Just Because I Don’t Remember You Doesn’t Mean I Didn’t Care

In the Emergency Department where I work, the number of patients we see pushes 200 some days. We assess and treat a lot of people, mostly for lumps and bumps, breaks and bruises, but also for major, cataclysmic, life-altering events — MIs, trauma, stroke, what-have-you.

I have a problem. The moment to the patient leaves the department I tend to forget them. Completely. If you are a run of the mill STEMI, I swear I will not remember you the next day. I may not remember you in an hour. A little while ago, my manager asked me about a case receiving some, um, legal attention. It was only after a good deal of prodding that I vaguely remembered — and this was a Code Blue! (Fortunately the legal formalities were about treatment received on previous visits, so I wasn’t directly involved. My charting was good, anyway.)

I do remember some cases which for one reason or another have stuck in my mind. (For example, like here. Or here. Or here, among others.) But mostly, nah. Maybe it’s because of the sheer volume. Maybe because my head will explode if I remembered the details on each and every patient. Maybe it’s just coping skills. Who knows. Anyone else have this problem?

Anyway, I was triaging the other day, and a patient told me how much she appreciated the care I gave her husband. (He was a Triple A, and survived.) I goggled at her for a second — we don’t frequently receive compliments in the ED — and said, “Yes, of course, I remember him.” She beamed. I made her happy. But I didn’t remember him at all. The patient’s husband was all in a day’s work for me — and a hugely important day in her life. We tend to forget what impact we have on patients and families. So a small lie for a good cause, I guess, a tiny bit of therapeutic communication.

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Some stupid to ponder, or how a local employer treats their nurses like idiots. Our local CCAC — the provincial agency which arranges for Home Care and related services — hath decreed that case managers are no longer permitted to use hospital-provided educational materials because 1) they haven’t been vetted by CCAC and 2) because the case managers haven’t been in-serviced on them.

Really.

CCAC evidently thinks their case managers — all RNs, by the way — are complete idiots in that they can’t tell patients using a hospital provided form when to come back the ED because (for example) their saline lock is infected. And CCAC believes that hospital put out bogus and misleading educational materials.

Sometimes you just have to shake your head. And mutter. Who comes up with these bonehead rules, anyway? Do managers lie awake at night thinking them up?

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On a personal note, thanks to all who emailed or tweeted or otherwise left messages of support regarding the family medical emergency a couple of weeks ago. All is well again, but I was a little frightened for a while. Your concern was really appreciated, and made me realize that I — we — have a great little community around this blog. Thanks!

Observations and Assessments

NOTIONS TO SMALL FOR A BLOG POST, ALL IN ONE PLACE, A.K.A. THE PERIODIC LINK DUMP.

Further to my post “Sleepy Sleepy Nurse”: Sleep or Die. Really.

My job: Registered Nurse.

We don’t know as much about infection control as we think we do. “Less than a quarter of the Clostridium difficile cases in a hospital could be traced to patients in the same ward, challenging a common assumption about how the infection spreads.” Medscape summary. Original article here.

And we’re not as smart at Triage as we think we are. Analyzing the records of 519 patients aged 65 years or older who were triaged using the Emergency Severity Index, from University Hospital Basel in Switzerland, found that 117 patients were undertriaged and 15 were overtriaged.” Anecdotally, I think this is true. My only quibble is why the small sample size? I mean, 519 patients is two days of volume in a busy ED, which means only a few poorly trained triage nurses could skew the results.

Nurses’ Presenteeism and Its Effects on Self-Reported Quality of Care and Costs. I read the article and went “Meh.” Rather evades the real issues around presenteeism, i.e. workplaces penalizing nurses for taking sick time.

Oh, dear.

On the menu: Pink Slime! I swear I will never, ever buy ground beef ever again.

And they didn’t live happily ever after. Real life Disney princesses, fallen. A photo exhibit by Dina Goldstein. My favourite: Cinderella knocking back shots in a bar on Hastings Street in Vancouver’s Downtown Eastside.

Younger than the Happy Meal. An important reminder from Fred Clark the supposedly “eternal” truths about abortion maintained by evangelical Christians are of much more recent vintage than you think.

