Monday, April 27, 2009

Conversations I am Tired of Having (Or Don't Have Time to Have) at Triage

Forgive me, this is more of an "I am triage, hear me vent" sort of a post and will likely not be very cogent because I am sleep deprived and trying to figure out how I am going to scrounge my first tuition payment due in August ($ 64 000 CDN--thanks for asking).

I have often felt that ER departments are the final resting place for all the crap that runs downhill in the health care system. Public health programs get less and less funding (and harm reduction programs just get canned altogether) so people aren't getting the education/programs/information there. They are sicker and know less about how to manage it. So they go to their local walk in clinic (because no one seems to actually have a GP anymore). Or better yet, they just wander down to the local ER on a Sunday evening.

My favorite quotes from last night:

"well I saw a doctor already and had an xray and was told it isn't broken, but it still hurts"
--did you take any tylenol or advil for pain?
"no, I don't like taking pills"


--how long has Junior had the earache for?
"oh about 2 h"
--did you give him anything for pain?
--are his 3rd year immunizations up to date?
"we don't immunize our children"


"I saw my doctor and he started me on this antibiotic...but it isn't working"
--how many doses have you had? (my inside voice finishing the sentence with--'for your virus')
"1 dose this morning"

The medical floors are understaffed so they can't take more of our inpatients, therefore these patients are stuck in the ED which means that we have fewer actual beds to see the incoming emerg patients. This pushes the backlog to the waiting rooms, which is where it gets ugly.

Voila. The crap comes to a halt, just at the final threshold of the hospital...the emergency waiting room door. Let me clarify, when I say 'crap' I mean the policy, the lack of funding, the shortage of staff, the health care CRISIS if you will, finally stops rolling and is allowed to show itself in all its glory.

The urgent and will-never-be-urgent are squeezed together in a tiny place, clamoring for their moment with the triage nurse.

One woman with diarrhea threatened to call 911 from the waiting room to get an ambulance so she could be triaged faster. I know this isn't a new tactic but last night it seemed particularly poignant as

a)the ambulance service is on strike right now and there have been code 3 calls that have had to be dispatched to cars over 100kms away because of the dirth of running cars right now

b) I was the triage nurse but was also looking after the inpatients and the IV therapy patients which meant that I didn't even have TIME to address this threat or give any direction to patients as to WHY they are waiting and what other strategies they could use to access health care or gain relief from their chief complaints.

I felt like imposing the triage method described to me by the South African doctor I was working with last night:

ask everyone in the waiting room to stand up

whoever stands up is told they are not sick enough to require ER services and is told to leave.

Ok so maybe a little Draconian, but...I was so incredibly frustrated at that point it almost seemed reasonable. If she had called 911 then an ambulance would have been dispatched, and could have possibly been sent from anywhere in a 100km radius...thus removing that car from it's region and putting REAL emergency patients at know those pesky time-sensitive things like heart attacks, traumas, strokes, allergic reactions, etc.

Am I done venting?


We were simply lucky last night that we had no codes or REALLY sick folks in the department because things could have gone south very fast. Short 2 nurses in an ED is dangerous. There is no other word for it. And I know this is the case all over the country. It seems every emerg doc or nurse I know has similar 'flying by the seat of our pants' stories from their departments.

Here's to saving lives on a shoestring.


Bostonian in NY said...

Sounds like someone has spent a little too much time out in front of the trenches lately making some cash for school.

Sadly, the majority of people will never understand that what constitutes an emergency in their world is not a true medical emergency. You should see the BS admissions that we get on the other end of the triage process...after being treated in the ED. God only knows what it would be like otherwise. If you can ask for your methadone and a sandwich but not stay awake enough to give a decent history because you're strung probably deserve to go to rehab instead of taking up a hospital bed.

Albinoblackbear said...

Hahah, I know...after I posted it I realised how cranky I sound. Oh well. I was cranky.

I know the ER admits major BS and so it goes right? Yesterday we kept a lady with abd pain overnight because she was afraid to go home "in case the pain came back" before her a.m ultrasound. What? Yeah.

Thankfully my jaded shifts are usually few and far between.

Anonymous said...

Great post which tells it how it is. I see similar things in our A&E departments over here too!
However, I'd like to back up a little....
" the ambulance service is on strike"????
Do you have by any info on this? What's that all about and how far does the strike go, I.e are they only responding to certain things or nothing at all?

Keet said...

Oh EBSCO.... You and i need to open a polyclinic together. We'll employ health navigators to send people away with advice like "Did you know immunization is the only reason life expectancy in the developed world is higher than 50? Yes, that's correct, people like you are the reason diseases like the measles are coming back. Thanks for that, time to leave and give your child some over the counter pain medicine. buh-bye!". And the ones who pass our navigator's screens will get the best, most holistic and effective care they've ever received and we'll become famous for changing the way patients experience healthcare.
Oh, and can we lock up the antibiotics and antidepressants as well? Make it a two signature prescription? LOL
Can't wait to see you!

Albinoblackbear said...

Keet! Don't even get me started! hahahahah Oh dear, I my pal Lawrence says, "polio is just a plane ride away!"

But seriously...we can't talk about vaccines because otherwise this comment section will turn into a bunch of interweb-'researched' opinions about autism...and before you know it they'll be drawing parallels to vaccines and chronic fatigue and fibromyalgia...AHHHHHHHHH!!!

I really dig your polyclinic idea. You know a former student of my granddads has a form that all patients that he takes on must sign which states he does not prescribe sleep aids or narcotics, and not to ask him for either! :)

Dude, circle your calender for Canadian thanksgiving in Ireland this year!

Can't wait to see you too buddy!!!