Thursday, December 28, 2006

Change of Shift, and "Minor Complaints"

This week's Change of Shift, the nursing blog carnival, is up over at NeoNurseChic. Thanks for including me, Carrie!

And, while we're on the subject of medicine, here's a subject that's been nagging at me for a while: the issue of people showing up in the ED with "minor complaints." DisappearingJohn wrote this post a while back kvetching about the problem, and during a recent volunteer shift, I heard a doctor venting about the same thing. "These people come in with nothing, nothing! They don't need to be here!"

A few notes: Everybody who talks about this acknowledges that people who don't have insurance have to use the ED for primary care; in addition, DisappearingJohn informs me, laws designed to protect the uninsured mandate that EDs have to evaluate anyone who walks in, even if the triage nurse considers the problem minor. There's also a trend where primary-care providers tell patients, "Just go to the ER," even for problems that might be better handled with an office visit. And some nurse hotlines, cautious about liability, seem to use "go to the ER" as a default (although the one I use has always been good about saying, "No, that's not that serious; you can see your primary tomorrow," or, "This doesn't sound serious now, but if XYZ happens, go to Urgent Care").

However, all these factors aside, I hear in many such complaints an exasperated expectation that patients should be able to figure out for themselves which problems are minor and which aren't.

Dear doctors and nurses:

Newsflash: We can't do that. In most cases, we don't know how to evaluate our own medical conditions. We aren't the doctors and nurses: you are. You're the ones who are trained to figure out if something's minor or if it isn't. That's why you get the big bucks. (Ed. note: Since this line has deeply offended certain readers, I feel obliged to point out that it's ironic; I've never heard it used any other way, but I guess some people have. See comments.) That's why you wear the scrubs and white coats and we wear the oh-so-fashionable gowns gaping in the back, okay?

Also, there are entirely too many people who go to the opposite extreme, who consider their own problems minor and won't seek medical treatment unless other people tell them to. Consider:

* My classmate in graduate school who had a huge red boil on her arm but wanted to wait until after our three-hour seminar to go to the university health service. My cousin had once had a boil like that, and it developed scary red streaks and he had to be in the hospital for a week, so I told her to skip class and go to the doctor. She said no. I said yes. I convinced her. She went to the health service and received very prompt treatment from ashen healthcare providers; about a week later, she told me, "My doctor's only now telling me how serious that was."

* Another friend who had an annoyingly painful paper cut, one she couldn't even see but that hurt like blazes, and who finally went to the doctor for it, feeling really foolish, and who then discovered that she had an antibiotic-resistant staph infection, and who spent quite a while in the hospital and had to take several months off work.

* The time I thought I had a stomach virus and was really embarrassed about going to the ED, even though my aunt the nurse told me to very firmly; the ED staff thought it was gastroenteritis, until the bloodwork came back with a white count of 29,000 (I know I've told that story here before, but it was pretty traumatic, believe me). A friend of mine told this story to a friend of hers who's a nurse, who evidently turned pale and said, "She could have died."

And then there's the sort-of-funny story an urgent care nurse told me once when I went in, feeling very embarrassed, to have a very small and painful splinter removed. (She took it out, and told me that I'd been right to come in.) She'd been working in an ED once when a call came in from a guy who said, "I have a splinter in my hand. Are you busy? Would it be okay if I came in now?" She told him to come in, but she and her colleagues were rolling their eyes about the wuss with the splinter -- until he came in with a 2x4 driven through his palm.

You see, doctors and nurses, if you ask us to decide what's minor and what isn't, sometimes we're going to err on the wrong side. We aren't the best judges of this. You are.

And yes, we all know that you have to deal with too many hypochondriacs, too many people who come to the ED for the wrong reasons (drug-seeking, social contact), too many people whose sore throats and coughs would respond very nicely to over-the-counter medication, and whose germs aren't doing the ED staff and the other patients in the waiting room any good, either.

But think about the other side: the times you have to tell a patient that he's having a heart attack, that she's had a stroke; the times when you have to tell patients and their families that a suspicious mass has showed up on the scan, that it looks a whole lot like cancer, that emergency surgery has been scheduled.

You hate those moments. I know you do. I've seen you steel yourself to deliver bad news. I've heard you say, "Oh, man, we just had a guy come in with an inoperable brain tumor."

I know that the patients with the coughs and sore throats take up valuable time, time you'd rather spend with the patient who's just been diagnosed with cancer. I know that your frustration with "minor complaints" is really a larger frustration at having too many patients and not enough staff. I know you wish you had the resources to give everyone your fullest attention.

But think about it: wouldn't you give anything to be able to tell your cancer patient, "It's nothing, really. You just need a bandaid and some aspirin. You can get dressed now and go home."


  1. I agree that sometimes it's really hard to decide when to go to the ER. My son has an uncanny knack for getting very sick on the weekend and his doc isn't open on the weekends - so off to the Children's ER we go, because I'm not willing to take chances. One time he had strep - his throat looked aweful but no symptoms until the strep flaired; the next time it happened I thought it was the same thing...but it wasn't, and the doctor asked us why we brought him in for a sore throat...well, we thought it was strep. I'd rather feel silly.

