Monday, July 6, 2015

Emergency Severity Index

How do we decide who gets to be seen first, anyway?

Like most EDs in this country, we use a triage system called the Emergency Severity Index. It's a set of rules that helps categorize patients and prioritize care. Many such systems exist, but this one is relatively modern and specialized. It was first developed in 2001 specifically for use in hospital emergency departments.

Under ESI rules, every arriving patient is assigned an acuity level from 1 to 5, with level 1 being the most urgently in need of care. Patients are not necessarily seen strictly in order of acuity, but the levels are used to prioritize care, so a patient having a heart attack needn't wait in line behind one with a papercut.

One of the main factors is that triage is fast. At the front desk we don't have the time for a complete head-to-toe assessment. The ESI level is assigned based on apparent immediacy of the problem and, for lower levels, the anticipated amount of resources required. (The presumption is that patients who need more complex care also need it sooner.) Here, "resource" means a process that takes special equipment or skilled intervention, like lab tests, x-rays, sutures, or the like.

The full ESI definition fills a book, but the categories can be generally summed up like so:

Level 1: Resuscitation - The patient is dying. Immediate life-sustaining intervention is necessary. Drop everything else and come a'running, because without help the patient's condition will be incompatible with life. Such a patient will usually (hopefully!) come in by ambulance with care already underway.
Examples: Cardiac arrest. Bullet wound to the chest. Brain injury. Traumatic limb amputation.

Level 2: Emergent - The patient should be seen immediately if at all possible. They are not trying to die at the moment, but are at high risk of having their condition degrade. Delay of care could present jeopardy to their life, limb, or major organ.
Examples: Cardiac chest pain. Eye injury. Acute asthma attack. Two-week-old infant with fever.

Level 3: Urgent - The patient is stable, and care will require two or more types of resource. These are people with vital signs in the normal range and who are not at high risk of immediate harm, but who need in-depth testing or treatment of some sort.
Examples: Abdominal pain. Displaced ankle fracture. Elderly patient with fever.

Level 4: Less Urgent - Also stable, with care expected to require only one type of resource. This is the one without an evocative description. It's just a middle ground between three and five.
Examples: Finger laceration. UTI. Sore throat. Abscess. Healthy adult patient with fever.

Level 5: Nonurgent - Stable, with no resources required except physical examination, routine care, oral or topical medication, and/or written prescriptions. This does not necessarily mean the patient is not sick! They might be miserably uncomfortable, but they are safe to wait an extended period of time for care if necessary.
Examples: Earache. Suture removal. Dental pain. Prescription refill. Work note request.

One thing to remember is that you can't tell just by looking. Lay people often seem confused at who gets up-triaged and brought in earlier, and patients sometimes complain about who got to go in before them, but we always have a reason. If two men present with back pain, one might go first if he recently had a high-risk spinal surgery. If two women complain of cough, one might go first because her pulse is very high and we suspect pulmonary embolism. If two kids have sore throats, one might have to skip the line because his tonsils are so big that his airway is at risk. There's always a reason.

Making triage calls requires significant book knowledge, a lot of professional judgement, and a little bit of intuition. It should always be run by an well-trained and experienced ED RN, because it's arguably the trickiest nursing assignment in the whole hospital.

Monday, June 22, 2015

Unclear On The Concept

One of my patients this weekend had special requirements before he would consent to be treated or admitted to the hospital. He instructed me at great length about all the difficulties of being a strict vegan, who will not eat or use any animal products of any kind, and how that will impact his care.

As we prepared to close his wound, he asked to see the label on the suture kit to make sure we weren't using silk thread. He also asked to read the ingredients on the antibiotic ointment to make sure it didn't contain lanolin. Later he had me call the food service department, on speakerphone, to confirm that our vegan meals are separately prepared and cannot cross-contaminate with any animal products.

He insisted we write in his chart that he will immediately sign out AMA and leave the hospital if his care products or meal tray were to contain anything at all non-vegan.

After all that was settled and documented, he asked for "a cup of coffee with 2% milk."

Monday, June 15, 2015

How Not To Be Seen Faster

Some people are always trying to skip to the head of the line in the ED waiting room. Last week in North Carolina, one patient who felt she had been waiting too long decided to set off the fire sprinkler system. This is not an effective way to be seen and treated sooner.

Other ineffective strategies include:
  • Shouting
  • Calling ahead
  • Coughing on me
  • Calling me names
  • Showing me money
  • Showing me a weapon
  • Showing me your boobs
  • Claiming you are a nurse
  • Claiming you are a physician
  • Claiming you are the hospital CEO
  • Offering me a ride in your new Cadillac
  • Offering me one of your McDonald's fries
  • Sitting in a wheelchair you don't actually need
  • Holding your breath while I measure your pulse ox
  • Telling me, "Write down 'unconscious' so I get seen first"
  • Telling me your buddies will "get" me if you're made to wait
  • Any sentence beginning with, "Now listen here, motherfucker"
None of these ever result in your being seen by the doc any faster. (Some of them will generate an immediate response, but only from a pack of several professionally looming young men with badges and crew cuts. Our hospital security officers are highly competent, intensely protective, and do not understand the phrase "just kidding.")

