Tuesday, November 11, 2008

the triage rant

WARNING: Disjointed, choppy vent session ahead. Someone needs a good nights sleep.

The system doesn't work. I don't care who you want to blame - the politicians, their policies, the tax cuts, the downsizing of social services, the lack of affordable health care - whatever. Blame it on whatever. Pick your target. I'm just making a blanket statement. The. System. Doesn't. Work.

"Normal" people will do anything in the world to avoid being in the ER. But there are "others" who consider it their destination of choice. And I'm at the point tonight where it is really getting to me. Because here are some of the things we see on a daily basis...

The Family Date Night. If one member of a family comes in to the ER to be seen, someone else decides to come in with them and have their (back pain, stomach ache, trick knee, ingrown toenail) looked at. Hey, if you're going to be sitting around a hospital while your loved one gets checked out, might as well get your money's worth out of it. Most prevalent on weekends, holidays, or any time we're getting slammed with ambulances.

The Enforcer. The people who haul their kids in because they're misbehaving. There's nothing wrong with the kids medically - they're just driving their parents nuts. So the parents will say something about anger issues or depression and the next thing you know we have to get a screener in to do a full-blown mental health workup. If either parent or child has played the system before, all they have to do is drop a couple of magic words (suicidal, violent) and the next thing you know we're down a nurse because now we have a 1:1 observation patient. Bonus points for the parents who check themselves in at the same time trying to get some Ativan for their "fried nerves". (I'm not talking about legitimate mental health needs. I'm talking about parents who want us to discipline their kids).

The Lonely Hearts Club Band
. Not to sound unsympathetic, but these are the people who have no life. In their world, three hours in the ER for "weakness" is far better than sitting at home alone and watching the news. Never mind that this social visit probably includes needles and expensive tests, they keep coming back for more. We really are better than ER on television.

The Frequent Fliers. My personal favorite. These are the people you see so often that you know their home med list by heart. And all their family members (who, oddly enough, are usually frequent fliers as well). This is the group who has figured out how to avoid those pesky waits in the waiting room or triage. They simply call an ambulance and utter those two (other) magic words. Chest pain. And in they sail, triumphantly cruising by all those legitimately sick schmucks in the waiting room who, because they're too busy leading productive lives to learn how to abuse the system, actually have the idea that you only come to the ER when you think you're dying. Silly rabbits.

The Penny Pinchers.
This is the group that says things like "Oh, yeah, I know that my doctor could have taken this splinter out of my finger, but he wants a $20 copay every time I go in. It's just easier to come here. Besides, I can get a hot meal while I wait."

The Quick Trigger Syndrome. The patient who wakes up from a nap with some nausea and immediately heads to the ER. A stomach ache for an hour? A dime sized bruise from last week that isn't going away? A zit that won't pop? A paper cut? That's what we're here for, right?

The Legitimately Clueless. The mother who calls an ambulance for her teenaged daughter with a toothache. The people who tell you that all of their symptoms started last week when they started a new med - yet they're still taking it. The twenty year old who is all freaked out because every twenty eight days or so she bleeds "down there". The chainsmoking mother who never opens a window and can't understand why her toddler's asthma is so bad this year.

I could go on and on. Don't get the feeling that people can only fit in one category, either. I can think of enough patients to fill the fingers of one hand who fit at least five of the above seven slots simultaneously. The number of those who match at least three are enormous. And we have one lucky family that proudly represents every single one of the previous groups. Every single one.

To a nurse (or anyone working in emergency medicine), the only thing more frustrating than HIPAA (our lovely privacy act) is EMTALA. (Who the hell comes up with these acronyms?) I don't even remember what EMTALA stands for, and I don't give a crap, either. It's an even bigger pain in the ass than HIPAA, because it states that we cannot turn anyone away for any reason. Period. Our hands are tied. We have to treat them no matter what.

So much is made of the fact that so many people don't have health insurance. There is no hiding your insurance status in the ER, but honest to god, none of us care. We're there because we want to help people - we really are. And we all totally understand that there are people out there who are doing all they can to survive, but still can't afford health care. This is not directed at those people. It's directed at those who have no intention of paying any of their bills - not for the meal they ate, or the ambulance they called or the EKGs or the blood work for nonexistant issues - nothing. This is why we're more attractive than a private doctor, because they can (and do) refuse to see patients who don't pay. We can't. And we don't.

