(NOTE: scenarios have been slightly changed for confidentiality, and identifying features removed or altered)
Ah, the the computer sits in front of me. The sun is shining through the windows. No patients awaiting triage and I'm on Allnurses.com - one of the few websites I can have full access to while working. I'm in the lobby, the official meet and greet person. I've picked up some overtime and critical bonus hours to make my 12 hour shift a 16 hour shift. My time in the lobby is going to be 1900-2300, and boy, is it looking great!
My Job these next four hours will be to have the patients sign in. Direct family members to the appropriate rooms. I will take Vital signs and their sign in papers to the nurse performing triage. The patient will then be called from the waiting room, be triaged, and depending on how many rooms are availabe in the back, the pt will be sent to a room based on acuity level or back into the lobby where I will continue to monitor.
A panicked middle aged man enters and asks to see his father. "He was just brought in by the ambulance!" he exclaims. If this is true, the patient hasn't even been triaged yet and will not appear on my board. I politely encourage the man to calm down, have a seat, and I'll phone back to the main ED.
I discover the patient has been sent to shock room one for a code stroke. I am forced to hold the son out in the lobby and explain that the nurses and doctors are triaging him, getting a line, blood, and getting a head CT. I let the son know he can go back once the patient has returned from CT. The son surprises me at his willingness to comply instead of argue.
Within minutes a mob of people arrive. I get the vital sign machine ready and its going to be time to start the ground running.
"No. I'm not here to see a doctor. I need to see my mom. She was just brought in."
"My son and wife just rode in on the ambulance. Where are they at."
"My grandfather doesn't speak much English, he was picked up at home by the paramedics and they said they'd bring him here"
Well, this is interesting. Apparently, no one is sick today except for the ambulance arrivals. I call back to the main ED so I know where to and if I can send these people since no triage has been performed yet and I can't pull up room numbers without the triage. I send some people back and make others wait until. The secretary says they just got 6 ambulances back to back in the last 30 minutes and you know what is hitting the fan.
I thank my lucky stars I'm out in lobby and not back there today. Little do I realize...
Eventually I manage send everyone to the appropriate places when the herd of ailments and illnesses arrive shortly after 2000. You've got your rashes, the earaches, the lacerations, STDs, miscarriages, abd pains and of course.... of course the chest pains.
The interesting thing about my hospital is that there is a separate heart hospital not even 1,000 feet away from the ED entrance. There are two emergency signs as you enter the hospital campus. One says, "EMERGENCY". The other says, "CHEST PAIN". Ppl with chest pain don't ever see the chest pain sign. Le sigh.
A woman walks in carrying a large bottled water. She's laughing and joking with her friend. I honestly don't know which will be the patient and which is there just for moral support. I approach them and find out who our patient will be. "Are you here to see an ER physician?" I ask. "Yes. I think I'm dehydrated. Its happened before. Usually, a liter of saline will just perk me right up."
"Has the bottled water not been helping you?" I ask, motioning to her drink.
"No. I still feel like I'm dehydrated."
I inwardly groan and had to bite my tongue from saying, "The first sign of dehydration is tachycardia" and her heart rate of 77 BPM doesnt fit the mold!
The lobby is filling up and filling up fast. Its just me, myself, and I to control this herd. I'm running two Dynamaps (our VS machines) at once, as soon as we get a new person walk through our doors.
A girl, with the pale, white skin, skinny pants, dark eyeliner and well... you can guess it, the emo-look to put it bluntly, arrives with her mother. Mom says she overdosed on Trazadone- approximately 8-10 pills, unknown dosage. Occurred approximately 2 hours ago. Pt vomited once since then per mother prior to ED arrival. I'm not overly concerned. The patient will be triaged within 30 minutes at the triage nurse's current pace. BP on the low side of acceptable, will continue to monitor. Respirations even / unlabored at 18 per minute.
Simultaneously, a young black woman is then dragged in through the lobby. Her family is coming up to me saying she needs to be seen right away. She just had an overdose of unknown # of aspirin and vicodin. Every member of that family is trying to vie for my attention. I look at all of them and politely and nicely, encourage them to make her comfortable. I am with another patient but while I finish up here they can fill out the sign-in sheet .