If you want to be seen first, all you have do is be the sickest person in the room. Manage that and you'll go straight to the head of the line.

Friday, May 22, 2015

This Will Hurt

A patient came to the front desk and said, "Nothing's really wrong with me but my wife made me come in. I took about eight Sudafed, and my chest feels a little funny."

No shit your chest feels funny. Your pulse is 211. Also, your fingernails are blue. Come sit right here while we stick these electrodes on you.

Have you ever heard of a Joule? No? Well, you're about to receive a hundred of them.

When you hear the word, "Clear!" you'll want to brace yourself.

Monday, May 11, 2015

I Need To Study More

When multiple patients arrive at once, we hand them little index cards and have them write down their reason for visiting. That helps us decide who gets to see the triage nurse first.

Today I picked up a registration card and couldn't figure out what it said. First letter S... squash? spill? Or maybe that's just a squiggle and it starts with a J, or a G... hmm. No idea.

I called the patient into the triage bay, sat her in the chair, and asked what brought her to the ER today. She said, "I have a problem with my squirrel."

Oh, that's what the card says, I thought. But that didn't clarify much. "Excuse me? Did you get bitten by a squirrel?"

"No. I said have a problem with my squirrel."

"Um... what kind of problem?"

"A squirrel problem."

"Say that again?" She did. I still heard the same thing. "I'm sorry, You are saying 'squirrel,' right? The animal that lives in trees?"

She looked at me like I was stupid. "Yeah."

"So, what happened with the squirrel?

She actually rolled her eyes. "I'm telling you I have a problem with my squirrel." And she pointed down at her lap.

The penny dropped. "Ah! I see. What symptoms are you having?"

"I fucking told you five fucking times already! A squirrel problem! Fuck, didn't you go to school for this shit?"

I guess not.

Thursday, May 7, 2015

Happy Nurses' Week

I started last night with a wrestling match. EMS brought in a patient who was agitated, and aggressive, and started attacking staff. It took five people just to hold him still long enough to sedate him. He yelled insults and accusations the whole time, and I've got a nice bruise on my thigh where his boot caught me.

But who cares about that?

EMS also brought in a totally unresponsive patient in cardiac arrest. We did CPR, and intubated him, and pushed medications, and gave a series of escalating electrical shocks, and we got him back. By the time we sent him to ICU he had a strong pulse, his skin had changed from dusky blue-gray back to its normal pink, and he was even starting to wake up and look around.

Any day when a patient comes in dead and leaves alive is a good day.

Monday, April 13, 2015

Why Nursing Is Stressful


A hospital supply room. Shelves line the walls, full of medical equipment. A handwashing sink is against one wall. An electronic medication cabinet stands on the other side of the room. One NURSE is standing at the cabinet, doing math on a handheld calculator.

Enter an orthopedic RESIDENT, carrying a plastic bucket.

Resident: Hi there.

Nurse: (distracted) 'Morning, doc.

Resident: Where can I dump this?

Nurse: What is it?

Resident: Leftover plaster. I just finished the cast in room three.

Nurse: Oh. Just leave it there. I'll take care of it.

Resident: (noticing the sink) Can I dump it in here?

Nurse: (paying attention now) No, that sink can't take it.

Resident: So what should I do with it?

Nurse: Just leave it there. I'll take care of it.

Resident: Just leave it?

Nurse: Yes, please. I'll get to it in a minute.

Resident: It's leftover plaster. We just put a cast on in room three. Can't I just dump it in here?

Nurse: No, it'll clog the pipes. We add a hardener to it and then throw the whole bucket in the trash.

Resident: Really.

Nurse: Yes. I can show you, if you like, as soon as I finish this.

(NURSE tries to go back to doing math. He is interrupted before he can find his place.)

Resident: So where should I put the bucket?

Nurse: Just set it down in the corner.

Resident: Can't I just dump it in the sink?

Nurse: No, you can't, sorry. It will clog the pipes. Last time somebody did that, engineering had to replace some of the plumbing.

Resident: Are you sure?

Nurse: Yes. You can see where they cut a hole in the wall. We couldn't use this room for two days.

Resident: I've never seen that happen on the ortho floor.

Nurse: You don't pour plaster in the sink up there. They have a special drain for it.

Resident: Oh, yeah, right. So can I use this sink here?

Nurse: No. Our plumbing can't take it.