Great music in the cause of crap content. Dissecting the cultural significance of country music. Quote:

The conservative movement has been cannibalizing conservative art for years now, to the point where I’d say country music is far from a victory of conservative cultural or artistic success and is instead a mirror image of what conservative politics have become: easy and unthinking. No depth, all surface. Superficial and insular. Maybe I’m wrong, but building an entire genre on the back of the idea that regurgitating the same sound on top of the same basic premise over and over again hardly strikes me as a triumph of cultural conservatism.

What language do deaf people think in?

Ayn Rand is the Karl Marx of the Right. Mostly because she tells people with incredible amounts of privilege they are the real victims in life’s lottery. Quote: “She offers them something that is crucial to every successful political movement: a sense of victimhood. She tells them that they are parasitised by the ungrateful poor and oppressed by intrusive, controlling governments.”

The Reformed Whores respond to Rush Limbaugh: “I’m a slut.” Hugely funny and right on the money.

Triage

The world in four patients, plus interruptions.

Who’s next? Come in.

Do you have your Health Card?

Take off your hoodie and sit down. What brings you in today?

Where exactly is the pain?

On a scale of one to ten, if ten is the worst possible pain, what number would you give the pain?

How long have you had it?

Three months?

What changed tonight?

How would you describe it? Sharp? Dull? Knife-like?

Is it constant?

Does the pain go anywhere else?

Any nausea or vomiting?

Any diarrhea?

Does the pain get worse after eating?

Last bowel movement?

Last menstrual period?

Any problems peeing? Feeling like you have to go all the time? Blood in your pee?

Any allergies?

What medications are you on?

Any medical conditions we should be aware of?

Here’s urine bottle. There are directions on how to collect a sample in the toilet.

Your blood pressure is okay.

Take this to the registration clerk over there. We’ll make up a chart, get some blood work done, and have you seen by the doctor, okay?

Yes, over there.

Hi there, who’s next? Come in.

I can’t estimate the wait time. Today is very busy. Do you want to see a physician?

Sorry.

Who’s next? Come in.

Do you have a Health Card?

Do you mind taking off your jacket so I can check your vital signs?

Thanks.

What brings you in today?

When did the chest pain start?

Does the pain go anywhere else?

What kind of pain is it?

Heavy?

On a scale of one to ten, if ten is an elephant sitting on your chest, and one is a chihuahua, what number would you give your pain?

Any nausea or vomiting?

Were you sweaty?

Any shortness of breath?

Any weakness or dizziness?

I’m going to to do an electrocardiogram now. Come over here , take off your shirt and lie down on the stretcher, okay?

This will take just a minute.

It won’t hurt.

You won’t get a shock.

Okay, I’m going to bring you in to a bed.

Can you register your husband?

Can you call the doc to Resus 2 stat please?

This is a 53-year-old patient, two hour history of retrosternal chest pain radiating into the jaw and axilla, positive associated symptoms,  ST elevation in II, III and AVF. He’s a bit hypotensive. I’ve called for the doc. Okay?

Hi there, who’s next? Come in.

Nuclear medicine is on the other end of the hospital.

I’ll find a volunteer to take you there.

Thanks. You’re welcome.

Hi there, who’s next? Come in.

Do you have your health card?

Can you take off your sweater? Thanks.

What brings you in today?

What medication?

I’m sorry, the doc won’t renew your prescription for Percocets?

You’ll need to get a new prescription from your family doctor.

Sorry.

I can get you in to see the doctor if you’re having pain, and we can treat that here.

I’m pretty sure any other emerg will tell you the same.

Sorry.

I’m sorry. This is the best we can do

You have to see your GP.

Sorry.

Who’s next? Come in.

Do you have your Health Card?

What bring you in today?

I”m sorry about the wait.

Your family doctor said you would be admitted right away?

The emergency physician will have to see you first.

Do you mind watching your language, and can you please tone it down?

Please don’t swear at me.

Look, I mean it. There are small children in the waiting room.

Can you call security?

Do you mind taking her to the quiet room for a few minutes so she can calm down, and I’ll triage her when she’s settled?