  2. It is a tough issue, because although sometimes people make the wrong choices, some choices just seem to be obvious to everyone else.

    My MIL just told me the story of her coworker who was bit by a brown recluse spider and didn't go to the hosptial for 3 days. It was when her hand blew up like a balloon and started turning black that she decided seeing a doc was a good idea. (Again with the seeming obvious to others).

  3. And, actually, it's "job security"-- because those people keep the ER's running, heh heh!

  4. I don't know who you think is getting paid "big bucks", but it's certainly not me (a nurse) or the MDs I am friends with. I, personally, make a comfortable living when my salary is combined with my spouse's, but neither of us could even own our (tiny) home without the other's salary contribution. We also have a combined monthly student loan payment of just over $500. I paid dearly for my education, sacrificed 4 years of my life to constant study, clinical rotations and more studying (all while working full time to pay the rent and make the car payments so that I could drive all over creation to get to my clinical sites) to earn my nursing degree. Furthermore, medical professionals in emergency rooms to not get paid ("big bucks" or otherwise) to deal with the myriad of sniffles, coughs, sore throats, and GI upset that continue to clog the departments and eat up valuable resources. All Disappearing John and others are suggesting is that people understand that it's called an "Emergency" dept. for a reason. Your sore throat, GI upset, etc... is not an emergency. Although it is sad that you are alone for the holidays, it is not an "emergency" that has you calling the cabulance to bring you into the ED for some company and attention. The state of the American health "care" system is a national disgrace. We should all be ashamed of ourselves, allowing our legislators to spend billions of dollars in Iraq when Americans can't access appropriate healthcare. That said, a cold is still a cold. There is no cure. Spending hours waiting in a ED waiting room so that an overworked (and underpaid, sorry to say) medical professional can tell you that is a waste of everyone's time.

  5. Kookaloomoo:

    The "big bucks" comment was a joke; I'm sorry it offended you. I'm well aware that hospital personnel (along with many other people) aren't paid nearly as much as they're worth.

    The hospital where I volunteer has a Fast Track area for non-emergency issues. I gather that John's hospital doesn't. Surely putting those in everywhere would help. And although I'm sympathetic towards the need to protect uninsured patients, I should think there has to be some way to empower triage nurses to say, "You don't need to be here; go home and take some aspirin."

    Healthcare in this country is indeed a disgrace, but that's not patients' fault, and they too often wind up getting blamed for it.

    And headcolds aside, there are still many situations where scary symptoms turn out to be minor. I went to the ED once with chest pain that turned out to be GERD; I'm sure that happens all the time. A doctor once told me that people wind up in EDs all the time with severe abdominal pain that turns out to just be gas. In cases like that, how is the patient to judge for him- or herself?

  6. I was a patient in a busy city ER one night and the patient next to me had put his hand through a plate glass window. The night before. He had, he noted, "been drinking..." He said he'd "stopped by" the night before, but the ER looked busy, so he decided to wait a day and come back when things were slower. Which the ER staff did not seem to appreciate as much as he expected, while they debrided the wound and prepped him for surgery for the severed tendon and infection. I am always amazed by the small things that send some folks to ER and the really huge things that others try to deal with on their own. This guy had an unbelievable pain tolerance!

  7. I am a nurse, not an ER nurse. None of these issues are simple ones, and for the nurses and doctors on the "front lines", it is particularly difficult. It's unbelievably hard. Sometimes we do need to kvetch or else we would go crazy. I think a sense of humor is the one necessary ingredient to keep on least it has been for me. It's easy to say have compassion for everyone no matter what but when you've been on your feet for up to 12 hours running ragged it's just not so easy. At all.
    In my job, I frequently have to send very sick people to the ER and am amazed when they are not kept in the hospital (I work with the elderly). I have seen some things lately that shock me to my core. I don't blame any individual but this system we call our health care system is already broken, not just at the breaking point.
    I've been a nurse for 25 years. It scares me to see what is going on.

  8. Hi Susan,

    I read your post 'Minor Complaints' and instantly felt guilty for the griping I do on my blog. Then I realized instead of feeling guilty, I should use this excellent opportunity as a time for me to share what really happens when someone comes in with what I consider to be a 'minor' complaint. For a real-time example, you can read (or re-read if you were already there, as there is an addendum) my post 'What to do?'.

  9. Wow. This has generated more response than I expected!

    One clarification: Yes, I also get annoyed when people show up with headcolds (not least because I don't need that particular virus, thanks). That's not what I'm talking about. I'm talking about situations where the patient genuinely has no way to know if the symptoms are minor or serious.

    Another factor here is that, almost by definition, ED personnel have a very different standard of "serious" than the rest of us do. I recently saw a family who'd come in with a patient after a grand mal seizure. The family was very upset. (Watching someone have a seizure is scary!) The patient was just with it enough to ask for water, so I went to ask the nurse if that was okay; we've had seizure patients before whom I've been told couldn't have water, "because if they seize again, they could aspirate."