Resident: Are you sure?

Nurse: Yes, I'm sure.

Resident: I'm just going to pour it in here.

Nurse: Please don't!

(RESIDENT pours the plaster in the sink)

Resident: What should I do with this empty bucket?

Friday, April 10, 2015

Lead A Horse To Water

Here's the text of a note I entered in a chart:
Patient refused placement of Foley catheter. Patient also refused to use urinal while in bed. Patient stated he intends to stand up to urinate. 
This RN and Dr. Foramen educated patient about the severity and instability of his neck fracture, that the external cervical immobilizer does not provide complete protection, and that attempting to stand or walk in his current condition presents a very high likelihood of spinal cord injury leading to death, nerve damage, loss of function, paralysis, organ dysfunction, or death. Patient verbalized understanding of these risks, and further repeated his adamant intention to stand and ambulate against medical advice.
(My nursing notes are professionally polite. What the patient actually said was, "I understand you, but I don't fucking care. I don't piss lying down unless I'm blackout drunk, and nobody is shoving anything up my dickhole. I'm standing up whenever the fuck I want. Pardon my fucking French.")

Profanity notwithstanding, this patient was in his right mind and in full possession of his faculties. He had no head injury. He was not mentally ill, confused, nor delirous. He wasn't even drunk (anymore). We did not have any justification to physically or chemically restrain him against his will. So, we very carefully documented that we educated him, and we asked him to sign a paper which listed the risks. Then we had to let him make his own choices.

I don't think he harmed himself the first time he stood. When his knees buckled, we carefully caught and supported him before he could fall. But if he keeps trying to move around before surgery, the fragments of his shattered cervical vertebrae will shift positions, and he'll wreck his spinal cord beyond what the neurosurgeons are able to repair.

And there's nothing I can do about it.

Wednesday, April 1, 2015

Third Base!

At about two this morning I finished a run of many evening shifts in a row. On the way home I stopped at the all-night grocery store, and among all my other purchases for the week, I thought it appropriate to buy a six-pack of beer.

When I got to the checkout, the cashier took the beer off the belt and stuck it behind the counter. I was surprised, and I asked why he did that. We had the following exchange:

Cashier: "I can't sell alcohol right now. Sorry. It's after midnight."

Me: "Okay. When can I buy it?"

Cashier: "You can't. It's too late. It's after midnight."

Me: "You said that already. But when can I buy it?"

Cashier: "You'll have to come back tomorrow."

Me: "I can't buy beer until Thursday?"

Cashier: "No, Wednesday."

Me: "Today's Wednesday."

Cashier: "No, today's Tuesday."

Me: "Not anymore."

Cashier: "I don't mean to contradict you, sir, but I think I know what day I go to work."

Me: "You went to work on Tuesday. But now it's after midnight."

Cashier: "That's what I said. I can't sell alcohol after midnight."

Me: "I understand that. I want to know what time I can come back and get it."

Cashier:  "Like I said, not until tomorrow, which is Wednesday."

Me: "Fine! What time tomorrow?"

Cashier: "Any time, as long as it's before midnight."

Me: "Any time before midnight."

Cashier: "Yes."

Me: "How long before midnight?"

Cashier: "Doesn't matter."

Me: "How early in the morning?"

Cashier: "As early as you want."

Me: "But it's early in the morning right now. If the time doesn't matter, then technically it's before midnight, too. Like twenty-one hours before midnight."

Cashier: "Look at the clock, sir. It's three a.m. It's not before midnight. It's after."

Me: "Is this some kind of an April Fools joke or something?"

Cashier: "No, sir, April Fools is tomorrow."

I opened my mouth to try and keep arguing, but I decided was too tired and life's too short. I just abandoned my stuff on the counter and came home. I never did get my beer, but I've broken out the bottle of the good Scotch, because after that conversation I feel even more like I want a drink..

And I honestly have no idea whether the guy was joking.

Tuesday, March 24, 2015

Big Guns

People joke about being nice to your nurse. "We decide what size needles to use, tee hee." It's not really meant seriously. We have a lot of options for how to manage your care, but nobody casually suggests we go around abusing our control.

There are good reasons that nurses are the single most trusted profession in the US. We are in this job because we care about helping people. Nobody lasts long as a nurse unless they truly do want to do the right thing for patients.

Plus, it's not easy to upset us. We develop thick skin very early on, because we really do meet a lot of mean and nasty people. A good nurse can take the meanest insults and the nastiest shouting with barely more than a shrug, and still do her best to make that patient comfortable.


All that being said, I don't think most people realize exactly how many control options a nurse really does have.

