Multitasking (and why migraine patients wait)
At any given moment during the typical shift in the ER, here is what is happening:
- There are 10-20 patients in the waiting room. Some have been waiting 6 hours. A couple of them have ankle sprains and were already X-rayed, and their X-rays were already read by the Radiologist as "no bony abnormality, soft tissue swelling." They would like to leave without being seen. We don't argue too much.
- I'm waiting on a callback from a specialist, and I have two more calls to make after that one. If I paged them all at once, they would all call back at the same time, then two of them would hang up before I was finished talking with the first one. They would be understandably angry when they were repaged, and they would take an hour to call back the second time. So I page them one at a time. As soon as I introduce myself to the next patient I see, the first one will call back.
- I have one patient in the CT scanner and two more patients drinking contrast waiting their turn to get scanned. One of them just vomited, and will need some more antiemetic (and some more contrast). The other one wants more pain medication. One of these will need to be admitted for surgery, another will need to be admitted for IV antibiotics, and the other can be discharged after several hours of medical management and serial evaluations in the ER.
- I'm waiting on the Radiologist to interpret the head CT scan and X-rays of the lady that passed out and fell down the stairs. I need to see her blood tests too, but the lab is taking longer than normal. I still need to suture her lacerated lip and eyebrow.
- I have a dialysis patient who has missed his last couple of dialysis treatments, preferring to go to the crack house instead. His blood pressure is dangerously elevated, he has chest pain, his lungs are full of fluid, and his potassium is dangerously high. It initially appeared that he might need to be intubated, but after 20 minutes of aggressive medical management he is starting to breathe a bit easier. There are no ICU beds available, so he requires a nurse to give one-on-one care until he is stabilized.
- There is a homeless patient who is "suicidal" after running out of money to buy crack who is taking up an ER room (and a tech to act as a sitter) while waiting for his transfer to the first Psychiatric facility that will take him. No facility will accept him during my shift, and he will be turned over to the next doctor in the morning.
- One elderly patient with chest pain and known coronary disease is waiting to be admitted to a telemetry bed, and a nurse is standing behind me (as I am charting on someone else) asking me for a Tylenol order because he has a nitro headache, and by the way, his blood pressure is still high. Two other new patients with chest pain are still waiting to be seen. I need to look at their medical records to see what their last cardiac admissions revealed, and to see who admitted them the last time. The tech is standing next to me waiting to show me their ECGs.
- I can hear a toddler screaming with a fever of 103 and (hopefully) an ear infection. I would love to see him quickly and get him out of the ER ASAP, but I have to pop in to see the new chest painers first. His nurse is taking care of the dialysis patient, so the kid still hasn't gotten the Motrin I ordered half an hour ago. His father is standing angrily at the door with arms crossed, glaring at all who pass by.
- EMS just brought in a drunk guy on a backboard who is now in the hallway because there are no rooms to put him in. He's cursing and trying to take off his cervical collar. I'm going to have to quickly look him over before I see the two chest painers. But he will have to wait a minute, because...
- EMS is transferring a frail nursing home resident with fever and mental status changes onto our stretcher. Her mouth is open, her tongue is as dry as the Sahara, dried feces is caked on her legs and fingernails, and she smells strongly of urine. She doesn't speak, staring blankly at the ceiling. Her blood pressure is low, and she is pale. No family is present, and she has never been to our facility before. She usually goes to Big City Hospital, but they are on drive-by. I wonder for a second why we aren't, then I remember that we are. It doesn't matter. She's our patient now.
- A patient who was admitted by the doctor I replaced is waiting on an inpatient bed, and her family keeps coming up to the nurses' station to ask for an extra pillow, a cup of ice, somebody to come help them lower the head of the bed, and the all-important "how much longer?" Oh, and the IV machine is beeping again. All the nurses are taking care of other patients, and since I am stuck at the desk charting, I am the default question-answerer. I tell them I'll ask their nurse to come in as soon as I can, but I am quickly sidetracked with other concerns and never do so.
- A migraine patient was brought into her darkened room 30 minutes ago, not because she was necessarily the most acute patient in the waiting room, but because she had already been waiting for 6 hours. Her concerned mother had been pestering the triage nurse relentlessly. Mom is standing in line behind the other people who are asking me questions, ready to ask me "How much longer? She's really hurting." This is her tenth ER visit this year for the same complaint.
Labels: chest pain, ER, getting old, homeless, nightshifts, pain, patients, worried mothers
posted by scalpel at 3:35 AM
21 Comments:
It's true, patients want to know 'how long.' A few months ago my beloved and I abused an ER and asked exactly that question.
He works with his hands and had cut his finger and it was getting infected. He doesn't fight infection well or heal quickly even when not infected, so we were concerned enough to think of asking for antibiotics in some form. Especially as he needs full use of his hands to work. (I fight infection quite well and have an office job - I would not consult for a cut finger for myself.) We went to a late-night clinic first, but the spots were already all booked up and we were advised to visit the ER of a particular hospital. We did. (Sorry.) We went through all the triage, then asked the usual question (How long?) and got the predictable unhelpful answer (Impossible to tell). Next question: Are we likely to wait until 2:00 in the morning? Answer: Yes.