I finish up with young trazadone girl and move on to aspirin girl. Aspirin girl is ignoring me, cradling her abdomen rocking back and forth, curled up in the arms of the chair where she sits. I know she was just talking to her family, so she's purposefully neglecting me. I ask the family more specific questions. The amount of ASA is unknown but they're very sure it was just one vicodin she overdosed on.
what?......Yah... thats right.....one vicodin..... just my luck....
ok, back to the story. So we don't know how much ASA but we know there was only one vicodin. Ok ok. Let's get vitals. Vitals are PERFECT. She moans, groans, and shakes and only weakly answers my questions after asking repeatedly 5+ times. Ok.
Let me give a shout out to my Correctional nursing buddies!! You all taught me to trust my objective data and properly non-pertinent subjective! You all improved my assessment skills and because of my 11 months in corrections I am now able to prevent this family mayhem from going to my head. I've seen better actors in prison and I'm not letting this little girl and her hysterical family fool me now.
I move on. I'm not playing into her drama.
I hand the triage nurse a list of 4 new people ready to be seen. The Triage nurse is still playing catch up. Soon even more people roll in, all of who need to be seen by an ER physician. More thanks to all those tables, pre-nursing school, that ran me rugged. Always needing refills and checks cashed out at the restaurants. It made me fast, if not somewhat messy.......7 more people. Its like a bus unloaded.
One very loud woman is moaning about how much her legs hurt. "Omg. I can't walk anymore. I think its a DVT. I just know it. Oh Lord, help this poor soul." I look around to see if anyone else is seeing the irony that despite this commotion and her new liking to being wheelchair bound, she actually drove herself here. Sadly, it is lost on all others. I grab her Vitals. She's stable. Nothing that will overtake anyone else at this time.... I mean, the ambulances saw to it that we no longer had available beds for anyone.
I catch up. I can breathe. Sadly, this new walk-in doesn't look like he can.
I had just put gloves on to clean off all my dirty BP cuffs when I see this older gentleman with glasses who has "THAT LOOK". Yah, you know what I'm talking about. Mouth agape, Bugged eyes, skin looking kind of moist, and he's trembling head to toe with a very unsteady gait.
"Omg! Sir. Are you ok? Please have a seat." I point to a seat already occupied. I speak up in a commanding voice, "you. I need your seat please." The pt was there for a thumb laceration and gracefully gave his seat up in a lobby without any spare seats. Bless his kind heart. I speak to the old man and ask what's going on.
"I've got some blood pressure problems." He smiles at me and chuckles a bit. "It was real low like last time you saw me. I'm pretty sure you were my nurse. You worked at the prison, right?"
"Yah! That's me. I'm so happy you remembered." I can't remember who this guy is. I'm drawing a total blank. I go over a quick assessment for cardiac issues other than blood pressure. The old man denies everything. No pain anywhere. No shortness of breath. No history of heart problems other than HTN, and as of late, orthostatic hypotension.
"Its at its worse when I'm standing. I feel like i'm going to pass out every time I stand up." The gentleman plainly states. I'm going to get this guy quick admitted and have him go next on the triage - despite the lack of MI symptoms I just don't feel right about this situation and I'll do his triage myself from the lobby. But I don't think he needs to go str8 back without a triage first since he was able to walk and talk by himself. He tells me his wife is parking the car now.
As I'm obtaining the man's personal info, a woman comes into the lobby shouting at me, "Nurse! Nurse! I need your help. Please I need you to come with me."
The triage tech who is assisting the RN doing triage and walking patients back to rooms comes out to inspect the shouting. I pull the tech over to help write out the old man's name, DoB, and last 4 SSN while I go assist the shouting woman.
"My mother is 96 years old. Her blood pressure has been dropping like a rock. I can't get her out of the car and she needs to see someone right now."
"No problem. You came to the right place." I assure the hysterical woman. "We're going to take very good care of her". I have the wheelchair in hand and walk up to the car door. The hysterical woman jumps in the driver's seat- totally not bothering to help me get her mother out of the car and then proceeds to instruct me on the best way to move her mother. Srsly...
I get the mother safely in the wheelchair. The 96 year old woman is smiling a toothless grin at me and seems to be acting very well for someone of her apparent age and suspected mental status. I direct the daughter to the overflow parking lot and wheel the old woman into the ED Lobby only to see 3 security officers and the tech standing over the body of the old man sprawled supine on the lobby floor, slowly moving his hands to reset his glasses.