We have one guy who has been in nine times in eleven days, seven of those by ambulance. There's nothing wrong with him that twenty years of psychotherapy wouldn't cure. He's an impossible IV stick, so we need IV therapy every time. Thousands of dollars of labs and scans and, to add insult to injury, once he managed to talk his way into an overnight admit because you can't prove that someone isn't having pain. A normal EKG, normal vital signs, rating your pain at a 10/10 even though you were sound asleep when we came in the room...all pale against someone pleading chest pain in the litigous world we live in. And he's not homeless, either. It's not like he's looking for a place to sleep.

People have forgotten what the word Emergency means. Or they don't care.

Or both.


Altaglow said...

I remember when I was in a private curtained in enclosure in the ER. They had just diagnosed that I had a broken hip but didn't have a room to put me in. I laid on the bed for quite a while and listened to the emergency room doc deal with people around me. I was incredibly surprised by the number of folks he talked to that he knew were there for drugs.I was there for two or three hours before they moved me and most of what I heard was people asking for pain meds. I suppose this goes on all the time. Now that I recall though, I didn't get any pain meds for my broken hip until I got to my reserved room and I had a great nurse looking after me!

CrazyCath said...


Even in the UK in psychiatry I saw so many through the revolving door with those magic words "suicide" or "homicidal thoughts" and suddenly it was my beef and I had to prevent it or else.

My heart goes out to you. I have never worked in ER, yet I know *exactly* who and what you are talking about.

Maggie May said...

Oh dear, sounds like you are bombarded with people who don't really need help at all.
This must be so frustrating.
Good for you though, for putting up with it.

Anonymous said...

I feel your pain....I hate the shifts where I see more vaginas than a marine home on leave at a strip club. This weekend I had a girl scream at me because she had waited an 1.5 hours for a pelvic exam on a Saturday and "she had things to do". Not to mention the c/o NVD while they eat a bag of chips and wash it down with a coke in triage. Nice blog..I'm going to have to subscribe.

Iota said...

Did you get your good night's sleep?

One of the good things about the jolly old NHS in Britain (National Health Service), is that we're all brought up to be so darn grateful for it. Most people instinctively start a conversation with their doctor "I'm sorry if I'm wasting your time, but..."

I know it's changed in recent years, and I know that there will probably be a follow-up comment from someone who works in an ER in Britain, saying that I've got it all wrong, and I KNOW that ERs in Britain probably have all your problems plus all the huge alcohol-related ones, but even so, I still think we treat our health care with more respect. (This is very counter-intuitive - most people will tell you that if you have to pay for something, you value it more.)

Marti said...

Wow, RC, I admire that you put up with that everyday. It is the very people you describe that make the average person cringe going to an ER when they really should. Case in point, I waited entirely too long to go to the ER when I was feeling horrible on a weekend. In fact, I had hubby stay at home with Lu b/c I didnt want them to have to wait and be subjected to the stangeness of the ER.

I ended up calling him less than an hour later b/c they needed to take my addpendix out. I am eternally grateful to the nurses and ER docs that took me ahead of all of the moanging and groaning and got me in surgery!

Thanks for all that you do!

Kate said...

I think I'm going to be the person who disagrees with Iota. Last year I spent a couple of hours in our local A&E waiting to have my hand stitched and saw examples of all the people you mention. One man arrived by ambulance and then started verbally abusing the staff because they didn't think his stubbed toe meant he should jump to the front of the queue.

It never used to be like this, not so long ago people wouldn't have dreamed of going to A&E for something trivial. I'm not sure why attitudes have changed.

the rotten correspondent said...

altaglow - believe it or not, we usually can't give pain meds until the surgeon sees you and checks you out. Personally, I'm convinced it's just one more way surgeons make themselves look better. "See? They gave you pain meds because I said they could".

crazycath - I know you know exactly what I'm talking about, since a lot of the people I'm talking about have psych aspects.

maggie may - it is incredibly frustrating. Most of the time you just deal with it. It is what it is. But other days it really wears you down.

anonymous - welcome! And don't even get me started on the nausea/vomiting/diarrhea trifecta. If I had a dollar for every person who has to put down their Big Gulp to tell me that they haven't kept anything down since last week - I'll scream.

