How to Be Taken Seriously by Your Triage Nurse

Most of the people you described should have been arrested and charged with criminal fraud. I’m personally sick and tired of all the “professionalism and restraint” from medical professionals. This abuse of the medical care system, and interference with the provision of good and timely medical care to people who really are in urgent need of care (who are also disproportionately the people who are paying for all this), will not stop until medical professionals insist that it stop. We need legislative changes that make faking symptoms in an ER a crime, and these crimes need to be routinely prosecuted, and the perpetrators ID’d by photo and fingerprints for a national database to be used to put them at the back of the line for medical care even when they DO really get sick.

JAG, no apology necessary. It is true that the ER system has a lot of problems. Most of these problems can be attributed to some kind of failure in one or all of the three ER process: input, throughput, and output.

So many here have expressed their disappointment in the system that I feel prompted to write a piece on the ER process aimed at the general population. Much of what I hear in this kind of venue is anecdotal. That does not make it any less valid; it simply means that objective data is lacking.

I think that while certainly there are many who have had very unpleasant experiences, what I am also getting is that there is a serious lack of understanding related to the ER process. Perhaps providing more information might help people to understand the difficulties that ERs face, and how we can improve things if we all understand each other better and work together to solve the problem.

Gov, you got right to the heart of the issue with this post. Well said!

I will definitely address the issues you bring up in my next posting. In the meantime, I can tell you in three syllables why no malingerer or drug-seeker is ever going to be prosecuted for abusing the ER system: EMTALA.

That is, the Emergency Medical Treatment and Active Labor Act. The short version is that it is against federal law to turn away any person from the ER. We must first medically screen them for any life-threatening problems and either treat those conditions or transfer them to a facility capable of treating them. And even then, we can only transfer a patient to another hospital if that hospital consents to receiving the patient or is not full.

And the medical evaluation must take place before we can determine the insurance status of the patient or their ability to pay.

I can see the spirit of what EMTALA is about. To toss an acutely ill person out on the street if they cannot pay or are uninsured is callous and anathema to the creed of the caregiver, which is: First, do no harm. But every year, millions of selfish people abuse EMTALA to get drugs or attention. Those people are the reason why we have the bottleneck in the ER; They are the reason why people with broken collarbones and kidney infections have to wait for endless, miserable hours in Triage while a malinger who claims chest pain gets whisked right back; and those people are the reason why we have expensive ER care.

Can you tell that I have a rather heated antipathy towards those social parasites? Nobody sees the damage these people do more than I do. I see firsthand every damn day what these leeches do to our system and how they, in their supreme selfishness, think their need for attention or narcotics trumps the need of the wheezing 5-year-old girl for air.

I would love to be able to tell those people to clear their worthless arses out of my ER, but I cannot legally do so. But when I am Triage Nurse, you can bet that I make them wait instead of the asthmatic 5-year-old or the young woman with a kidney infection.

EMTALA is the kind of legislation that, while demanding the best from the healthcare provider, invites the worst of society to abuse the system with impunity. If you are cheesed about the long wait and high cost of ER care, you can thank the malinger, the Entitlements Generation, the illegal aliens, and especially your Congressman. But don't blame the Triage Nurse.

I mentioned we recently took my son to an ER for screening of a possibly broken bone after a sports hit/fall.

This happened to be a military ER. In front of me at the check-in line was a young couple with a baby who really didn’t look or act sick at all. But the parents said the baby had “cold.”

Much to my surprise, the check-in person actually began to ask questions and, essentially, dissuade the couple from using the emergency room for routine care. He asked who the baby’s doctor was; the husband said the baby doesn’t have a doctor, we come to the ER if we need to! To that, the check-in person explained that the ER was not to be used that way, that babies should have a regular doctor or clinic that follows them, that the couple needed to sign up for the military health care program that was available to them, etc.

IOW, someone finally said “NO” at the ER! I’m sure this was partly because it was a military facility; maybe they have more leeway. But everything that we have talked about re how horrible it is to go to the ER (note: the experience of getting treatment, not necessarily the treatment provided) is in large part because so many people abuse the ER. I bet if ER’s had to report the number of cases each 24-hour period that were true medical emergencies, the numbers would be very, very low.

ERs are asked to handle too many kinds of cases, many of which are not emergencies. Too many people use the ER as their regular doctor, which makes people who really need screening for a possible emergency not even want to go to the ER.

I have always been interested in ER reform and followed some of the proposals over the years. We went through one in the military where the proposal was to charge a patient $25 per visit to the ER. $25! You know what happened? Complete uproar. So that never happened.

I have read about two-tier systems, similar to what I described, where “quick and easy” cases go on one track and those who need more extensive evaluation go on another. That takes more personnel, maybe, but otherwise I don’t know how that has worked (outside the military, where it seems to work great in the field environment).

I think most people DO understand the triage process. They just don’t agree that it works well in the real world of who actually uses the ER. Everyone knows if you go to the ER, you are very likely to be sitting there for many, many hours. Explaining why that is really isn’t necessary or helpful. It doesn’t matter that the wait is justified by the process or not. It’s just we all know we should be able to have a better, more efficient experience at the ER.

The people who regularly use the ER for routine care don’t seem to mind the waits at all. I have seen people who acted as though they had said, “I’m bored; let’s take the baby over to the ER and hang out.” It’s the people who rarely go to the ER who are incensed at the waits and inefficiencies.

