Monday, November 24, 2008

Road Fest Part Five: Leaving Kingman

Kingman, Arizona; 0800 (8AM for the rest of you) on day 4:

I awoke to the bewitching aroma of coffee, sizzling bacon, and Southwest omelettes. Melanie (ER nurse) and Kevin (ICU nurse)- the married couple who so graciously took this wayward colleague and his wrecked toe into their home for a day- had just arrived home from their shifts and were preparing what was shaping up to be a smashing breakfast.

I pulled the blanket from over my eyes and sat up on their couch, squinting against the brilliant sunlight that streamed in from the living room window. With some trepidation, I carefully lifted the blanket from my left foot and was relieved to see that my big toe had returned to normal proportions. While the bruising to my foot looked like hell, it had not extended; and I felt only very mild pain, although the ibuprofen had worn off at least two hours ago. I had good distal capillary refill and sensation. The perforated nail looked, well... perforated; but no signs of infection were evident.

I stood up tentatively, testing my ability to bear weight on my left foot. Standing was okay, and walking was... well, not so much; but it was quite bearable, and I could probably get by alright with ibuprofen and stops every two hours for ice and elevation. I tested my ability to withstand using the clutch pedal by putting all my weight on the ball of the left foot, and had no trouble. I was ready to hit the road again.

I hobbled over in my scrubs (which also serve quite nicely as pajamas) to the breakfast nook as Kevin turned around to greet me with a big mug of coffee.

"Morning, friend. How's the toe?"

"Much better than I thought, thank you. But if this ever happens again, I think I'll forego the digital block. How was your night?"

"Mine was uneventful," Kevin replied. "Mel's was busy."

"Nothing awful, I hope." I said, resting my elbows on the counter and lifting my coffee up for a sip.

"Nothing awful. Just your typical Sunday Night crowd. But every time we would discharge a patient, we'd get another one back there. We never really had anyone waiting in triage; they just kept coming in one or two at a time all bloody night long. Nobody had a break all night, and I'm starving." Mel emphasized her point by staring sad-eyed and waif-like (with a boo-boo lip thrown in for good measure) at her husband as he flipped an omellete.

"Oh, stop," Kevin retorted as he reached out with his free hand to ruffle Mel's Tinkerbell pixie-do. "You're going to make me cry and I'll ruin breakfast."

I snorted in my coffee. Mel snickered and handed me a paper towel to dry off my nose.

"Thanks," I said. "Listen, guys: I can't tell you how much I appreciate your hospitality. I'm glad I listened to you and stayed off my foot for a day. It made a huge difference. But I ran through all my crossword puzzles and I have to say that daytime television ranks a ten/ten on the Suck-O-Meter."

Kevin nodded. "That's one of the greatest benefits of working the night shift: sleeping through Oprah."

I nodded and sipped more coffee.

"So are you heading to Phoenix this morning?" Kevin asked as he placed a plate of bacon and eggs before me.

"No, I have to skip Phoenix. I already called my kin down there to let them know. I will be going to San diego today. My sister is graduating from nursing school at San Diego State tomorrow."

"SDSU?" Mel asked over her tea. "Didn't they just have a huge drug bust there?"

"Yeah. My sister told me about it. She said the bust has prompted the Administration to give up any pretense of dignity, embrace its licensious culture, and change the school's name to "SDEASU."

Mel laughed. I handed her a napkin to dab the tea from her nose.

Kevin asked, "When are you leaving?"

"Well, as soon as I help you clean up I'll load up Baby-san and be off."

"Baby-san?" Mel furrowed her brow. "Who is that?"

"My car."

"Oh, my God," Mel laughed and set down her tea. "You gave your car a name?"

"Yes, I gave my car a name," I answered with a childish defensiveness. "It creates a kind of bond."

"I gave our car a name," Kevin offered. Mel turned to her hubby with her hands on her hips.

"Oh, really? And just what did you name our car?"

"Squeaky," Kevin said with a grin.

"'Squeaky'? What inspired you to name our car 'Squeaky'?

Kevin answered in the form of a smirk and an upward roll of his eyes.

Melanie shrieked and punched Kevin on the shoulder. It was an odd, Newlywed Show kind of moment. I covered my face in my hands and cleared my throat.

"So Mel, would you like me to help you clean up the blood and hide Kevin's body before I head out?"

"Naw. I can take care of that," Mel replied as she launched a fiery glare at her imperiled husband (who laughed), and punched him again.

An hour later, freshly showered, I emerged wearing a pair of baggy shorts, wide-soled Keens, and a Hawaiian shirt loud enough to strip the paint off a Buick at fifty meters.

"Wow," Mel said as she shielded her eyes. "I guess I'll cancel my chemical peel now."

