"But for me, 98.4 means I have a fever...." - page 7
Just a pet peeve....I hate when I do a set of vitals on a patient and the vitals are clinically stable but the patient insists its abnormal. Example: Me - Just checked the temp - reads 98.4... Read More
Mar 19, '12I work with the elderly so I get nervous when I see a temp of 99. Most of our patient's seem to run in the 96-97 range. I have called our medical director and told him about a temp of 99 on one of our patient's and he took my concerns seriously. Especially with elderly patients vital signs are usually the last to go. I had a patient whose vital signs were normal but just seemed "off". I told the doctor and he ordered some tests. It turns out she had a very serious UTI.
Mar 19, '12I recognize that I am either opening a can of worms or offering something that will most probably be ignored..
Why do ERs, part of huge hospital complexes, not have some form of urgent care for sick kiddos in the middle of the night? A place where the ear aches, strep throats, etc. can be treated away from the gun shots, MVAs, stabbings, full and near code folks?
Many of you work in ERs. You probably have to go to staff meetings where you are placed on some quality improvement committee that is tasked with something. On these committees do you find any upper management who is willing to look at things differently? ER nurses are expensive, ER beds are expensive to maintain because you need all the bells and whistles for codes and near codes. Kids high temps, ear aches, and strep throats need none of these. Why do we not see a dividing line done by someone when the family shows up? Instead we bog down an ER bed and nurse to do no emergent but urgent care. This is not a new concept. "Doc in a Box" storefronts have been around for years. They are a good place to take these families. I think any times they do not do insurance and other third party payers well.
Another situation came to my attention clearly recently when talking about trying to get a 15 yr old girl into a gyn office. She was not a pt. (mom was). The girl had to be seen in the ER, where they could do little except a CBC. After this the girl would get into the gyn's office. Bottom line for this girl was 3 months of bleeding continuously, a crit of about 7 by the time anyone took it seriously. It was a total waste of resources to not get her definitive treatment when her mother determined there was a huge problem. Perhaps it is because we see so many parents that are not schooled as well. Certainly the gyn knew the mom and knew she does not freak out.
Bottom line for me is that our health care system is broken in so many places. Nurses take a lot of the flack and the other stuff flying around but the problem is a corporate mindset. Unfortunately our patients do not carry the same numbers or respond in the same way with similar numbers. If we treat our patients with that same mind set we are in danger of only looking at numbers like the rest of the bean counters. At that point we fail to be nurses. I am not sure what the proper name would be, but it cannot be considered nursing.
Mar 19, '12Quote from aknottedyarnBoth of the hospitals in my area have a "fast track" section of their emergency department -- everyone goes to the central triage, then they get assigned to either the "urgent" or "emergent" section accordingly. In both hospitals (which are both Level 1 Trauma Centers also), the "urgent care clinic" is in a completely different room from the "emergency department", with separately assigned doctors, nurses, and clerks.Why do ERs, part of huge hospital complexes, not have some form of urgent care for sick kiddos in the middle of the night? A place where the ear aches, strep throats, etc. can be treated away from the gun shots, MVAs, stabbings, full and near code folks?
The urgent section is usually only open until about 11pm (due to lack of demand after hours), so after that time everyone gets placed in the emergency section after triage, but we're fortunate in our area that staffing and space are both sufficient so that nobody ends up waiting twelve hours for strep throat.
Mar 19, '12Okay, we're veering off topic, but here goes.
There are several urgent cares in my area, including one right on the hospital campus. Problem is, our urgent care is so poorly managed, they can barely keep their doors open. Several docs have left because of this, and now they're short doctors, and so they close at 8pm.
There is also an after hours pediatric clinic in my area, open for limited hours on weekends.
There is an indigent clinic, but their resources are so limited, they can only operate three days of the week, and people have to get there really early in the morning and line up to be seen, and often the clinic cannot fit everyone in. These are poor people who take the bus, walk, ride their bike, etc. super early in the morning, stand in line all day, and may not even be seen.
There are low-cost clinics for uninsured/underinsured, but again, these require appointments that are hard to get, especially on short notice when a person feels like they have something urgent going on.
I won't even mention the VA clinic, except to say it's shameful how we treat our veterans.