It was one of those moments I just silently curse myself for having left the lobby and I just rolled my eyes in frustration. I park the lady next to the immediate greeting desk and hand a sign-in slip to her her blind eyes and weak hands, politely and briskly telling her to sign in, knowing she's not going to have the foggiest idea what to do with it.
I kneel next to the old man. He's conscious. I feel his radial pulse. His heart rate feels faint. The RN comes out of the triage room and has an ambulance gurney. She asks what happened. I tell her the guy has orthostatic hypotension and I'm guessing he passed out. The old man tells us he's got tunnel vision. The RN says, "hold on. Let me get someone. Keep him right there."
I think to myself, "Who are you going to get? We ARE the people you get! I inwardly groan, but she's the new grad RN and I'm the LPN, albeit with two more years of emergency nursing under my belt.
I begin to requestion the old man, "Are you hurting anywhere? Do you have any chest pain or arm pain?" The old man denies it. "Is your neck or back hurt?" The old man denies it. "Stay with me, John Doe!" I sternly speak to him. "Tell me what your experiencing."
"Its just blurry" and his eyes close.
"Hey! Hey!! Wake up". I do a firm sternal rub. He lethargically comes to. I grab him by the arm and tell the security officers and our tech to help me lift the old man on the gurney. "John, you're not going unconscious in this lobby, dude! Its bad PR and I can't have that!!" I look to all three others helping me and tell them, "LIFT". We hoist the man up tothe gurney and he is wheeled back.
Later on, I discover he was Dx'd with orthostatic hypotension and a possible acute MI.
I'm feeling awful about the whole situation and second guessing myself on if I did everything properly. However, more and more people are pouring into the lobby. They are using wheel chairs to sit in and now I'm fresh out of wheel chairs. Ambulances are being diverted to the lobby as well.
One woman and her 7 year old son came on an ambulance because her son hit his head on the corner of a coffee table. A very small gash, that resulted in an overdramatic ambulance ride. The woman was fuming that she was sent out into the lobby and tried multiple times to call her husband to pick them up because she did not want to wait to be triaged. Eventually, she caved in to the 2 hour wait time and duked it out.
The ASA overdose girl and her family begin cursing and causing a scene about their wait time and leave the ER Lobby to go elsewhere. The triage nurse concurred with my assessment the patient was being overdramatic and had a long hx of Bipolar disorder.
My Charge nurse comes out of the main ED and tells me the minute clinic down the street is sending a 3 year old who ingested 5mg of his father's methadone approximately 20 minutes ago. I keep an eye out and spend most of my time comforting the mother when they arrive as I try to get the feisty child to hold still so I can take his pulse-ox and BP. While multi-taking the VS equipment, I comfort the family letting them know that this is more of a learning experience. We're okay right now. The best thing you can do for everyone is to be calm and focused on the child .The kid waits a few and is eventually bumped up before several other people.
Then an older black man is being wheeled up. He's huffing and puffing, and trying to blow this whole ER down (but not in a scary way). His elderly wife strides over to me and tells me, "My husband is having heart problems. He had open heart surgery last month and now he can't breathe." I look over to her husband. He actually looks alright to me. He's not sweaty. His respirations are actually normal when he's speaking, and only has SoB when left idle. I'm thinking anxiety, however, I do take cardiac issues seriously.
"Why didn't you go to the heart hospital, ma'am?" I inquire as i take another patient's blood pressure and pulse-ox.
"We usually do, but this just seemed closer." She tried to explain.
Her explanation made no sense to me being that the heart hospital is literally next door.
"Ok, please fill out the sign in sheet next to your husband. We'll get a stat EKG on him once your finished." "I don't understand. He needs to be seen."
"He will be seen, ma'am but we need his personal info before we can put him in the system. Go ahead and fill the form out and your husband will receive treatment."
"At the heart hospital they just take him straight back. My husband might be having a heart attack!" her voice becomes shrill.
I begin to lose my temper and I use my most authoritative voice. "Ma'am! If you do not fill out that paper for your husband, you are wasting time and time is cellular death. The more time you do not fill this paper out the more damage your husband's heart could be suffering." She snaps back, "When is he going to get a room? He needs..."
