Saturday, April 27, 2013

Telephone Advice

{Medicolegal boilerplate warning: Reader(s) of the following advice scenarios acknowledge(s) in a legally binding manner that by following any of the advice given below , he/she/they have stipulated to being dumber than a box of hammers, and accept full responsibility for all subsequent results, included, but not limited to, death, dismemberment, ridicule, and/or subsequent Finalist status on the Darwin Awards Website Hall Of Perpetual Fame. They further assume full responsibility for all government legal costs for recovery of penalties related to posthumous prosecution and conviction under the Air Theft and Skin Waste statutes of the Omnibus Ohmygod Howinblisteringhell Did You Ever Make It Onto The Internet Without Setting Yourself And Nine Contiguous States On Fire Act of 1972, as amended in U.S Code.}

RINGRING!!...RINGRING!! [which double ring designates an incoming call from outside the hospital].
“Thank you for calling Emergency Triage.”

“I have a thing on my whatsis, and it looks horrible? Should I come to the Emergency Room?
“Describe the thing please.”

“Oh, it’s ginormous! It’s multicolored, and gives me transient attacks of anaphylactic fibromyalgia and intermittent pseudosiezures, with cranial impaction to my sigmoid colon. And it’s excruciating!”
“Sorry, as you’ll know from reading WebMD all day, the alien larvae have almost reached full gestation, and they’re about to rip through your sternum and go in search of a new host for the next subbronchial  egg implantation. You should probably just book the cruise you’ve always dreamed of, and max out all your credit cards. B’bye. [Click]”

“Thank You for calling Emergency Triage.”

My child looks sick. What should I do?”
“You mean besides taking your child to the doctor?”

“We tried that. The doctor’s office is only open Monday to Friday from 8-6, and 6 hours on Saturdays, and I’d have to miss my soap operas AND wait almost 45 minutes to be seen for a $25 co-pay.”
“Gotcha. We can’t have that. Let me take a look. Hold the phone up to your child’s face so I can have a look.”

“What?? You can’t see my child over the phone!”
“Wow, ma’am, lazy and smart is a rare combination. So you must have figured out how this is call is wasting my time and yours, and I’m getting paid for it, whereas you aren’t. B’Bye! [Click]”

“Thank you for calling Emergency Triage.”

“How long is the wait there?”
"Twenty seconds longer than it was before I answered this call. B’Bye! [Click]”

“Thank you for calling Emergency Triage.”

“I ran over my foot with the lawnmower, my toes are in a tree, and I can’t get the bleeding to stop spurting. Should I come to the ER?”
“Oh heavens no. Just soak that extremity in  warm running water in the tub until the pain goes away, and you start feeling sleepy. And tell St. Peter I sent you. B’bye. [Click]”

“Thank you for calling Emergency Triage.”

I’ve had this headache for 47 years. Should I come to Emergency?”
“Wow, I know exactly how you feel. I’ve had this headache for 20 years, three times a week, whenever I answer the phone here at Emergency. So honestly, I think Emergency CAUSES the headaches, and you should stay right where you are. But if the headaches ever stop, rush right down here, m’kay? And promise to donate your body to scientific research after you die, so maybe next century, neuroscientists can find a cure for headaches like you, er umm, I mean like yours. B’Bye.[Click]”

“Thank you for calling Emergency Triage.”

I need help right away!”
“No problem. I’ll tell the 47 people in the waiting room, including the two febrile pediatric leukemia patients, the 70 year old guy with crushing chest pain and blue lips, and the 37 people hurling into trash cans with flu to just hang on while I deal with you. Let’s start with your phone number.”

“In case we get disconnected?”
“No. I’m posting it on a 3x5 card I’m sticking up in the front window under the heading “Complaints Hotline”, so that when people here wonder why we’re taking so long to get their sick family members into rooms, they can get right to the source.”