I packed up my things and got squared away for departure. After an exchange of telephone numbers and email addresses, Mel gave me a hug and a peck on the cheek and instructed me to call when I got to San Diego and let them know how the toe held up. I promised I would (and I kept it). Kevin shook my hand in that huge paw of his and wished me well. I told him I would pray for his safety, since upon my departure there would be no witnesses to his impending demise at the hands of his 5'3" powderkeg of a wife. He laughed and kissed his bride. She punched him on the shoulder again, but followed up with a kiss, so I guessed he might live to see another day.

After stopping at a market for more ice and snacks, I gassed up and headed west toward San Diego with a roar, a cloud of dust, and two new friends.

Tuesday, November 04, 2008

The ER: Stuff You Need to Know. Part 1: Triage


I recently wrote an article describing a variety of examples of poor behavior demonstrated by patients in the Triage section of my Emergency Department. While the article was written primarily to introduce the reader to some of the actual (rather than media-generated) challenges encountered by an ER nurse in a humorous vein (which is the modus operandi for all of my writing), my article evoked a tremendous negative response with regard to the readers' personal ER experiences. A majority of responders related their unpleasant experiences when they or a loved one was treated in an ER.

The most common complaint was that an extraordinarily long time was spent simply waiting: waiting to get back to a room while others who arrived in Triage later were brought back first; after arrival in a room, waiting for the nurse to come in and perform an assessment; waiting for the MD to come in; waiting for medication; waiting for tests to be performed; waiting for test results to come back; waiting for diagnosis or treatment; waiting for transfer up to a unit bed; or waiting for discharge instructions and prescriptions. Furthermore, more deeply entrenched in these woes was a complaint common to all: not being informed about what was going on with the process. These people were simply never told what was happening at any point throughout their ER experiences. (It is perfectly understandable that a person in that situation would feel forgotten and ignored, and thus become upset.)

After considering these problems, and at the suggestion of a colleague, I have determined to do something about it. I hope that this series of articles will inform and enlighten the reader regarding the challenges and intricacies of emergency medicine. I hold the firm belief that a well- and accurately- informed public makes for a great patient, because a better-informed patient is far better equipped to actively participate in the care process and is able to more effectively advocate for oneself. I have found that patients treated in this manner nearly always described a far more positive and satisfactory experience, even if an extended wait was involved. Thus, when I teach new nurses (and students), I pound into their minds the following adage:

Keep them SAFE, Keep them WARM, Keep them COMFORTABLE, and Keep them INFORMED. When a nurse does this, it goes a very long way towards making the patient feel cared for- which is the whole point of nursing, if memory serves me correctly.

Returning to the issue at hand, I begin this series where the ER process begins: Triage.

The Purpose of Triage

In the civilian sector, triage was adopted by emergency departments in the early 1960s when the demand for emergency services grew beyond capacity to provide everything to everyone at the same time. The process enabled overloaded emergency departments to quickly identify and treat the "super-sick" patient from among the crowds. (Interestingly, it also proved a useful tool in identifying malingerers who were inappropriately using the ER.)

With the advent of government-subsidized medical entitlement programs, emergency departments were rapidly overwhelmed with non-emergent and non-urgent cases that slowed the entire emergency care process down. The need for, and value of, an effective triage system became immediately evident. As a result, four-tier and 5-tier triage systems were developed. With either system, patients are classified by level of acuity (how sick they appear based on objective data such as vital signs, obvious trauma, or body system affected).

Level of acuity is generally classified as follows:

Level I: LIFE-THREATENING condition requiring immediate care. Not stable. Examples: CPR or intubation in progress, acute MI, major trauma, acute respiratory distress, or major burn;

Level II: EMERGENT but stable. Seen ASAP (within 30 minutes); Examples: Open fracture, kidney stone, testicular torsion, "hot" (surgical) abdomen, sickle cell crisis, frankly-ill child, neonate with fever, eye injury, narrow-angle glaucoma, suicidal ideation.

Level III: URGENT. Stable, no distress. Seen ASAP if no Level I or II patients ahead of them. Can wait up to one hour before being seen. Examples: Closed fractures, laceration without bleeding, Drug ingestion > 3 hours prior to visit with no signs or symptoms.

Level IV: NON-URGENT. Stable, no distress, can wait at least one hour before being seen. Examples: Typical migraine, rash (without fever), abrasion, anxiety, cough/cold.

Level V: DELAYED. Can wait four or more hours before being seen. Examples: out of medications, routine exams.

The patient is classified according to objective findings (abnormal vital signs, obvious distress, etc.) The experienced and astute triage nurse also develops a "sick sense" (being able to quickly visually assess a patient for the appearance of a life-threatening illness as they come through the door).