I cut her off, "Ma'am, you need to write down his name, date of birth, and last four of his social security number. If you do not do that, I will do it for you, but I am busy right now. So If you want him to be seen you need to do that. Do you understand me!?"
She looks baffled and confused. "The form is right there on the table. Please fill it out now and I will be right with you." Eventually, the realization seems to dawn on her that the form is her key to the ED.
I finish what I'm doing. I grab the oxygen tank and put the new pt on 2L per NC. The husband is now reprimanding me for talking to his wife like that. His SoB seems to have disappeared. His vitals are excellent. Nothing interesting. I have him quick admitted by our registration people and have our tech do a stat EKG. The old man was in Normal Sinus Rhythm and nothing apparent. The SoB seemed to ease and become tolerable after the EKG for this new patient and he was sent back out into the lobby to wait with everyone else.
Sadly.... The domino effect happened.
A 47 year old woman who looks 20 years older walks up to me, "I have chest pain and when it gets bad I go down hill quick".
"Thank you for telling me that. I'll monitor your status every few rounds" I say.
A 28 year old woman with asthma says, "I've got this tightness in my chest, I think its chest pain. I've never had this feeling before". I respond, "ok, we'll get an EKG on you too."
Remember that loud lady, I briefly mentioned who thought she had DVTs. An hour later, she is still out in the lobby still being loud and now she's shouting, "I had stents placed in my heart last year. My chest is aching! How can you just leave me out here!?"
"Ma'am, when you arrived, you said nothing about chest pains." I respond.
"I didnt have them then."
"Then what suddenly brought them on?"
"I don't know. I might have a DVT or PE. Let me see a doctor and we'll find out!" she seethes with animosity.
"I'll let the RN know that you're having a new onset of chest pains." I flatly inform her.
All of them had to be quick admitted and receive a stat EKG. All were fine and sent right back to the lobby.
I turn around and see 5 more people filling out sign in sheets. A middle aged suburban housewife stops me and says her son went to his first concert alone, got dehydrated and drank a gallon of water that was drugged with something. "Do you think it will be long?" she asks. I look at her son and then at the packed can of sardines that is my lobby and say, "i don't know for sure." I make my rounds to all of them, and eventually run into the last of the four new people. It was a young, strapping 18 year old male who was "drugged at concert" approximately 40 minutes ago.
I get the boy's vital signs. They're great. I ask the boy, "What do you think you drank?"
"I had, maybe a gallon of water" he says, looking at me with scared eyes.
"I understand, but what do you think was in the water?" I probe deeper.
"It was a jug of bottled water. I don't know." He seems confused, which only makes me more confused.
"Wait." The mom interjects our conversation, "Let me explain." The mom proceeds to explain to me and her son that it was HER BELIEF that he was drugged because he was acting so out of it when she first picked him up.
Eventually they walked out due to the long wait and her son feeling so much better after staying in an air-conditioned environment and being rehydrated.
Its almost time for me to leave. its 2250 now. Soooo close!!! Soooooo close!!!!!
The loud and obnoxious leg pain lady is throwing another fit. "I have chest pain! Why haven't I been seen yet!? Wheel me out. I'm not staying in here another minute. I'll just walk to the heart hospital." "But ma'am" I politely start, doing my best to hold out the sarcasm, "what about your leg, the DVT or anything else? Are you able to walk out?"
"No, but I'll crawl if I have to! I will never come back here. This is the worst service I have ever seen. Refusing a patient with chest pain. That's ridiculous."
"Well, hold on, ma'am. Let me speak with my charge nurse and see if we can arrange you proper transportation over there."
I enter the back ED and immediately spot the charge nurse coming my way. She smiles and waves to me. I let her know that DVT lady wants to leave. The Charge nurse asks, "Is this her?" and sure enough has her chart in hand.
"Yeah! Is she finally going back?"
"Yes, sir! I was just on my way to call her and this person back."
"No! You can't do that!" I flail my hands up. "If you call her back, she's going to think that her bad attitude and threats to leave are what sped up her wait time! Its only going to encourage more bad behavior in the future."
"I know. I hate that, trust me. But we gotta keep this line moving."
I sigh and inwardly groan. "Yeah. I know."
Thus concludes my four hours of Lobby Nurse!