Iota - the attitude we get a lot is "It's your responsibility to take care of me. You have to do what I want you to do." I don't see a heck of a lot of gratitude from most of our clientele. Now the "normal" people, the ones who avoid the ER like the plague...those are the ones who start out with "I'm sorry if I'm wasting your time". It's totally bass ackwards.

marti - we all take great pride in being able to spot the "genuine article". I like to think that I can pick the one person in genuine pain out of the pack of drug seeking whiners. We all do. And it's people like the ones in your situation that make it worthwhile. Someone is sick. Someone is hurting. You do your part to make it better. They stop hurting. They get better. Bingo. This is why people work in an ER.

Kate - I had someone throw their ID bracelets in my face yesterday because I took someone with a kidney stone (excruciating) in to a room ahead of them. They seemed to think that their four week old shoulder pain was more critical.

Rudee said...

You need a break from triage. It can be overwhelming but look at the bright side: it makes for a great topic. I don't miss ER in the least, nor ICU for that matter. I hope you got that sleep.

Anonymous said...

I believe you, bill & I were in ER waiting one time and a "yuppie" Mom was in with her little girl that had a cut,tiny,on her finger, Needed a bandaid. Believe me I avoid hospitals if at all possible. I have been there enough for more than one lifetime. Marti thinks I go tothe doctor too much, but I think my immune system is way down since I had a staph infection in an artifical hip. I just take care of what I need to do to have good health. M.s Mom

Devon said...

It is pretty sad. My hubby is a firefighter and he gets a lot of frequent fliers. 911 gets you a ride to the ER. He has told me that 'someone' in the ER gives the cronic abusers a bus ticket to San Francisco. There is usually a police officer available to give them a ride to the bus station.

The hospital probably pays for the ticket in an effort to save money. Have you ever heard of such a thing for your local homeless?

aims said...

I hate to look like a complete idiot all the time - but what do you mean they get a hot meal and then they don't pay for it?

Do you have buffet in the ER?

the rotten correspondent said...

rudee - I slept beautifully, thank you. Nothing like a good rant before bed.

M's mom - People can be a little unreasonable with their kids. I know I'm overprotective, but I'd like to think I wouldn't make a jerk of myself over a bandaid.

devon - I've never heard of such a thing. Where do I sign up?

aims - no buffet, just a cafeteria down the hall. They give us their order, we call dietary and they got a hot tray delivered right to them. Lots of times our regular menu isn't good enough and we have to special order. If we served beer, we'd never have an open bed.

the rotten correspondent said...

oh, and aims? since they have no intention of paying for the ER visit, and the meal is part of the visit...it's a freebie.

Katy said...

RC- Your ER sounds just like the one my friend used to work with. Frequent flyers and all.

Now she is an OB nurse at the county hospital so all her frequent flyers are from the county jail. Lot of pregnant women in jail are looking for a more confertable bed to sleep in for a while.

Akelamalu said...

I've often thought "who in their right mind wants to visit ER if they don't have to?" - thanks for clarifying it for me. :(

ped crossing said...

I needed you last January. I was the kidney stone patient and because of all the stupidity ahead of me (2 am Sunday morning) I sat in the waiting room (with the family in tow) for 2.5 hours without ever getting in before I decided I could suffer at home instead. At least then I wasn't suffering in public.

Now I know, call the ambulance. Then I get in and the family gets to stay at home.

Anonymous said...

curious. (having a daughter who works ER and I've heard this from her too)

Do you have any ideas how to fix it?


the rotten correspondent said...

katy - I know several nurses who work in the jails. Their stories are way better than mine. Yikes!

akela - I think the same thing. Why would anyone want to come in unless they absolutely HAD to??

ped crossing - well, wait a sec now. If you call an ambulance, you get a bill. A big bill. And I know you. You'd insist on paying the bill. That's just how you are. The insurance companies in all their wisdom probably wouldn't consider a kidney stone an emergency. And besides which, all the ambulances are already out picking up the teenagers with period cramps.

Ivy - I wish I did. I think we really should have the right to not treat people who are on record as abusing the system. But it's such a complicated issue, since there are untold numbers of people out there who depend on the ER for ALL of their health care needs. The whole thing is a vicious cycle.

my two cents said...

Devon - That explains a lot.

aims said...

You don't get any of that up here! You would only get a sandwich perhaps if you had been there a VERY long time and a couple of mealtimes had passed.

Tiggerlane said...

Funny, you are reminding me of the stories I heard about in the days my hubby worked the ER...and he called that the COBRA law, that says you can't turn someone away. I actually knew the names of all the 'Frequent Fliers' - but that was before HIPPA was such a big deal. In our town, they actually read the "hospital report" on the radio, not too many years ago!