I work in an Emergency Room that is usually full, has a long wait time and what you would think were the unhappiest patients on the planet, according to my manager. I know this is far from true, but I get so tired of hearing about “patient satisfaction” and reimbursement based on recommendation that I just feel sick to my stomach. People are entitled to the care, compassion from the caregivers and the best treatments available. I firmly believe that anyone who is legitimately sick understands how much a healer is willing to do to make sure they’re taken care of and comfortable.
That’s the dilemma, we see so many people every day who have no business being in an emergency room, because they have no emergency. Back pain you’ve had for six months, a toothache, and an inability to remember when your last period was while you’re sexually active…. Yeah, they’re all horrible to the person who’s experiencing that loss of control, but certainly not emergencies. BUT! There’s more! They are entitled to the same level of compassion and concern as someone who is dying, someone who has a broken bone, an impaled object in their body, or are losing control of the ability to breathe without assistance.
You might say I draw comparison to extremes, but when the 80 year old man who is dying is going to get a little more of my time than a 40 year old with back pain. Just how it is… And guess what… the grumpy jerk that ‘was in a car accident a year ago and is out of his pain pills’ is going to be the one who writes the comment card or speaks up about his experience when someone calls his house to see how his visit was in the ER. It wasn’t as good as it could have been, but a visit to his pain management clinic or primary care doctor would have been a lot less painful for everyone. Probably would have been his choice… but wait, his doctor fired him as a patient because he was non-compliant with his other medical problems, and the pain management clinic was raided by the police last week and is now closed. Ugh!
Definitely a society and cultural problem going on today… people selling Lortab on the street, ‘getting medication from a friend’, knowing what Dilaudid is when you don’t have a chronically disabling condition. Being allergic to every non-narcotic pain medicine, bringing a friend with you because you know you’re not going to get narcotics unless you have a ride, telling someone you go to the ER because its “free”, or a myriad of other things that irritate ER staff… in other words, knowing how the system works and how you can get around it.
Triage. That word means, very basically, to sort. In the ER, you get triaged twice whether you realize it or not. You get triaged when you get there, they ask you all kinds of personal questions about why you’re in the ER in the first place… what kind of history you have, and try and get a general sense of how urgent it is that you see a doctor. Usually you get assigned a number that corresponds with your expected treatment, and that puts you somewhere on the list to get back to an actual room to see another nurse and a doctor. The part you don’t realize is that you’re triaged again when you get to the room. The nurse who comes in to see you, usually hooking you up to monitors or drawing blood, asking a few questions and generally getting an idea of your mental state, how you appear, and just an idea of your demeanor is your second triage. That nurse then puts you in his or her own personal triage relative to the patients they have in the other rooms they are assigned. If you look legitimately ill, your vital signs are not normal, or you present yourself in a way that rings alarm bells to a nurse, you go higher on the priority list.
That second triage is probably more important than the first as far as how ‘satisfied’ you’re going to be as a patient. If your nurse builds a rapport with you, believes you are actually sick enough to require emergency care, the more likely it is that the physician is going to arrive to the same conclusion. It’s also more likely that the little things that would make your stay more comfortable are going to happen more expeditiously than if you are someone who doesn’t appear to have an emergency.
In other words, you will see the doctor sooner rather than later, if the nurse is concerned about your life, limbs, mental or general health. If you have no obvious signs of distress, trauma, abnormality or other concern, you go lower on the priority list for care. Not to understate the obvious; everyone in an ER will see a physician and be treated based on the physician’s medical judgment. Regardless of where the nurse puts you on a priority list they have internally, there is room for adjustment when and if it’s necessary.
A piece of advice: Being a jerk, telling me your pain is ten out of ten on a numerical scale or writhing around the bed and ‘carrying on’ is not going to endear you to anyone in the department. We’ve seen it all and our bulls&*t meters are probably better attuned than any others in the world. We know what pain looks like, not just what you say it is… and if you start at ten… and then it gets worse… how are we going to know by a number? We’re not. BUT, we are going to see changes in your affect and demeanor that suggest it has increased. If your pain is so bad that you feel medication may be necessary to treat it, start at six or seven. That way, if it does get worse, there is a number that will correspond and we will have a quick reference to whether or not any treatment is working. And, while I agree that everyone’s pain tolerance is different, telling a nurse that you have a ‘high pain tolerance’ only suggests that you have or have had an addiction to pain medication. I’m not saying everyone does, but it’s a red flag in the back of the mind when someone says to a nurse “that dose isn’t going to work” before you’ve even been given the medication. Unless you’re a cancer patient, someone with a crippling disease or some kind of weird metabolic thing that affects pain management, having an idea about medication doses is another flag to anyone working in an ER.
Another piece of advice: if the ER staff knows your name before you tell anyone what it is, may be an issue. There are at least five names I can spout off at any given moment that belong to “frequent fliers” in the ER where I work. The worst part of this, is I probably know their medical history better than their significant others, and some people don’t believe this is a problem. Seems to me, that a primary care physician and their office staff should be the ones who ‘know you on sight’… not the staff in an ER. What’s even worse is when the rescue people don’t have to get directions to your house. Maybe it’s time for a lifestyle change, because something that’s going on in your house is not healthy.
I realize that some people have no other place to turn to for care. I know that every population has those people who cannot or will not use resources in a way that is beneficial to everyone. The ER is not free. If you’re not paying the bill; many people, including the ones who are taking care of you, are the ones paying for it. Nothing is free. Someone is either writing it off as ‘charity’ or you and those who are doing the same are costing the hospitals millions of dollars in revenue that would be more beneficial in other ways. Think about this, if a hospital was to take all the money they ‘write off’ they could probably build, staff and maintain a clinic that offered care at little or no cost for those non-emergencies you have at 10pm on a Wednesday night because there is nothing you want to see on the television and you ran out of Percocet.
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