I certainly don’t blame the triage nurse individually. But it really pisses me off that there seems to be a complete lack of organized opposition from medical professionals to EMTALA and related socialist abominations. EMTALA is not a Supreme Court ruling, it’s legislation, and legislation can be repealed or amended into unrecognizeability. If doctors, nurses, physician assistants, and medical paraprofessionals would organize against this, it would stop.

Problem is, huge swaths of of all segments of the medical profession actually SUPPORT socialized medicine, and aren’t willing to organize against it. EMTALA is the front door of socialized medicine, under which ANYONE — illegal alien, faking, nonpaying, refusing to comply with previous medical instructions, fugitive from the law — can walk into a hospital and demand medical attention from medical professionals who have been terrorized by this socialist legislation into declining to exercise common sense, out of fear of being fired, sued, and financially and professionally ruined.

Once this infernal election is over, I really would like to see FR set up a Medical/Healthcare forum, to encourage discussion and focused action to take back our medical care system. It appears to me that politicians like Obama and Ted Kennedy, with their plans for hauling the country down the road to fully socialized medicine, are encountering virtually no organized opposition. It’s hard for non-medical professionals to muster a fight, when there’s no leadership from medical professionals.

I work for a big hospital system in the midwest.

5 hospitals and 1 children's hospital in the same city.

They also operate about 12 free standing walk in clinics all over town.

The free standing clinics have taken a huge strain off the emergency rooms.

If you have the flu, a minor laceration, asthma,UTI or other minor illness, no PMD or you can't get into see your regular PMD for 4 weeks you can walk in.

The clinics do a fabulous job..They can xray, ekg and basic labs. If something is serious you get an automatic ticket to the Er with lab work and preliminary tests in hand.

They also operate an all night pediatric walk in clinic for the 2 am ear infections and acute fevers.

It has taken a strain off our ER’s and the other 4 other independent hospitals in town.

Everybody wins..If you don't have insurance it's only $40 bucks plus labs to see a doctor..They do take insurance but since it is so economical they don't have a cow if you don't.

then another HOUR before the nurse came to do the dreaded “discharge” instructions, which drone on and on.

My wife recently had go to the ER. We went up around noon. At 11pm we were still awaiting the results of an MRI. This was 4 hours after the MRI. Of course we were told that the delay was due to the late hour but it was only late because the wait had already been so long.

Finally we got the results but no discharge. After another long wait I went out and found where the nurses were having a nice chat and asked if we could get discharged. With all the enthusiasm of a Home Depot employee one of the nurses said she would go find the doc. As far as I know she has never been seen again.

I wandered the ER for a while until I found the doc and brought him back to discharge my wife.

Vermonter, I'd have been ticked too. There is neither reason, nor excuse for that nurse to have treated you that way.

Furthermore, discharge instructions are supposed to be brief, succinct, and concise. It's hard to pay attention when you've been in there for hours and hours, have maybe some narcotic on board, and have to listen to someone drone on and on. The MD usually covers the main stuff before the nurse comes in anyway. (At least, the MD is supposed to.) I usually just go in and ask, "Do you have any questions about what to do with your stitches/cast/etc. or when to see your PMD or specialist? If there are questions, I answer them BRIEFLY (10 words or less) while pointing them out on the discharge paperwork. I then give them the number for our nurse line if they have more questions later.

The whole process takes about a minute, and I am taking out the IV and disconnecting the patient from the BP cuff and pulse oximeter at the same time.

But getting to be that succinct takes practice. I had an excellent preceptor who taught me the value of brevity. I learned to watch for the telltale blank "smile and nod," which cued me to just shut up and let the poor souls go home.

Finally, I document on the patient's chart when the patient goes to Diagnostic Imaging, when they return, and if an hour has passed I start banging on desks and hunting down the DI tech or the MD and get on their cases to get things rolling along. (It's fun being charge nurse!) Part of the job description of the ER nurse is to watch for, and inform the MD of, lab and DI results as they arise.

I've been a patient in my ER a couple of times. The ER bed is not exactly ass-friendly. I can empathize with folks about that and the wait.

I was reminded of the “discharge” procedure in the ER when I read the recent article about doctors prescribing placebos.

A clarification was issued that by “placebos” including telling people to take OTC pain meds (such as motrin).

Unless you end up truly needing treatment through an ER, the discharge process involves waiting around for a few hours for someone to come in and tell you to rest, take motrin, and watch tv for a while.

I think once you are told you do not need emergency care, you should be able to sign a waiver and bolt. Of course, you can do that anyway. but it should be an official process.

Once my son had had a very bad cold for about a week. Then he developed a very strange rash in the middle of night. Won’t go into detail, but under all the circumstances, we debated and debated and finally decided, we’d better have it checked out considering his fever etc.

Get to the ER and it is packed to the rafters with kids with very bad colds. We finally get to check-in and I mention to the nurse, wow, it’s busy. She says, yes, it’ll be about six hour wait to even get taken in for vitals. I asked what was going on as she was looking my son over; she said, oh, this-—indicating the same thing that was going on with my son. I asked her if she’d seen this rash, she said yes. So I realized then that for sure the rash was related to the cold, not something else.

I told the nurse that, based on that, we were going to go ahead and go home. She got rather worried. I told her I was only there to find out if my son had an “emergency.” Obviously, he didn’t. We’d continue to take care of him and, if he needed it, we’d take him to his regular doctor on Monday. I also said my son is actually quite sick and uncomfortable and the last thing he needs to do, if he doesn’t need to do it, is sit in a room with 100 other sick kids for many, many hours through the late night.

She sort of freaked, but I thanked her for her time, gathered up my children and left.

I think this should be encouraged for people who are confident on how to handle the situation so long as they know it is not a medical emergency.

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