Who’s next? Come on in.

Do you have your health card?

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How to Clear Out a Waiting Room

A couple of weeks ago we had a spectacularly bad day, traumas, codes, STEMIs, septic shock, status asthmaticus, what have you, plus (of course) a department filled with the haunted faces of the damned admitted patients and volumes of epic proportions. Faced with an angry and hostile waiting room overflowing with the walking wounded, the triage nurse made an announcement.

“Can I have your attention, please!” she shouted. “Because of four critically ill patients in the department, THERE WILL BE EXTENSIVE DELAYS TO SEE A PHYSICIAN. Thank you for your understanding.”

Ten patients immediately got up and left.

I know patients come to an emergency department for reasons the health care  professionals treating them might question, and that what we consider to be an emergency often diverges wildly from how a patient might perceive it. Nevertheless — I’m thinking, maybe, for those patients it wasn’t that much of an emergency, and just maybe, their GP or (God forbid) a walk-in clinic might have been a better option and better use of health care resources.

“What You Don’t Want to Hear Me Say at Triage”

[A rerun. I will be back tomorrow. Really. Slightly modified; first posted 27/01/2010.]

“Let me see if I can find a bed for you right away.”

“You look a bit unwell.”

“Your blood pressure is a little low — let’s get a wheelchair.”

“Let’s do an ECG right away.”

“Can I get a stretcher at Triage, stat?”

“Call a code.”

“Your wife can register you while I bring you in.”

“Wait here while I find an oxygen tank.”

“Let’s put a few more abd pads over that cut.”

“How long have you had the black stools?”

“Did the drainage start after you hit your head?”

“At what time exactly did the chest pain start?”

“At what time exactly did you notice the right arm weakness?”

“Can you page the RT?”

“Can you page the doc to the Resus Room?”

The words “ST elevation”, “shock”, “distress”, “hypotension”, “precode”, “neurological deficits”, “CTAS 1“, “actively bleeding” and “new onset” in any context.

If, on the other hand, I tell you it’s going to be a longish wait and send you to the waiting room with a urine specimen bottle, you should be grateful, happy and relieved: you aren’t likely to die.

“How Not to Dump a Patient”

[A rerun. Craig and Ricky are no longer partners, incidentally, and I’m not sure if Ricky is even in the ambulance service any more.]

Tuesday morning, 0205, and I’m in charge. Ricky and Craig push an elderly female patient in a wheelchair through the ambulance doors.

These guys are capable and competent paramedics, by which I mean if they say a patient is sick, I tend to take then at their word. No quibbling and no second guessing.  Craig is a bit goofy, wiry-thin, rapidly approaching middle-age; he tends to diagnose patients in the back of his rig and elaborate his conclusions at triage. So he’s acquired the title “Doctor” among some of the emerg nurses —and this isn’t meant to be kindly. But he’s okay, really, he knows his stuff and that’s good enough for me. Ricky is well, Ricky. Younger, early thirties, maybe, good-looking in a solid, conventional way. I don’t mind telling that I’ve carried a small, private torch for Ricky for a couple of years, mostly because he exudes confidence,  stability and a sort of farmboy charm: if he weren’t married and I weren’t married and if I were twenty years younger. . . well you get the idea.

Craig pulls up to the Desk and winks at me. “Piece of cake,” he says. “She woke up with abdominal pain, nausea. No vomiting, no diarrhea. CTAS 3. Can we take her around to triage?”

I’m distracted by the psych patient who’s come up to tell me for the fifty-third time about the worms in her brain. I nod agreement, reassure the psych patient that the worms aren’t showing, wash my hands and walk around to triage. Ricky gives me the story: 79 year old, woke up with nausea and abdominal pain, extensive cardiac history, diabetes, hypertension, blah and blah and so on, with a med list as long as your right arm.

I look at the patient.

Patient looks like crap. Tachycardic.  Pale, cold, clammy.  RUQ pain, yeah, but boys, did you appreciate the audible gurgling or the laboured respirations or even the +3 bilateral ankle and foot edema?

