Saturday, January 12, 2008

ER Schmee-are...


Another busy day today... Had a poor 4 1/2 year old come in after falling off a top bunk of a bunk bed. (I understand the space needs of homes but this is my second horribly broken arm on a young tot from a bunk bed in two days..). Such an incredibly nice family. His arm was visibly deformed above the elbow. We knew he was a surgery candidate right away. The orthopedic surgeon who specializes in pediatrics was called and came in right away. Our only problem: our hospital does not operate or admit pediatrics! How was this poor family supposed to know this as they rushed to the nearest hospital in distress. Our options were to transfer him to another nearby hospital or have them sign out AMA (against medical advice) and drive 8 blocks to UCLA. I was a fan of the latter. Let them know the legistics and allow their son to be treated in a hospital that specializes in pediatric surgery. Our wonderful doc who was in charge got on the phone and started making phone calls. I called our house supervisor and told her the situation. It turns out we can operate on pediatric patients but they cannot be "admitted" to the hospital. The doc felt this was the best option for the kid. He's already here, lets fix his arm, and send him home after the surgery. Okay, great, but the kid had eaten dinner at 6pm and you have to wait at least 6 hours to do the surgery after a meal. The operating room is open only to dire emergencies at midnight. So this wonderful family had to wait until 7am for the surgery. I give props to the orthopedic surgeon for bullying the OR staff into pushing all their other scheduled surgeries back so this kid could get in first. Meanwhile, we were managing his pain and fear, and the fear and worry of the parents. I continually try to imagine that it is my nieces in these predicaments and give the optimum care that I would want for them. I also give props to the ER doc that kept every option open (even the "controversial" one of letting them go AMA so they could take him to a pediatric hospital) if that would give him the fastest and best care. I am amazed at times of the caring and "fuck the system" attitude of ER doctors to try to get the best care for patients within the constraints of the health care system. I did not notice what kind of insurance this family had. I don't think I'm going to last long in health care if I dwell on it.. I know there are problems but I don't know what I can do except keep patients informed of their choices...

I also learned a lesson in humility (and not overstepping my scope of practice) the other night. A patient came in who I recognized. She was making a big scene in the waiting room, moaning and yelling. I got her into an exam room and I realized I recognized her from several previous visits. I immediately labeled her as a "drug seeker". Her behavior was typical for drug seeking and her visit history was at least 15 visits in the past 3 months for various pain complaints: headaches, back pain,etc. Her behavior was always over the top and she always demanded strong pain medications by name. This visit she was complaining of abdominal pain. We started an IV and gave her a small amount of morphine. She insisted on more and could never exactly tell where the pain was located. She would say "All over" when asked where her abdominal pain was. I doubted her and told the doctor "If she has an acute appy (appendicitis) I will run the halls naked!" Luckily, the doctor believed her and not me. The CAT scan report revealed and inflamed appendix that needed to come out that night. The doctor is still asking me to pay up on my bet... (Yeah, right!) It is sad for me to realize that I have become so cynical towards patients that I don't recognize a real emergency. At least the doc backed me up by saying "She still is a drug seeker. She is displaying the over-the-top behavior. She just actually has a medical condition".

It is hard when so many people come into the ER "crying wolf" or over-exaggerating their problems. It's easy to become cynical. I'll try not to. But it's hard..

3 comments:

Anonymous said...

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LA RN said...

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JaniceNW said...

Glad she got a correct dx. Check out my blog http://janicenw.blogspot.com for my nightmare(not really but I'm the kid's mom and I don't mess with head injuries)in our local ER.

I know you nurses work very hard. It's the system that could use work.

I've applied for a LPN program starting in the fall, it's a lottery so if God wants me there, I figure I'll get in.

PS~I've started a new career/college 2.5 years ago at age of 43. I think I'm vertifiable.

:D