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.

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