Um, no. Ricky looks embarrassed and Doctor Craig has taken a powder to the paramedics room.  Then I get it: they’re trying to dump the patient. In other words, they’re trying to avoid an off-load delay by routing the patient directly through triage (and then to the waiting room) by pretending the patient is less sick than she is. Better, they figure,  than waiting with the patient on the EMS stretcher for a bed.

I shake my head. I’ve seen some games from some EMS crews before, like the time a crew dropped at triage a hypotensive rectal bleed passing clots the size of canned hams without a by-or-with-your-leave, or told an inexperienced triage nurse the suicidal ideation wasn’t flight risk. But not from Ricky and Craig. Never.

I don’t even bother doing her vitals.  Resus room, I direct Ricky — and in ten minutes, she is catheterized, diurysed, and bipaped.  CHF, of course: the RUQ pain was all the blood backing up into her liver.

I am severely annoyed. Not so much they “missed” the presenting complaint — that’s bad enough — but by the assumption I wouldn’t offload an obviously critically ill patient immediately. And they know I’m pissed off. Usually at night paramedics hang out in the emerg as long as reasonably possible, avoiding dispatch, shooting the breeze, trading war stories, flirting with the (much younger) nurses, buying coffee. Socializing. But Craig and Ricky are gone before I can get out of the Resus room to, um, express my concerns.

Craig has been avoiding me all week, and Ricky won’t look me in the eye. I still don’t understand what the rush was about. It wasn’t that busy, and the patient would have been offloaded quickly, regardless.

But I just want to ask them: whatever it was, was it worth losing my trust? Really?

 

How a Resident Views Nurses at Triage

Some amusing toing-and-froing in the comments of this post at Movin’ Meat, which originally dealt with media coverage of a triage miss and the death of child as a result. NurseK, Cartoon Character and others have some fun taking their resident-beating stick to a PGY1 for ill-advisedly smacking down triage nurses. The relevant excerpt:

PGY1 said…

“A febrile child with petechiae or purpura is a medical emergency, and this is clearly one of those cases where the triage nurse missed it.” 

At the risk of drawing some hate, why are nurses responsible for determining what constitutes a medical emergency? The clinical acumen of triage nurses depends on a combination of intelligence and clinical experience, both of which vary widely among ED nurses.

Same goes for doctors, you say? Compared to medical education & residency training, nursing school is brief. Nurses don’t do residencies and are taught by other nurses. How can we expect even an excellent nurse to have clinical judgment on par with a that of a physician who has trained for years prior to entering practice?

1/14/2011 4:47 PM

[Cue beatdown music — ed.]

I won’t rehash the rebuttals for this particular piece of wisdom. NurseK et al. do a better job than I could, but I have to add that PYG1’s observation that  “nurses . . . are taught by other nurses” (O, the horror of it all!) is pretty funny too. Old nurses like me have heard physician criticism of nurses performing triage for a very long time — usually in the form of “how can they — nurses don’t have the 27 years of education that make me a great physician!” or “how can they — they’re doing what physicians are supposed to do!” or “Look at how the stupid triage nurse missed this exceedingly esoteric complaint!” In the hospital where I first practised, the Chief of Emergency Medicine* was adamant nurses could not triage because triage was tantamount to diagnosis — and nurses don’t diagnose. In any case, he said, nurses didn’t have the critical thinking skills to do it properly. This attitude reflected then, as does PGY1 comment does now, a fundamental misunderstanding of role of the triage process and underscores the archaic notion of the role of nurses as uneducated and passive tools of physician knowledge and experience. Well, plus ça change, plus c’est la même chose.

Yet I have to say, in my experience, the attitude that MDs must micromanage every element of patient care is slowly disappearing  among physicians. Occasionally you get one who appears to have slept through the lectures on collaborative practice and the critical role of nursing on the health care team, but this is increasingly rare. I actually hope PGY1 isn’t one of these and does take something away from the reaction to her comment — namely, that her view of nursing is skewered. She seems to indicate she will. She’ll be a better physician, and ultimately, her patients will be better for it as well.

[UPDATE 26/01/11: Minor word changes for clarity.]