Many of our non-emergent patients are insured and have PCPs, but when something non-emergent but urgent comes up, such as an upper respiratory infection or viral gastroenteritis, they cannot get an appointment for weeks at a time.
Any mention of chest discomfort (as in pneumonia, not cardiac) or abdominal pain (as in viral gastroenteritis, not a ruptured appy), and the urgent care will not see them. Won't even assess them to determine whether the urgent care can provide the services needed. They just punt them.
Like the above poster, our ED also has a Fast Track area, but sometimes we cannot staff it (because our hospital administration keeps us understaffed to save money), so our non-emergent 4s and 5s have to sit and wait, and get merged into the flow with the rest of the patients.
I don't blame the patients for all of this. This is how messed up our health care system is. I completely understand why people just come to the ED when they feel sick, even if it's not an emergency. In my mind, the problem is lack of access to primary care. When you're experiencing abdominal pain, or you've had a fever and cough for a week and it's not getting any better, and you can't get in to see your PCP for three weeks, what the heck are you supposed to do?
Not only do we need more PCPs, but we need more PCPs who can see their patients on short notice for those little things in life that come up. What ever happened to the family doctor that you could call in the middle of the night because little Johnny has an ear ache?
Part of the problem is that medical school is so expensive that new doctors come out with a gigantic debt, so they specialize because it's more lucrative than primary care. Also, the way reimbursement works, it necessitates that PCPs run on the assembly line model, with no time left in their day to squeeze in someone with the sniffles or who just doesn't feel right. They have to think about whether it's going to be billable or not. Reimbursement dictates practice.
I'll do it. Pay me to go to medical school so I don't come out of it with a mountain of debt that I'll never repay, and so that my home isn't repossessed while I immerse myself in school for the next ten years, and I'll do it. I'll happily open up a clinic in my area and see my patients on short notice instead of punting them to the ED unnecessarily.
Oh wait, there I go dreaming again. Nobody wants to pay for doctors. Nobody wants to pay for education. Yet we expect to have access to health care when we need it.Last edit by Anna Flaxis on Mar 19, '12
Mar 19, '12A recent experience.
I had a pt. who was legitametily knowledgeable, as in the pt had "been there, done that." I "lit a fire," because I felt that his pulsatile bleed was, possibly, over my head. The pt informed me that the bleed was not important, I should be concerned about the contralateral pain. pt. may well have been correct, but, for me active visible bleeding is more significant. The point for my patient was that we were addressing that problem well, however, we were not addressing another problem.
Yes, I'm omnipotent, I'm dealing with your truly significant, high temp., pain, etc., but what you see is my concern over what you perceive as a lessor problem. No sarcasm, your perceptions of what is my priority, is meaningful.
Mar 19, '12Never?! I've seen a few doctors do it in the last 2 years in the ER. They'll just pop on the cuff while talking if they don't like the number currently glaring at them on the monitor.
Mar 19, '12Quote from tech1000We posted at the same time. That's sorta my point. the numbers are important, but not always meaningful. The signs mean something, but really, do you treat symptomatic tachycardia differently from asymptomatic tachycardia? That's an extreme, but symptoms, often, are more important than signs. So, a temp of 35.2, is "a fever for me", is more significant than a temp of 38.5 without symptoms. Still, I treat the problem I see as most significant. And yes, your treatment is delayed because you did not consider taking an antipyretic for a fever before seeking professional help.Never?! I've seen a few doctors do it in the last 2 years in the ER. They'll just pop on the cuff while talking if they don't like the number currently glaring at them on the monitor.
Mar 20, '12Quote from abbakingInsist about getting a rectal temp to make sure "it is right". ;-)Just a pet peeve....I hate when I do a set of vitals on a patient and the vitals are clinically stable but the patient insists its abnormal.
Me - Just checked the temp - reads 98.4
Patient (40 something drama queen) - "Thats high for me...I think i have a fever"
Me - "Do you know what your temp normally is?"
Patient - "My normal temp is 98.2"
Me - "Your temp is FINE...all your other vitals are FINE"
Patient - "But i really am sick if I go above 98.4.......blah, blah, blah
Just irritates me....