It is absolutely essential that the reader understand this system because it governs the entire flow of the emergency medical process. The patient is not merely classified randomly and arbitrarily by the triage nurse. It also provides the inarguable reason why one person may arrive first but be seen later than another person who comes in after them. While one person my have a migraine and be completely and undeniably miserable, if another person arrives with signs and symptoms of a higher-acuity condition, that person is going in first, and no amount of complaining is going to change this fact. Furthermore, screaming, crying, or otherwise acting out will never qualify a patient to receive a higher acuity "just to shut them up." It just upsets everyone else who has to endure the tantrum.)

Challenges of Triage

Triage is one of the trickiest, most challenging functions for the ER nurse. Symptoms of a potentially life-threatening condition can be subtle, and can even be discovered "accidentally" when a patient is complaining of a problem that would itself provide for a lower acuity assignment. In my career, I have had at least six patients who complained of abdominal pain without vomiting or diarrhea (which at face value, merits an acuity of II to IV, depending on vital signs). But every single one of those six made a seemingly-offhand remark, or described their pain in a particular way, that my "suspicion index" sent up massive red flares. In each case, acting merely on my suspicion through the simple act of looking at and feeling both legs revealed one being colder and paler than the other- and that the patient's pain was not gastrointestinal at all, but that he or she was suffering from a dissecting abdominal aortic aneurism, which merits an acuity level of I with an exclamation point. (Only one of those patients died, and that was because his aorta completely tore within moments of sitting down in my triage booth. When the aorta blows out, there is nothing anyone can do; death occurs in ten seconds or less- there often isn't even enough time for the patient to say more than a startled, "Oh!" (It happened once). He just said, "I can't breathe," and he was gone. But had I been less experienced, I might have missed all six.)

Traits of the Effective Triage Nurse

The effective and safe triage nurse demonstrates experience, awareness, astuteness, coolness under pressure, and razor-sharp critical thinking skills. Where I work, no nurse with less than two full years as a full-time ER nurse is allowed to go anywhere near triage- even if only to give the triage nurse a 30-minute break. It is no place for the neophyte or any nurse who is still in the process of gaining confidence of his or her abilities. As illustrated above, people live and die on the quality of the triage nurse's assessment. When a waiting room is packed and more people are coming in, and just when three rooms are opening up the charge nurse informs triage that three medics have arrived with Level I patients, the triage nurse has no choice but to hold the line.

I have had many nights like that in Triage. In some ways, it is more difficult than working in a Level I thrash. Instead of one patient, I have thirty or forty with variable levels of acuity. This, again, is where experience and calm is an absolute requirement. Nobody likes to be stared at; and the awkwardness is amplified when every one of the people staring at the triage nurse is not feeling well and has been waiting for hours. How does one cope with this potentially-volatile situation? The question introduces two more equally-vital traits of the triage nurse: empathy and compassion.

In my experience, it really does not take much effort to help even a miserably uncomfortable person endure a long wait. It is amazing how calming to a room full of patients it is to simply circulate around the waiting room periodically, offer a blanket or pillow, and say "I know you've waited a long time. Has anything changed? We are working as fast as we can. We haven't forgotten about you. As long as you are out here, you are my patient and I will look out for you."

When people see you actively following up on them and looking after them, they feel cared for. All it requires is one minute of time to infuse calm into a crowded, highly-charged waiting room. Granted, there are times when it may not help (a demented patient with "sundowner's syndrome," a belligerent drunk or drug user, for example). But otherwise, I have never, in all my experience, known this approach to have failed me in calming down a room full of upset patients.

In fact, the triage nurse is required to re-assess everybody waiting on a regular basis. Making rounds is a quick and efficient means of doing that.

Concluding Remarks: Doing Your Part

I cannot speak for the practices of every nurse, hospital, or emergency department. Many factors not mentioned here can create a positive or negative experience for the patient. But I strongly encourage you, the reader, to advocate for yourself or your loved one. This is not Cuba; our medical system is still driven by a free-market economy. That means if enough patients get upset, they can tell their friends not to go to that hospital, and so on. People will start avoiding that hospital. The hospital is a business. No patients means no revenue. State agencies will begin to wonder what is going on at that hospital. The hospital will either change, lose accreditation, go bankrupt, or lapse into backwater obscurity.

Here is what you can do: If there is a problem, speak up! If more than an hour has passed since you have been informed or have seen your nurse, speak up! If you have not been seen, gone to a diagnostic test, received results, been treated for the diagnosis, or received your discharge instruction more than an hour after being informed of the step, speak up! And if you feel that you are not being informed about any part of the care process, speak up!

You, the patient, do not exist for us; We, the Emergency Department, exist for you. If we work together as a team, we both will be the more satisfied and enriched for it.