“You’re crazy! I’m not giving you my number for that!”
“Wow, with diagnostic skills like that, you should seriously consider a career in the psychiatric profession. B’Bye.[Click]”

 Morals of the Story:
Dear Beloved Telephonic @$$clowns Of The Universe:

1)      Make an appointment with your doctor.
       2)      Keep the appointment with your doctor.
       3)      Follow the doctor’s advice. (Yes, that includes GETTING the pills, and TAKING the pills, until you’re FINISHED with the pills. What a concept, right?)
       4)      If it doesn’t work, either repeat steps 1-3 with that doctor, or get a second opinion by repeating steps 1-3 with another doctor.
       5)      If this is a real life-and-death emergency, call 9-1-1.
      6)      This includes when it takes 5 of you to drag grandma’s comatose body down 5 flights of stairs, bringing her to the drive-up door, and expecting all 1 of me to pry her out of the backseat of your MiniCooper.
       7)      If you’re too stupid to figure out if this is a life-and-death emergency or not, don’t call me or anyone like me. Just sit down and wait. If it isn’t a life and death emergency, and you refuse to try steps 1-3 above, you’ll be fine.  And if it is, we’ll be fine without you. Remember, all bleeding stops, eventually.

And note for reference that in Eternity Hereafter, if I don’t find Florence Nightengale and Clara Barton kicking Alexander Graham Bell in the junk forever, know that the line for that will be forming right behind me.
Thank you for calling Callous Bastard Hospital ER.

Monday, April 22, 2013

Please Stand By

Work is crazy busy, which is a good thing in this economy, so paying bills is taking priority at the moment. I'll have some new posts by the end of the week.

Sunday, April 14, 2013

Soundtrack 3.0

Once again, another magical Mix To Treat Patients By, 21 cuts to cover all the bases, and get you through another long weekend in the ER:

"No Particular Place To Go" by Chuck Berry
"Why" by Annie Lennox
"Cuts Like A Knife" by Bryan Adams
"Ring Of Fire" by Johhny Cash
"Emotional Rescue" by the Rolling Stones
"Maxwell's Silver Hammer" by the Beatles
"Heartache Tonight" by the Eagles
"How Do The Fools Survive?" by the Doobie Brothers
"Mack The Knife" by Bobby Darin
"Crash and Burn" by the Bangles
"Can't Get It Out Of My Head" by ELO
"She Blinded Me With Science" by Thomas Dolby
"I'm Hurtin" by Roy Orbison
"Heartbeat City" by the Cars
"Only The Good Die Young" by Billy Joel
"The Bug" by Mary Chapin Carpenter
"You Wreck Me" by Tom Petty
"Murder By The Numbers" by the Police
"Homeless" by Paul Simon
"I Think I'm Paranoid" by Garbage
"O Yeah" by Yello

Friday, April 12, 2013

Sour Trout

The title is one of the best and funniest sign-ins I've ever seen as a triage nurse, and I only wish I'd written the first 500 like that down, because I could write a book, and retire on the royalties. Or at least get a nice week on Maui.

In case you, unlike just about any ER nurse worth their salt, can't tell what the chief complaint is, it's "sore throat", approximated lovingly and with due diligence by someone whose English skills are somewhat lacking, which is about half my patients hereabouts.

And while that one isn't bad to read, it isn't the first time I've run across it.

Once upon a time, as a tender apprentice in the program at Seventh Circle Of Hell Hospital, where they took six months of class and clinical to push larval ER nurses out of their little Playdoh Fun Factory Mold, I ran across the same chief complaint.

Helpfully, they would do our classes two days a week, and run us through 3 days a week of clinical, on training wheels, with experienced nurses nearby. Which was good, because while I'd been a nurse for half a dozen years and worked without a safety net outside the hospital, their particular brand of patient experience was truly a priceless way to learn, by which I mean the place was ghastly in terms of volume, acuity, and overall suckiness. But hey, once you've played at the Palace, you can work anywhere, right?

