Are there doctors on duty in the ER?

[Anna Flaxis, BSN, RN]

Non medically fragile adult woman in her mid forties with mother and grandmother in tow, c/o nausea and body aches x5 days. Previously diagnosed with "the flu or something" (actually viral gastroenteritis, according to the paperwork Mom showed me) at Urgent Care.

Whining "My head hurts, my stomach hurts, I feel so bad. They just sent me home and told me to take Tylenol (the word Tylenol said as if it were the most ridiculous thing she's ever heard)."

It's a busy day, I know it's going to be a long wait for her, so I go ahead and start a line, draw labs, hang a liter. No, I'm not going to go pester a busy doctor for pain and nausea protocols. She can wait.

I pop in every once in a while to check in, recheck vitals, etc.

Grandma asks, in all seriousness "Are there any doctors on duty in the ER?"

Me: "Yes, there are four on right now."

Grandma: "Well, where are they?"

Me, politely and with a smile: "Working. There are a lot of sick people here today, and the doctors are working really hard. It's actually a good thing when you don't have doctors hovering over you. It means you're not the sickest person here. The sickest people here in the Emergency Department are usually people who are actively dying."

It felt. so. good.

Am I bad?

I didn't tell her that they were getting ready to extubate someone over in the next hallway, who would most likely die.

I think I may have been making up a little for yesterday's episode, when a dental pain kept coming out into the hallway to ask what the holdup was. We had just received an infant Code 3 who didn't make it. They had worked on the infant for a long time, and every time I walked anywhere near the room, I could hear the mother's sobs. I just couldn't even look at the dental pain guy without feeling very angry. The best I could muster was to tell him "The doctors see patients according to how sick they are, and we've had a lot of sick people today", with only the most superficial attempt at politeness.

Dental pain ended up leaving very happy, after his nerve block and a take home pack of Vicodin.

Sigh.

[SHGR, MSN, RN, CNS]

People just want magic...to instantly feel better. Honestly, the hardest part of my job in primary care, is convincing sick people to go to the ER, and trying to convince not-very-sick or just plain uncomfortable people, to stay OUT of the ER.

I phone-triaged a lady this week that I thought was having a stroke (she did, too!) and I could not convince her to call an ambulance. I offered to call it for her. She wanted to come to the clinic. I said, if you come here, we will just send you to the ER.

I think the barrier is, they have so many times gone to the ER and waited, with their earaches and sore throats, and know that this new thing, this thing happening now, can't wait, so they think they will wait that long this time (following me here? :) ).

So frustrating...

[Anna Flaxis, BSN, RN]

Oh, I really don't mind taking care of not-very-sick people, in fact I really like working the Fast Track area. Generally, they're a quick, easy fix and leave happy. With the gastroenteritis lady, I did a ton of education on viral illnesses, how they have to run their course, that the duration is often 7-10 days, what kinds of comfort measures she could use at home, and what kinds of things would signify a serious complication that would require an ED visit. She left feeling much improved after a couple of liters and some Zofran (she didn't get any narcs).

No, it's not the people who don't need to be there that get to me. It's the lack of understanding that we see people according to acuity, not first come first serve, and that if you're waiting, it's because someone else CAN'T wait.

It's that we are witness to horrific pain, tragedy, and grief, and have to just stuff it down and keep going. Trying to dredge up an empathetic presence for someone who is NOT ill, who is being impatient, after just having been witness to something awful is really, really hard sometimes.

But, I still do it. I stuff it all down and treat everyone as nicely as I can muster, then go home and have a really good cry.

[shoegalRN, RN]

I hate it when we are coding someone, or have a trauma going on that has taken a turn for the worse, and all the other pts SEE the doctors and nurses running towards a certain room and this is the time they want to ACT OUT!

And granted, they have been waiting patiently for the last 4+ hours without any complaint, but the moment the attention is not on them, they want to loudly complain about the wait.

I had a pt come in because her toenail was about to fall off, not her toe being broken, or her foot being broken, her freaking toenail was ABOUT to fall off and we were coding someone at the time. When I finally got to her room, I apologized for the delay, explained that I was tied up with a very deathly ill patient and the doctor will be in shortly. Her 20 something daughter had the nerves to say "there is not any other doctors in the ER? Everybody HAS to work on that one person". I looked at her in the eye and said "yes, that patient is actively dying right now. Their family is outside the room and is not doing well right now, your mother is here for a broken toenail, God forbid if your mother was deathly ill, you would WANT all of us to work on her and save her, right? And how would you feel if another family would be questioning our decision because they had to wait to be seen for a broken toenail, but yet, still breathing, walking and talking? You wouldnt like that now, would you?"

