Fast Food Medicine.

[rnjlin]

had to share this article written by a pa in our department.

the girl with the 365-day headache curses after waiting for 30 minutes. her headache that has waxed and waned for over a year reaches its peak at 6.30 pm. she yells at the triage nurse: "how long am i gonna wait? it's been an hour. my head ******* hurts. that woman who arrived after me went straight back." 


i consider the straight back woman: ravaged by cancer, flushed with fever, desiccated by intractable vomiting, with barely the strength to stand on our scales. she craves water like a dried out river bed. we start an iv wide open, flood her veins with normal saline, and send her to a room. 


how long has it been? i look at the tracking board. the nurse peers over my shoulder. er wait time 32 minutes. i consider the girl's story: a headache of varying intensity and duration for the past 12 months, worse in the evening, better in the morning. she denies trauma, focal neurologic symptoms, fevers, worst headache of life. she came to the er today because she got insurance yesterday. the girl has waited 365 days for this day, this moment, her time. i take her complaint seriously, pay attention, and listen carefully to her narrative. i neither hear nor see signs of imminent danger. i decide to put her back in the waiting room. no beds available immediately, not unless you are dying. the girl does not understand this, but others do. 


they sit quietly. i doubt any of them enjoy waiting. a young guy in his pajamas slumped in his chair leans forwards to vomit into a cardboard bowl. opposite, a woman with depression sits grey and unmoving like a graveyard memorial to a lost soul. in the far corner sleeps a homeless man with painful blistered feet. they have hurt for 5 years. a miasma of desolation hangs over him: urine, bridges, and dark, empty streets. 


the girl fumes at my side. i catch her glancing at the indigent man. the hungry homeless man and the cachectic cancerous woman make her uncomfortable. i explain we are waiting for a room to become available. we see patients on the basis of acuity, not the order of arrival. the girl has no time for my explanation. she rolls her eyes and lets out a frustrated sigh. her expression is sullen; her face a painting. i look farther in; i see fear tinting her anger: a bad diagnosis, slow starvation, not existing, an inoperable tumor? 


in the background, i hear the wails of the daughter whose mom is coding in room 2. further down the hall sobs the 
kid in a collar on a backboard with maybe a broken neck? an ambulance pulls in with an alpha trauma; team 1 prepares for the patient. i know "the trauma" has a bullet wound somewhere and is close to dead. 


i offer the girl pain medications and a bed in an empty triage room. she ungraciously accepts both. later, i will check her again, suggest perhaps she get a family doctor, and all the while remind myself that hospital means shelter. 


another wait, another family on the edge: how long until my wife goes to ct? the wife fell and hit her head. she is 75 and comes in with generalized weakness. the husband looks irritated. he has been to the er many times with his ailing wife. this wait added to all the other waits is too much: sick and tired of it! sick and tired of caring for his wife? he looks exhausted. he wrings his hands, rocks on his chair, steps out of his wife's room multiple times. the wife appears happy, comfortable, not so weak, quite demented. he worries about his dog: fido needs letting out. fido gets upset. fido is old and sick. the husband wants to leave. 


i ordered the scan 25 minutes ago. i explain that er wait times are unpredictable: "if a patient arrives with a life threatening medical condition, they jump the line. we cannot predict this." he mimics me, repeating what i say word for word, mockingly. 


i pause, considering how to redirect his anger. i reply: "i know you are irritated by the wait. waiting is hard when you are anxious about your loved ones. how can i make this easier for you?" he tells me he wants a time to work around. i understand this. i offer to call ct to find out more. he nods, grateful i think, and picks up his book. the man understands the reasons for delays in medicine, but he is tired and the truth is unwelcome. 


a patient with right hemiparesis and slurring of speech arrives on a gurney: onset 25 minutes ago, age 62; a candidate for tpa. the man's wife will need to give up the ct. another room in the er has gone. the girl's wait in triage lengthens. move on over, the wait just got longer, but it is not eternal, not for the girl nor for the wife. 


i tell the husband to go home; let out the dog. i will watch over his wife. his wife rambles, telling me they don't have a dog. hospital means shelter. as we wait in them, we lose and find humanity. sometimes, i want to tell my patients hospitals are not fast food restaurants. you can't necessarily have it your way; you cannot always get what you want. but most times, if you choose to wait, you do get what you need. sometimes i want to ask: do you really want to be that straight back woman? jaapa


---

alexandra godfrey practices emergency medicine at st. joseph's mercy hospital, ypsilanti, michigan

[Esme12, ASN, BSN, RN]

I think this article should be strategically placed throught the Emergency Department for all to read. :yelclap:

[GitanoRN, BSN, MSN, RN]

i couldn't have said it better myself. consequently, i agree with you 100% patients can't expect to have it their own way once they come to ed, even when you have inform every pt. about the unpredictability in ed. however, then you encountered the patients who know how to work the system and those are the ones that give you "drama" even though they came in c/o of a pain which they had for over a year!!! in addition, when you turn your back they are the ones on their cell phone laughing with their friends, but when they see you or the ed manager coming they start their drama all over again:uhoh3:

[MLB55]

I always hear, you don't want to be the guy they are rushing back with nurses and docs surrounding him.

[DroogieRN]

So beautifully written.

[RNfaster]

Beautiful. Would like more of her observations.

[sharpeimom]

that was magnificent! i was right there as i read it.

[tiredbeatupRN]

Gah! I wish I could write as well as the author. Excellent reading!

[MassED, BSN, RN]

i couldn't have said it better myself. consequently, i agree with you 100% patients can't expect to have it their own way once they come to ed, even when you have inform every pt. about the unpredictability in ed. however, then you encountered the patients who know how to work the system and those are the ones that give you "drama" even though they came in c/o of a pain which they had for over a year!!! in addition, when you turn your back they are the ones on their cell phone laughing with their friends, but when they see you or the ed manager coming they start their drama all over again:uhoh3:

i would add, to the op, that with the headache x12 months, offer a "left without being seen" form if they choose to leave, otherwise they need to go sit down so you can triage the next patient.

[PetsToPeople]

I agree, this was beautifully written and you are an amazing nurse, we need to learn how to clone you and fill the hospitals up with more of you!

[ChuckeRN, BSN, RN]

The great thing about where I work is that I can actually tell my "patients" that what you have is not an emergency and NOT get in trouble.

[Roy Fokker, BSN, RN]

Sometimes the issue IS fixable.

Lack of beds, for example. Or how empty beds get assigned...

And since management is ALL about "informing patients" - well, "informed patients" is what they get...

Especially on Press-Ganey....

.... specifically with regards to availability of beds...

cheers,