So we decided that sleep was more important than anything else, signed out and went home. (His finger was fine. Maybe it was all that hand sanitiser.)
Anyway, if I hadn't asked that all-important second question (Maybe until 2:00 in the morning?) we wouldn't have had enough information. The nurse didn't volunteer it. No, of course she didn't know for sure. But she does have a feel for how busy a Monday night can be and for how busy they are right now.
(In my business I might ask someone how much an optical patch cord costs. Useless but predictable answer: They vary too much, I couldn't say. Ok, I say, more than $0.25? More than $25,000? Then I'll get an answer I can work with: $50 to $70.
Yes, people can be really obnoxious, particularly when they are worried. Especially when they are also stupid and/or paranoid. But does your triage system involve some sort of order of magnitude ballparking to manage the rest of us?
If we knew how long, we'd tell you. "Not sure" or "as soon as we're able" is the truthful answer. We hate people to sit in the lobby too.
Remember, you guys in the lobby don't see all those patients in full arrest, septic or with multiple trauma rolling in by ambulance through the back door too. You get one or two of those, and the whole staff might be tied up for a long period of time. The ER is not as predictable as, say, the seating at a restaurant.
Oh, come now.
I *do not* think you are just sitting around playing games on the computer.
In fact I would rather stick pins into my eyeballs than go to an emergency room for anything, because I just don't want to feel like a nuisance.
If it's any consolation, every single person who is in a service-related occupation has to deal with this crap on a daily basis. Quite frankly, most of the time it sucks being around other human beings, which is why my life ambition is to be a hermit.
Ah, I fondly remember those days and nights, and am glad that I am now an Ex ER Doc... Glad I did it, and glad I don't do it any more.
Yeh...I heard that about you ER docs...all you do is waste time, you don't care how long people wait because you are busy playing on your computer. If you'd just get of that*%#%*% computer your patients would get the help they came there for!! NOT!!!
I hear you scalpel! The problem is is that people are caught up in their pain and discomfort and it seems many are not able to see the bigger picture, priorities, etc.
Many times when our ER would seem to be not as busy, pts would be irked because they weren't moving but they don't realize what is actually going on behind those doors and curtains....a little inconsequential thing ..oh ..I don't know..like SAVING A LIFE!
I remember my 1st migraine...it was March 1987. I was home and tylenol didn't work and now I was going to vomit. So, I called up to the ER and spoke with the Doc (I worked there) and he told me to take Benadryl if I had any in the house and said I just needed to rest. It worked like a charm. I woke up hours later feeling just fine. Fortunately, I rarely get them.
Although, last November I awoke with a headache and had to get out the door. By the time I got to the doc's office the headache was pretty bad. I then had to go to the hospital for a test and I took a percocet for the test. It didn't touch the headache and they almost had to stop because I was going to be ill. They called the doc and they gave me an IV of something to stop off the nausea.
Benadryl and I-buprofen-my drugs of choice every time. :)
Thank God for you and all the other medical professionals that work so hard to help others. Thank you! :)
P.S. I did have a negative experience in an ER in August and I actually wondered if I made a mistake in telling them to take their time (I was in pain and feeling nauseous with acute pancreatitis) because I worked in ER registration for 20 years and I knew exactly what they were going through. 11 1/2 hours later I was wondering if that was a mistake to say? :) To their defense I could hear the rigs rolling in one after the other so I did understand- just hard when your feeling real bad.
Long story short- after finally becoming an admit to the floor and there for a few hours, my PMD was not concerned and felt that since my numbers were low, that the whole thing was caused by a urological procedure I had had earlier that day in combination with not eating and medication. $9,000.00 for the ER and a few hours later as an inpatient-he was right. I'm fine.
I might write about the experience from the "patient" perspective. :)
They have even found you online. Aaaaaa.. the idiots are everywhere.
'The ER is not as predictable as, say, the seating at a restaurant.'
No, absolutely not. A restaurant is first-come, first-served. (Or biggest-tipper, first-served.) I didn't suggest it was.
If I say 'How long?' I'm not asking if I'll be seen soon - I know that I can be bumped at any time. I'm asking 'For a cut finger, am I going to be the top priority in this ER at any time in the next week?' Or 'What are the odds of me being seen within four hours?'
It's not about being given a time that I can expect to be seen at, just information I can use to make a decision with. If I come in short of breath and with chest pain and a two-day history of terrible toothache I really need to be in the ER - no decisions necessary - and I can expect that I will be seen pretty quickly.
If I'm there for something very likely to get me bumped, the information that odds are even that nobody will get to me for another twelve hours, at three in the morning, when they sometimes have a slow period - is useful. Precisely because I'm there for something bumpable, I can decide that while I would rather see someone for my whatsit now, I'll wait three days and go to a clinic instead.