So one day found me as the nurse in the back half, treatment, of the walk-in ward. The great part about this area was that everything would walk up, from hangnails to full-on heart attacks. We only kept the minor stuff, but in the pre-ratio days, that meant 8 hopefully minor patients for me, and 50 people waiting for the other nurse out front bringing them back.

And on this particular day, I not only had a brand-spanking new ER resident right out of internship, but the good fortune and favor of the Gods of Emergency Medicine had also helpfully provided me with Dr. DoneItAll. Dr. DoneItAll was able to open up his wallet and tumble out a cascade of about 200 cards, certs, training, and a like number of boards, peer-reviewed articles, etc. covering just about everything. Including probably radiation treatment in the Arctic for the hyperbaric chamber patient, come to think of it. On top of which, he was a really outstanding ED physician, excellent teacher, and a helluva nice guy to boot, which made him not just tolerable, but a genuine delight to work with.

And to help me in my monkey-see, monkey-do days of learning the business of emergency nursing, just the day before, the lectures had helpfully covered the main details regarding eye, ear, nose, and throat complaints we needed to pay attention for.

Thus when my patient presented with fever, sore throat, swollen neck, painful swallowing, drooling, and told me "I habb a sour trout" in the most classic I-have-a-hot-potato-on-my-tongue voice I could have hoped for, I wasted no time in stepping out to go tug on Dr. DoneItAll's sleeve, and inform him "You need to see the patient in Cubicle 2 NOW, please."
And, without questioning me, he stepped in, did about a 30-second physical exam, and stepped out.

"Peritonsillar abscess. Pt. to EENT Emergency, STAT."

And turned to me and said "Nice catch. Strong work."
Which, at Seventh Circle Of Hell, was the equivalent of hitting a home run.

But it's always nice when Fate lobs a nice slow breaking ball right out over the plate for you to smack over the fence in the first place. If only they were all that easy.

Tuesday, April 9, 2013

The Legendary Mr. Shipley

In my tenure at Seventh Circle Of Hell Hospital, it was observed on more than one occasion that we didn't see 3000 patients a week; actually, we saw 150 patients 20 times apiece. Which came far closer to the truth than anyone wanted to admit.

But King of the Cockroaches (as many refer to the patients who refuse to die, despite massive doses of radiation) was everyone's favorite, Mr. Shipley. And when I say everyone, I mean, everyone within 100 miles.

No mere gainsaying and hyperbole this, because on countless occasions, I personally witnessed paramedics from 3 cities away, who hadn't worked our area in years, or even decades, observe no more of him than Mr. Shipley's Santa-white mane of hair poking out from under an ambulance blanket as he lay waiting in the hallway for a room, who then kicked the gurney as they went past, and greeted him by name. And they all knew to take his cane away from him, because when sober he was the nicest guy you'd ever meet, but when he was drunk (about 90% of every waking moment) he was a mean mofo of a drunkaholic to deal with, not above whacking you with his county-supplied walking stick.

His modus operandi was stupid simple. He would get drunk, on whatever. He would fall down. His drinking buddies on Waste Of Skin Row would call 9-1-1, and report he was having a seizure. He would be picked up by paramedics. He would be brought to the hospital. He would receive multi-thousand dollars' worth of full-court work up, including head CT, all while roundly m*****f****** everyone around. He would sober up somewhat, along a blood alcohol continuum from 700 to the low 200s. He would be admitted. He would elope. Then he would get drunk, on whatever, and begin the cycle anew.

One July, a new resident guilty of nothing but unsupervised greenness, ill-advisedly called medical records, and requested Mr. Shipley's medical file. About 15 minutes later, two file clerks rolled up with two mini-shopping carts, and dumped the equivalent of four Manhattan telephone directories on the resident's desk. It was seriously a stack 3-4 feet tall.

"That's everything for this year, doc. If you want anything more, I'm going to have to call in some help to haul it all upstairs."