If you are aggressive, out of control, and present a danger to me or to my staff, I am permitted to:

  • strap you down spread-eagle on a gurney
  • tie a spit mask over your mouth
  • cut off all your clothes
  • shove a short tube up your nose
  • shove a long tube into your urethra
  • have all your visitors forcibly removed
  • prevent you from contacting anyone else
  • inject you with sedatives
  • and isolate you all by yourself in a very dark room where nobody can hear you shouting.

Of course such measures are never taken casually. Not a single one of the above things would be done unless it were necessary for our physical safety, and rare indeed would be the situation requiring all of them at once. And in truth, I can only maintain any of the above for a certain period of time without getting a physician's approval. If I were to make a vindictive judgement or even a bad call, I would immediately be made to answer for it. There is a lot of auditing and oversight for such things.

Nobody is ever, ever threatened with these major interventions just because they're mean and nasty.

Still, we really do all those things sometimes, and it makes me wonder. If people were aware of the kind of discretionary weaponry that gets issued with the letters RN, do you think they would choose to be nicer?

Monday, March 9, 2015

Every Four Weeks

Research indicates that emergency department activity during a full moon is no different than at any other time of the month.

Research clearly shows there is no statistical correlation between moon phase and the number of patients, their acuity of illness, or the occurrence of aggressive confrontations in the ED.

Research can bite my shiny metal ass.

This last full moon night was absolutely crazynuts. We had four cardiac complaints walk in during the first hour of my shift, one of which was a STEMI (an acutely life-threatening heart attack). Two aircraft with critical transfer patients landed right one after the other, so a third aircraft carrying a Code Stroke had to hover and wait for a helipad slot. Ambulances showed up an average of once every thirty minutes, all. night. long.

Every exam room was full, or even doubled up. Some patients had to be treated on stretchers in the hallway. Our major trauma bay was constantly in use for moderate injuries (mostly slips on the ice), because those patients were too bloody to sit out in the waiting room and we had literally no place else to put them.

We had multiple drug-seeking frequent flyers who refused to be discharged without their desired pain meds, and had to be escorted off premises by security. We had the obligatory uncooperative drunk who kept taking his clothes off and wandering bare-assed into the hallway. We had one dude tripping out of his mind on multiple substances, who was hallucinating and violently psychotic, who spent the night in locked leather restraints and a spit mask.

We had a guy who came to the desk and said he didn't need to see a doctor, but wanted to check in anyway so he could warn us about "those Obamacares that watch the people with the computers."

I know we have good and reliable science saying this all is completely unaffected by the pattern of light reflecting from a big orbiting rock. But, damn that is hard to believe sometimes.

Wednesday, March 4, 2015

Don't Touch That. Not Yours.

Recently I met a guy who thought we were doing everything wrong for his poor comatose grandma. He made a point of telling me that at least once an hour. He also hovered over my shoulder every time I was in the room, making a big show of double checking every little thing I touched-- the oxygen rate, the IV pump, the level of suction on her NG tube, the degrees of elevation of the head of her bed, everything.

That's all fine. I don't mind another set of eyes. Even though I'm a nurse and you're an unemployed waiter who knows only what you read on WebMD, you still might notice something I did not. Stranger things have happened. So I wasn't bothered that this dude followed behind me to double check the equipment.

What did bother me was how he went about checking grandma's abdominal wound.

I walked into the room at midnight to find that the guy had unwrapped her abdominal binder, disconnected her wound vac, taken down all three layers of the dressing, and was peeling up a corner of the Gore-Tex mesh beneath. Never mind that the mesh was stitched in place and not supposed to move. More worrying was that the mesh was standing in for the inner membrane of grandma's peritoneal cavity, which means genius was poking her internal organs with his unwashed and ungloved hands. (The technical medical term for this is "Yikes.")

I'm rather proud of how calmly I told him to stop.

Dude's response was to say I should "chill out," because he had "the legal right to check out her healing without all that useless stuff in the way." He further claimed that if I put the dressing back, he would only take it apart again as soon as I left, and there was nothing I could do to stop him.

I chose not to argue.

I just pushed a button on the wall. A pair of burly security officers showed up within about thirty seconds, and I let them do the arguing. When last I saw our friend, he was being politely but quite firmly escorted from the premises. He won't be back.

Getting the dressing rebuilt properly took over an hour of combined work for me, the surgery resident, and the wound care nurse. Fortunately none of the sutures were disturbed, and it appears that the patient won't be suffering any further complications because of this.

Sunday, March 1, 2015

Stuff happened

I've been busy. New job, new city, new house, new dog, new new new.

I have kept delaying a return to this blog, because I kept adding material to an enormous this-is-my-life post explaining all of what has been going on. But then, I had an epiphany, and I threw that post away. It was fun to live but boring to read. The fun, gross stories are much better.

Long story short: I'm working the ED at a big trauma center. I have stories. I'm going to start writing them down again.