Alternatively, if I hear that I have even odds of being seen within three hours because it's really quiet and they are fully staffed, I might decide to stay. Knowing full well that it's a gamble, that someone could come in at any time with a real emergency.
It's about probabilities, not about trying to make an appointment in the ER. For me, anyway.
Those are the days I really reconsider my decision to become an ER RN. ICU was always 'nicer' even when we were busy. If points came to 4 nurses, or our eight beds were full we got no more patients. The ER is not like that.
Thank Goodness those days aren't common. It's like all of those other things we hate to do that if our job only involved that we would quit. Like, holding a kidney basin for a GI bleed to puke in...or fishing through a commode for a stool sample for guaiac/O&P/WB..or telling someone that someone they love has died.
I still think that the ER doesn't hold complete responsibility for the care of the holding patients. The floors should also bear some responsibility and send down some help, call someone in...share the wealth! Not just for patient comfort but for their safety and the safety of the ER patients and staff.
I like the new quote on your sidebar. ;-)
As far as the discussion that it came from, I'm in awe of your ability to communicate with the crayzees for so long without losing your mind.
You are truly a master.
Two points: Our ER was recently raked over the coals because we had 50% of our beds taken up by floor overflow--being followed by OUR nurses for labs and other floor orders. The powers didn't like having so many folks in the hall. Cute huh? Also, my new observiation is that the first thing out of a patients mouth at our place after you tell them what you think and what you're going to do to work them up is: "Hey Doc, think I can get something to eat?"
Alison...there are certain conditions for which the time to be seen hypothetically approaches infinity in a busy ER, although the longest door to physician evaluation time I can recall offhand is 13 hours, and that patient actually had a broken nose, not just a sunburn or a bruise.
If we didn't have so much paperwork to do for each patient, it would be simple to go up to triage and whip through all the minor complaints every few hours. Sometimes I do that anyway, but even the simplest most accommodating patient takes 10 minutes or more, most of which is documentation.
There are nights where I barely have time to urinate myself, much less spend 10 minutes on a patient with a bladder infection when there are heart attacks and strokes rolling in.
Basically, Nurse K is right (as usual)...there just isn't a good answer for that question "how much longer?" because things can change at any time. As I've said before, "If you are sick, you'll stay."
Seaspray...I'm glad things turned out OK.
Sometimes when it's off the hook, a charge will come to triage and say "tell everyone they'll be here at least three hours before they see a doctor", or maybe it'll be six hours. However, if you come in with some bullshit complaint like a toothache going into the third month, you might be seen right away because the low acuity side isn't busy...until we do your vitals and see that you're ridiculously hypertensive because you didn't think you needed your meds for the last year or two. Guess what? Now you're moved to the three or six hour wait side, and maybe we'll give you some Catapres first or maybe we won't. You'll probably leave, but not before aggressively confronting one or more staff members with "y'all ain't doing shit!!!".
All ERs need good triage and 'clinics on the other side of the parking lot' to send people to, like migraines.
Unfortunately, the members of the "leisure class" and the uninsured use ER's as their primary care doctor in many places. That is my experience with 18 years of ER practice.
"What is wrong with your son?" sez I. Mom replies, "he has a fever". "what else is going on with him? Have you given him tylenol?" I inquire. Mom says, "no, I felt that he had a fever and rushed him right here".
It is a shame that ER's cannot send away people that don't have an emergent need for care. I understand that there has to be an alternative. Most places have urgent care centers that are oriented around episodic care of non emergency problems.
North Carolina has a policy for medicaid recipients called Carolina Access. All recipients are assigned a primary care doctor who must approve their care in the ER. Unfortunately, when denied approval, those same patients can say "I will pay for the visit myself then, bill me". What a joke.
Yes. That is EXACTLY how it is. I can feel the stress, irritability, and hypervigilence inside of me just like I'm actually at work. In fact, why am I even reading this on my day off? :)
My hospital recently posted a mandate from JCAHO that stated we were not allowed to tell people the approximate waiting time. The thinking was that people might perceive us as refusing care if we told them the wait was long.
Jayco mandates we keep the times a mystery? Terrific. I'll be using that next time someone asks.
Thanks Scalpel :)
How familiar this sounds! I am pretty sure we had that going on in our ER lat night too. Although our wait time is typically closer to 10 hours. OF course the people who really don't need to be in the Er are the ones who are complaining about the wait times and how come they ar no pillows and they need food. I always want to say "if you want it your way go to Burger King!"
as a nurse on a busy ortho trauma floor in a big(ger) city - i LOATHE families who get angry when we spend all that time "playing on the computer".
i am busting my ass to take the best care of your precious (insert mushy pet-name), but i am really more worried about checking for orders, her O2 sats and her 70/30 BP than i am about the last time she ate or the flippin TV reception.
good post.
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