Conservative guesstimates put Shipley's recidivism in the ER at upwards of 250 visits/year. One week, I worked 5 12-hour shifts, but he beat me, arriving there 6 times. I discharged him one early morning and he was back in the ER before I was, on the same day. Assuming a generously low rate of $2K/visit, you figure it out.

Even at Califrutopian real estate prices, it would have been cheaper for the County to buy Shipley a modest house, and have enough left over to employ both round-the-clock bartenders, and nurses, plus all the distilled consumables he required, with change back from what his medical care was costing annually(and been able to resell the house, someday). And Shipley was merely one of hundreds in our little slice of paradise by the Pacific.

I only half-mockingly proposed that instead of my third shift every week, they instead purchase a 40-pass. party bus, a paper shredder, and a couple of cases of 40 ouncers and other stuff. I outlined that I'd drive around downtown picking up our favorite derelicts, get them on the bus with free beer and booze, and deliver them, suitably lubricated, to a different city west of the Rockies every week. After helpfully shredding all their personal IDs and paperwork. Portland, Salt Lake City, Denver, Albuquerque, whatever.

There was some slight risk that those cities' constables might have figured out what was going on, when 40 bums they'd previously not seen arrived, all claiming to be from the greater SoCal area, and all without a shred of documentation in proof thereof. But such was a minor irritation, because
1) They might send the bums back to us, but we'd still have gained a few days respite from their predations on our medical resources.
2) They might retaliate by sending us their bums, but at least we'd get new faces, and perhaps set up a Bum Exchange Program among the various metropolii, which might also broaden the horizons of the bums in question, and give everyone new folks to play with.
3) Most likely, once they realized they weren't in Kansas anymore (or rather, were in Kansas, but wanted to be in L.A.) the bums would avoid the cops, and set out to return homeward. And pass a liquor store on the way. And that, quite simply, would be the end of that Grand Scheme.

I could never get the Head Wheels to go for my plan, but they were suitably impressed that I'd thought it through so thoroughly.

Leaving us, day in and day out, stuck in the clutches of the federal EMTALA act, mandating that we have to lather, rinse, and repeat, for everyone, despite the futility and wastefulness of the effort. Next time your grandmother has to wait in the waiting room, or her ambulance gets diverted three hospitals away for her heart attack, be sure afterwards to take pen in hand, and thank your congressman. And please remember, you're picking up the check.

Friday, April 5, 2013

Who's Taking Care Of This Patient?

Shocking as it may seem, I didn't become a smartass after years of practice in Emergency departments.

I think it happened when my DNA formed me in the womb.

And I'm absolutely certain the hard outer shell formed on Year One Day One of nursing school clinicals.

Flashback with me to 6:54AM, standing inside the patient room of My Very First Patient in Teeny Weeny General Hospital.

Scene: Me, and an empty patient bed, looking recently occupied.

Cue Doctor Godonearth, suffering from male pattern baldness, and a planetary rotation problem that has led him to incorrectly discern the center of the universe to be somewhere between his rectum and his bellybutton.

"Where's Mrs. Calabash??"

"I give up, where?" (And hey, thanks Sgt. Pinkney, wherever you are, for the best all-purpose answer to stupid questions by officious bastards I've ever heard or given, lifetime.)

> noticeably less pleasant, which is saying something < "She's supposed to be on her oxygen!!!"

"Okay, I believe you. What's your point?"
(Even as a fresh-faced larval nurse, I never acquired an ability to tolerate rude obnoxious jackassery, from any civilian, or anyone in the military whose first name wasn't "General". And this guy strikes me as the civvy version of "Captain", tops.)

> now with small wisps of smoke beginning to emanate from ears < "That oxygen isn't PRN, she's supposed to be on it all the time!!"

"Doc, I said I believe you. So what do you want me to do about that?"

"You didn't take her off her 02? And you don't know where she is?"