She then tried to attempt to argue why her mother was more critical than the dying patient. I told her I'm not gonna argue with her and politely had security escort her out the hospital.

I am waiting for the day that a family member of a trauma/coding pt hears another patient complaining about the wait and then says something like "it takes everybody to work on that one patient" and that family member punches them.

[Altra, BSN, RN]

I am waiting for the day that a family member of a trauma/coding pt hears another patient complaining about the wait and then says something like "it takes everybody to work on that one patient" and that family member punches them.

God, I hope I'm working that day.

[shoegalRN, RN]

God, I hope I'm working that day.

It almost happened one day, our security responded before blows were thrown.

We had an elderly woman, brought in by daughter and granddaughter in SVT. Of course, everyone is in that room, daughter is outside of room crying.

Someone who was in the ER for a med refill wanted to know what the hold up was. Another RN was attempting to explain we are dealing with someone critical right now, of course, this other pt can see what's going on, crash cart moving fast towards room, double doors opened, all staff mostly in this room. Well, the med refill patient says something along the lines of "well I been waiting for over 8 hours, I need a doctor in here now!" The RN then just up and leaves because someone is calling out for Adenosine, so this patient becomes upset saying "why does it take everybody to work on one person".

So, you guessed it, daughter came from out of nowhere, giving him a good verbal lashing. Someone hit the panic button and security was called and med refill patient was escorted out.

I wish she would have swung though LOL!

[VICEDRN, BSN, RN]

I am waiting for the day that a family member of a trauma/coding pt hears another patient complaining about the wait and then says something like "it takes everybody to work on that one patient" and that family member punches them.

If I am NOT on shift that day, you guys need to make video for me, ok?

Makes me feel better to know that both the actively dying patient and the delusional walk in urgent care people exist in everyone's ER.

Like Stargazer, I derive a pleasure out of telling patients we see the most critical patients first and at a level I trauma, its gotta be gooood. lol

[dirtyhippiegirl, BSN, RN]

I haven't worked in the ER for years but was chatting the other day with some old friends, etc. They updated the ER about six years ago to a huge, football field sized area with individual rooms. Before that, it was a smaller area with only two isolation rooms -- everything else was done in four large bays that held X amount of pts. The EMS entry and trauma bays were later add-ons that actually connected with the waiting room. Meaning that anyone in the waiting room got a full view of all ambulance entrances, plus the usual hustle that accompanies trauma patients.

We definitely agreed that the old "does anyone work here?" bs was definitely minimized with the second scenario.

[Anna Flaxis, BSN, RN]

I guess it shouldn't surprise me that people who go to the Emergency Department for things that aren't critical don't realize that they're going to have to wait, but it does. I mean it doesn't take a whole lot of brains to realize that.

Funny little addendum to the first scenario, after the doc went in and saw her, Grandma asked me if we were going to admit her.

[SHGR, MSN, RN, CNS]

I guess it shouldn't surprise me that people who go to the Emergency Department for things that aren't critical don't realize that they're going to have to wait, but it does.

The definition of ED to some people is the "alleviate my discomfort now" department.

We had a young guy who, after being noncompliant with his BP meds, went to the ED...the ED report basically read, he was kicking back with his buddies and then his hands felt tight. So he went to the ED to have his BP checked. He didn't follow up with us after that, either. (??) I'm sort of in charge of corralling people and trying to get them to follow up. With us. You know, the primary care people.

[GitanoRN, BSN, MSN, RN]

unquestionably, ed crowding is one of the most visible problems hospital administrators face, and it's also a fairly expensive one. however, most hospitals have been hesitant to address it, in part because federal law requires doctors to treat anyone who turns up at the ed. consequently, a small fraction of people who visit ed each year account for a huge percentage of the costs in emergency care. with that said, this is true of healthcare in general and it's known colloquially as frequent fliers, these individuals visit ed repeatedly throughout the year; often because they're chronically ill, uninsured, alone, or a combination of all three.

[applewhitern, BSN, RN]

This is why I don't work ER. I have a way of being too blunt, and I don't like to handle the PITA ones. I took my one-year old granddaughter to the ER due to severe dehydration and diarrhea. This was our third visit to the ER in a week. The first ER said just give her some pedialyte (kinda hard when she is too sick to drink it.) The second one gave her a 250 cc saline bolus and sent us home. You all know how quickly a baby can dehydrate! She was very lethargic and not taking anything at all by mouth. Constant diarrhea. While we sat in the waiting room on our 3rd ER visit, a woman about 50ish was talking, laughing and having a good time with the 2 women who came with her. When they called us back, this woman became livid and claimed her pain was a "12." Another woman with a little child with her started World War Three, just because we were called back first. The nurse's time was completely taken up, with trying to calm everyone down. I just don't want to deal with that kind of drama.