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*Fortunately, the Ministry of Health was pretty insistent nurses fill the triage chair. This physician was also the sort who if a nurse said “renal colic”, would say “aortic aneurysm” and proceed to treat on that basis — sometimes with unfortunate results.

Crossing That Mysterious Line on Facebook

The other day EMS brought in a 58-year-old man to a certain Toronto-area hospital. His chief complaint? He had broken a toe nail. Left great toe, to be exact.

Seriously.

Now, I have a ten-dollar bill that says you think you know where I’m going with this: stupid ambulance-calling patient abusing the system, har-har, look at the dummy. Right?

Wrong.

One of my spies tells me there is a nurse at this hospital who posts tales of triage on her public Facebook page. She nailed — she thought — this particular patient just after Christmas, and didn’t bother to change the details of the chief complaint much to protect confidentiality.* Nor did she much conceal her contempt for this particular patient.

The detail the nurse neglected to mention on Facebook was this patient’s early-onset Alzheimer’s. He was just beginning to have some very serious cognitive problems; he called EMS when his toe began to bleed, then became quite agitated. His wife thought there was something seriously wrong.

Maybe not so funny now, right? Maybe more a case for social work and home care intervention than public ridicule?

I know there is a veritable cottage industry out there devoted to silly emergency department stories. Patients, in truth, do some very strange and funny things, and sometimes their appearance at the triage desk are for reasons less than credible. Hell, I’ve spun more than a few stories on this blog myself. I hope at the end of it I’ve respected both the patients and their confidentiality. But clearly the nurse above crossed a line. To me it feels abusive and frankly, rotten.  There’s a huge confidentiality issue. The context was deliberately left out: it’s not funny at all if you know the circumstances. The patient and family are in a particularly vulnerable situation.

But the question I have to ask is, where exactly is that line, and how do we know when we’ve crossed it?

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*I have, however.

Robotic Triage

Long time readers know of my intense obsession dislike of equivocating nurses/nursing with robots, and here is a classic example. Somewhere, somehow, some engineer is just not getting what triage nurses do:

If a group of computer engineers gets their way, we will no longer hear stories of patients dying in the ER after excruciatingly long waits. A solution for overburdened triage staff and long emergency room wait times appears to be in sight.

If you’re willing to wait five years, robots could help speed the ER triage process, according to Mitch Wilkes, associate director of the Center for Intelligent Systems and associate professor of electrical and computer engineering at Vanderbilt University. He is the lead author of a paper presented yesterday at the Humanoids 2010 conference held in Nashville.

The paper describes an ER that would feature electronic kiosks (like those at the airport) at the registration desk and smart chairs. A mobile robot or two might monitor patients in the waiting room.

After I finished laughing a little too gleefully at the thought of patients screaming at a triage robot, it seemed to me there is some, um, misunderstanding about a nurse’s role at triage, which decidedly is not about taking the patient’s temperature and sending her out to the waiting room. And if patients are demanding more face time with a health care professional, installing robots seems, well, a little counter-intuitive.

Here’s a thought on how to relieve “overburdened triage staff”: instead of spending a gazillion dollars developing and setting up the technology, then a gazillion more for ongoing upgrades and maintenance (for you know these things will break down when someone looks at them cross-wise), why not just adequately staff emergency departments with real, live nurses?

Naw. Too simple.

Once Again, Triage Nails It

Overhead at Triage:

20-something guy arrives via EMS for a penile fracture. (How he fractured his penis — well, it’s a story Not Suitable For Work, though suffice to say, it involves repeated dosing of beer and shots.) Granted, it’s a horridly painful injury, and a true urologic emergency: I guarantee all of my male readers are wincing and all of my female readers are snickering. However, our buddy is drunk and carrying on far, far beyond the call of duty, thrashing around and fluently and imaginatively cursing out the paramedics, the housekeeper, the nurses, the physicians, anyone, in fact, within earshot or seen from beery, bloodshot eyes. He’s not only an caterwauling idiot, but something much worse, a drunken, caterwauling idiot.

Triage listens to the (slightly ridiculous) story from EMS, listens to the continuous, matchless bellowing on the EMS stretcher, and pronounces her verdict:

“Clearly,” she says,  “A brain injury.”