"Doc, I haven't even seen her. I'm 5 minutes early for my shift, my very first shift, as a nursing student." (Evidently the powder blue dork-ass lunch-lady smock with bilateral giant red medallions of the nursing school in question, worn by no other members of actual staff in recorded history, didn't immediately register with Doctor Godonearth.)

> Now both livid and intolerably obnoxious < "You're not her nurse?? Who's taking care of this patient?!?"

"I give up, who?"
"And by the way, Doc, in here, you're an attending physician, and I'm not even on the medical totem pole heirarchy yet, but out in the parking lot, I've got you by 10 years and 30 pounds, so if I were in your shoes now, I'd seriously consider lowering my voice, and trying a form of address that's not going to involve one of us spending some quality time with a dentist, if you know what I mean..."

> Exit Doctor, in a steaming rage, leaving skidmarks... <

Whereupon after serial histrionic exchanges reminiscent of a headless chicken, with the clerks, support staff, and other nurses, he determined that a registry LVN had assisted the patient to the bathroom, and, her 02 tubing being too short, the patient had removed it in order to use the toilet rather than crapping herself in the bed.

Which was the cue for Doctor Godonearth to begin loudly and unceasingly berating a middle-aged woman in front of the main nursing station on an inpatient med-surg ward at 7AM at a volume normally reserved for marching troops on a parade field.

And one by one, nurses started popping their heads out, and moving to the sound of the fury until at length, Doctor was facing about 27 women, all standing solidly grouped around and behind the LVN he was focused on belittling so egregiously in public.

Until finally, Charge Nurse Battleaxe spoke up from next to the target of the rage, and said, "Okay, you've made your point. Now how about getting your ass the hell off my unit before I have you thrown off it?"

It transpired in clinical notes after the end of my somewhat eventful first day, that the Charge Nurse had gone to the D.O.N. for the hospital, and in fact gotten Doctor Godonearth's privileges yanked at Teeny Weeny Hospital, and gotten him banished in perpetuity, for egregious public jackassery above and beyond the call.

They all allowed that no one would miss him or his bullying, but as everyone was busy getting ready for their change of shift, no one knew what exactly had set him off first thing in the morning.

Yeah, it was a mystery to me too.

Please allow me to introduce myself
I'm a man of wealth and fame
Pleased to meet you
Hope you guess my name

I distinctly remember musing to myself "I think I'm going to like this."

Thursday, April 4, 2013

Adagio For An Unplanned Exit

Work in Emergency long enough, and you'll find out the hard way that the worst way to end a shift is with the arrival of a patient in full arrest.

Once you start living the dream, you learn that the nurse who goes to get a shroud kit, and pre-rig the gurney to bag and tag the patient isn't a cynical burn out, but a coldly practical professional applying logic and experience to a very, very low percentage effort.

Less than half an hour before handing off to day shift, and in comes the parade of firefighter/paramedics, summoned to the scene when the patient got to the end of the commuter line this morning, in more ways than one.

God bless 'em for doing everything right by the numbers. They arrive with a guy doing full-court press compressions like they just started their shift a half hour ago, instead of 23 1/2 hours ago. It helps that this is a guy in his 40s, not some tortured octogenarian trapped in a used-up body and longing for release.

We pick up where they left off, the patient is intubated, drugs are pushed, labs drawn, around and around the cycle. Someone even has time to get a foley placed, while a new resident gets a femoral line going too. But we watch the faintest fibrillations turn into PEA, and then asystole. And that is simply that, for this guy, forever. Time of death: unfortunately still on my shift.

Now the other work begins. Tidy him up, D/C fluids and leave IVs and tubes intact. Collect clothes and belongings. Tag everything. Try to find ID, cell phone, something. Hope you don't, because what a crappy way to start someone else's day than to tell them a friend, relative, spouse, or child is in the emergency department, no I can't tell you how serious, but you need to come down to the hospital as soon as you can manage it. Make mandatory notifications to coroner, organ donation banks, etc. Then wait those last few minutes until the next shift comes out to take over.

