped you off on that score. No one EVER comes to us because they're feeling wonderful, and just wanted to show off their health and happiness.

I don’t sort people by the amount of blood on their face or dripping off them, the amount of panic in their parents’ eyes, or the volume with which they holler. Take this as gospel.
I also don’t care who got here first, unless we’re down to the minor complaints (by which I mean, you aren’t dying any faster than the rest of us).

I’m an experienced professional. I’m also human. I expect that when you (or your child or relative) is in pain, you’re going to be testy and a bit distressed. That’s normal. I can't recount how many times cranky parents or relatives have later apologized to me for being too abrupt or pushy at the beginning, because I forgive and forget those episodes. Of course they could have been nicer, but they were under duress, and we're none of us perfect.
But if you insult me and go above and beyond the call to piss me off, AND I determine that you aren’t a priority patient, consider the likely results for your plans for the evening. It’s my house, my rules, and I can count my mistakes on my thumbs. If you want to count the times I erred on the over-cautious side, I’d need my fingers and toes. I almost always shade my triage sorting decisions on the cautious side, BTW, because I don't know everything, and I can't see inside people. The same will generally be true for any of my colleagues you meet in YOUR town’s ER. Think well before you test this.

I don’t know “how long the wait is.” This isn’t the Chez FouFou, and I'm not the maitre de. If time is a consideration in you being here, this really wasn't an emergency, was it? And your doctor lied. He didn’t call ahead and make a reservation for you. He knows, and you should too, that we don't work that way. If he wanted you to go straight upstairs, he could have had you admitted directly. So if he sent you to be seen at the ER instead, he's either a cheap lazy @$$hole himself (5% chance),and/or thinks you're a PITA(10% chance), your insurance coverage is by cheap lazy @$$holes, because it covers ER visits, but doesn't reimburse him for additional office visits (15%) or just didn't want to tell you over the phone that he's legitimately too busy with other patients to see you right away (30% chance), and/or thinks that you do have a real or potential emergency, and should have had sense enough to get yourself here right away without being told to do so, because we're better equipped to do the tests/scans/etc. you need than his office is (40%).
It is a Jewish proverb that “The more you complain about life, the longer God lets you live.”
It is an ER proverb that the Triage Nurse is godlike, and the more you complain, the longer you will wait. (In fact, if you’re frisky enough to get up and whine, we generally know you aren’t that serious. That quiet guy in agony in the corner is the one we're keeping one eye on.) So again, weigh those repeat trips to the window carefully.

On a typical night in my house, I personally sort through 50-200 people. (For the record, that means I've personally sorted through at least enough people to populate Santa Barbara, CA, without screwing up on the job).  I ask enough questions to determine how serious they are, and how quickly they need to be seen. If there’s an empty bed, I put as many of them back with my fellow nurses and the doctors to be seen as quickly as I can. If you thought that calling 9-1-1 for your week-long flu-like symptoms or back pain would spare you any waiting...think again. My boss will meet you at the back door, and very likely tell the medics to bring you out to me. Then you’ll answer the same questions, and go wait with everyone else. And get a $500 ambulance bill that your insurance probably won’t cover on top of everything else. Save 9-1-1 for real emergencies.
And if you call 9-1-1 from my waiting room, you should know that the calling address shows up on the dispatcher's screen, and they seldom send the paramedics. Instead, they usually send the police to cite you. Which the police do, right after they come and tell me you've been calling 9-1-1 from my waiting room. Which I then report to my supervisor and the doctor who's going to see you. Any potential boneheads should think on that trick long and hard, and weigh the odds of the doctor subsequently writing a prescription for pain for anything stronger than Tylenol unless you have broken bones sticking out your skin, or of my supervisor subsequently paying any heed to your complaints after she listens to them.

If you’re having a serious or life-threatening emergency, I will get you in very quickly. If you doubt this, get in my way when I’m trying to get that old guy with the chest pain into a wheelchair and back to the cardiac room.
If you’re not serious, but you’re still in legitimate pain, distress, or just having a lousy night, I’ll get you in as fast as tonight’s patient load will allow.
And if you or your child are there “just to be safe”, I’ll respect that concern, and get you in too.

The more prepared you are to help deal with what brought you to us, by giving us the key information I asked for, the simpler and quicker your night will be. That, I can absolutely guarantee.