And this guy is dressed for a day at work. Shirt and tie, briefcase, backpack. And the medics left the gadget he was listening to, and his earbuds that they took out to work on him.

So Nameless Guy (he had ID, but we couldn't find contacts' phone numbers - fortunately) was sitting back on the morning train, and somewhere between settling into his seat, and the end of the route, he was sitting back, eyes closed, rocking to the rhythm of the wheels, and listening - I played it - to a CD of some of the most beautiful Mozart music ever composed and performed. And then, without disturbing his fellow passengers, nice and relaxed, just...had the big one, and checked out without even a peep.

As opposed to screaming at the walls in an Alzheimer's psychosis, withering while agonizing through metastasized cancer, or screaming in panic going off a cliff, not really a bad way to check out, though judging by his apparent age, certainly far too early, I think, for anyone.

But a gentle reminder for all of us left behind that nowhere, in any graveyard, on any tombstone ever made, is graven the final epitaph, "If only I'd spent more time at work..."

It's spring time once again outside right now.
Whether with someone whose company you enjoy, or all by yourself, please, go out and enjoy some of it.

Wednesday, April 3, 2013

Diagnosis Of The Week

Given: a waiting room filled with patients, multi-hour waits for beds, and any number of which waiting visitors to the ER are complaining of acute onset abdominal pain, nausea/vomiting/diarrhea. Trashcan from home optional.

Medically, as events unfold, you would certainly be right to assume with a high likelihood of success that many of those patients are suffering from what is variously known as Traveller's Curse, Montezuma's Revenge, the Food Court Two-Step, or, in medical parlance, gastroenteritis.

And you'd be right.

But the most correct diagnosis would be : Not Dying Any Faster Than The Rest Of Us.

I say this because for most any but the uber-frail, the pregnant, the very young, or the very old, they aren't.

Gastorenteritis is a fecal-oral vector, meaning of course that someone, somewhere didn't lave los manos, and thus got their peanut butter in your cakehole. Maybe right before they made or served you your burrito platter, or grabbed that doorknob, or when their cute baby had an accident on that nifty plastic seat on the shopping cart that's now yours. It might even have been your baby.

For whatever reason, your bowels have now made you their bitch, because in a blatantly evolutionary move to self-preserve, they have, in a matter of hours since you so foolishly ate without washing your hands (or someone helpfully didn't wash theirs), decided to hold serial nuclear launch drills for everything not attached to you GI tract, from both ends.

Which, in short order, finds you alternately pointing one of your ends or the other at the porcelain altar whereon you will worship, in between those oh-so-soothing periods of momentary respite laying on the cool bathroom floor.

But eventually, even though all good things must come to an end, this hasn't, so during a temporary truce with your innards, you and/or some soul of your intimate association ends up driving you to see me.

Some things you should know, in managing your own care, not to mention expectations, while you wait.

There are generally two phases to gastroenteritis.
In Phase One, you're afraid you're going to die.
In Phase Two, you're afraid you're not.
I know that by the time you and I chat at the ER entryway, you're likely well into Phase Two.
Please believe me when I tell you that after an unfortunate encounter with a hygiene-challenged server at the local mall's food court a couple years back, in which I was re-acquainted with the syndrome of which I speak now, I truly do feel your pain.

That fact notwithstanding, please accept as gospel, that unless you produce either the winning Powerball ticket, serial 24K solid gold nuggets, or the body of Jimmy Hoffa, there is nothing in your barf that I, the other staff, the doctors, or anyone in North America wants to "take a look at". I don't care if you ate alphabet soup and coincidentally horked up the entire Revelation of St. John, in Greek, or launched out something that's the spitting image (you should forgive the pun) of DaVinci's Mona Lisa. Keep it to yourself, and leave it at home. Don't even use a clear bag.

And please, right after you ate tomato and red pepper salad, shredded beets, and two helpings of ice cream with strawberries, don't come up to me and tell me you/your spouse/your child/Sumdood in the seat next to you is "throwing up blood". For heaven's sake not if you needed a knitting needle and a magnifying glass to spot the "blood fleck" in your precious child's puke. If you didn't see a fountain that looks like Yul Brenner's Nile-side lawn ornament in "The Ten Commandments" spewing a bucket of it, it's probably not. We'll check it, but as a rule, when I see your 6 year old you rushed in here at midnight after you waited 6 hours for every nearby Urgent Care to close first, and he's watching TV and eating Flaming Hot Cheetos, I'm not buying a diagnosis of his esophageal varices ripped asunder, no matter what you googled on the internet before you came in, m'kay?.

On that subject, stop "checking" to see if you can't keep anything down by continuing to stuff things in your maw. No, really. When I ask how often you/your spouse/your child/your spouse who's acting like a child has been vomiting, and your answer is "every time he eats/drinks something", I'm going to gobsmack you with the mackerel revelation from the Groucho Marx School Of Medicine, and tell you to stop eating and drinking stuff. If this is news to you when you/they have abdominal pain, nausea, vomiting, and diarrhea, put "brain death" on the sign-in sheet under "additional complaints".

Thanks for bringing a bucket, trashcan, lawn bag, whatever. Bonus points if it was clean and empty when you left home. But don't use my trashcan, or sinks, for your sudden urges. I get barfierre bags free where I work, and there's no limit to how many I'll give you, esp. if I see you filling them serially. But the first time you miss because the trash can next to my desk, or the sink with the strainer where I wash my hands looked like a better spot, or because the bag I gave you is in your purse, pocket, or backpack, instead of ready in your hand, please understand that you're now on My List, and have been mentally moved from "In Pain" to "Being A Pain". Work with me, and I'll work with you. Screw me, and...well, you get the idea.

Be advised further: you can bleed on me, and I won't bleed on you. You could spit on me, and I won't spit on you. You can even pee on me, and I won't pee on you. (What I will do won't be nice, but it won't strictly be eye-for-an-eye retribution.) But, I want to make it absolutely clear, if you puke on me, it's coming right back at ya, and believe me, I wasn't sick today, so I've got a lot more material handy to work with. Use the provided bag, not my scrubs, my lap, or my face. JCAHO frowns on me shoving your head in a bucket, but they aren't here, and I am. Once again, participate in your care by not making me want to kill you.

That goes out in the waiting area too. Spewing a fountain once is guaranteed to get you some space out there, but moving to a new area, and then repeating the process, is liable to add "victim of assault" to your check-in complaint list.

Please - pay special attention here - I have, no $#!^, worked on more movies and TV shows than you've seen, and with any number of Emmy and Academy Award-winning directors and actors. So I know good acting. And bad acting. And the nurse in your ER, even without my experience, can spot it too, because we've seen the triage movie short subject "Death Of A Whiner" an average of 6000 times in our careers, and it never, ever, ever works. The part you're auditioning for is "The Invisible Man", because that's how you're going to be treated, likely as not. Skip any inclination to dramatic endeavors, and stick to your day job.
I know you're miserable. I know if only you could go back in time a couple of hours or days, you'd have skipped tuna, and gone with a nice fresh salad bar salad. But between your first set of vitals and until I've finally got the space for you to get seen, get some meds, perhaps some IV fluids, and anything else the Dr. thinks appropriate, and despite what you perceive as an end-of-life event, you likely really aren't dying any faster than the rest of us are.

Take the word "patient" to heart, and believe me, the soonest I can get you to a bed, to cash in your ticket for the Zofran Express, I'm going to do it. And until you're officially diagnosed, there's always the possibility that more may be going on, so yes, you needed to be here. But try to understand why we maybe took the 70-year old with stroke symptoms, or the 55 year-old lady with chest pain first.