    This particular nurse yawned and said, "Oh, yeah, sure, that's no big deal. It's just a grand mal."

  10. Anonymous1:37 PM

    Maybe you are tired of this can of worms you have opened here, but there is an excellent post on this website about the ER situation:

    Look under the post entitled "Shande" which I think means shame.

  11. Well, all of us are tired of this can of worms, but it's still with us, yes?

    That's a great post, and everyone should go read it. Thanks for the link!

  12. Susan-
    I'm sorry I didn't realize you were joking about the "big bucks" comment. I've just been hearing this kind of thing a lot lately, and I'm a little sensitive, I guess. My colleagues and I get paid in direct proportion to the amount of education, experience and knowledge we have, and perhaps a little bit for the sacrifice required to earn a medical or advanced nursing degree. That's all.

  13. Kookaloomoo, I know exactly what you mean...I have heard that too lately. "You're an RN and can have your choice of jobs and make the big bucks"...Excuse me??? There is an abundance of jobs, yes, but does that mean those jobs are good jobs? NO ... the working conditions is some of the hospitals and nursing homes are just so outrageously bad
    ...and big bucks? ...not the last time I checked! I think you can be forgiven your "sensitivity".

  14. Kookaloomoo:

    Thanks for the second comment; I appreciate it.

    At some point, one would hope, market demand will start being reflected in pay. I've heard rumors that one hospital in my area is, or was, offering $6,000 signing bonuses to nurses, but I don't know what the base pay is like.

    In my own field (college English), people who've spent many years and thousands of dollars getting their PhDs are routinely paid a pittance each semester ($1,200, some places) to teach crucial freshman courses. Those of us who've managed to get tenure-track jobs do better than that, but in most specialties, those jobs are very hard to get: it took me three years to get mine, and I was hired out of a field of 160 people, which starts looking a lot like blind luck.

    So when I use the phrase "big bucks," I mean it ironically. This is the kind of thing adjunct English teachers tell themselves with a sigh as they're staring at toppling stacks of papers they have to grade.

    At this point, I'm tempted to edit the post and remove that phrase entirely, except that then the comments wouldn't make sense. Maybe I'll put in an explanation, though.

  15. I think this "debate" is an important one, and one that should be had in every devalued profession. We live in a country where professional athletes get paid millions of dollars a year, where huge corporations rake in profit by the billions, and where working parents (even when there are two of them!) have to struggle to make ends meet every month. The concept of "big bucks" is, obviously, a relative one. I spent my early 20s as a social worker, getting woken at insane hours of the day and night to be with sexual assault and domestic violence victims in whatever emergency room they ended up at. I got death threats and menacing phone calls on a weekly basis, I was physically assaulted outside a courthouse by an abuser, and I constantly feared for the safety of my clients. I worked 60-80 hours a week on average between my on-call time and my office/courthouse hours, and I earned a whopping $20,000 a year. Before taxes. It barely paid for the medication I had to take to heal the stomach ulcers I developed from the stress. This is the American Way, people. Doncha just love it?

  16. Your post brings up so many important considerations:
    Patients are not in positions to always make the most informed health decisions - in this case, when and where to seek treatment
    Providers don't and can't always treat patients as full partners in their health decisions
    There is an enormous gap between patients and providers that requires bridge building and partnering.
    (And no, the ED providers don't make high dollars, but having been a junior nursing faculty member on a tenure track, I remember well having to take a second 24 hour weekend clinical nursing position to make ends meet. Academia is akin to slightly above poverty earnings now. And many allied health positions pay horribly, as the social worker kookaloomoo so aptly described)
    Here's to many more conversations about informed and empowered patients and healthcare providers!

  17. I was just going to add that I really believe the complaints in general are not about patients who come in and wouldn't know how to tell if their symptoms are severe or not - but rather to the ones who very well know their symptoms are not worth a trip and the resources used up in the ER, yet go anyway. I wouldn't begrudge anybody who came to the ER who just didn't know if the symptoms were serious or not - better to be safe than sorry, and I've been the patient in that position a few times myself. When I went in with my anticholinergic toxicity, I had to wait for 3 hours and wanted to leave because I thought it was absolutely ridiculous and I was wasting time - but my heart was acting strange - my EKGs were abnormal. I just still thought I was overreacting. My friends convinced me to stay. Once I was back on the monitored bed, about an hour later, I was in the full blown toxicity, and I don't remember any of it. It was really bad - so what I thought was "no big deal" was actually a really big deal.

    It's never bothered me when patients came in for things they didn't know were serious or not. It's the people who have the routine ear infection, sniffles, etc that come in who don't need it that have always made me start on rants like those!

    At any rate - thanks for the link back to change of shift. Take care!
    Carrie :)

  18. This whole thing reminds me of the mother, more than a little irate, who told us "all you did was give her Motrin, I coulda stayed home and done that", to which we replied "exactly".

  19. Interesting and yes, this will always be "sticky wicket" won't it?

    I think neonursechic hit the nail on the head. If someone really doesn't know then yes, head to the ER but those that abuse it--that's a pain. At least it is for me when I have to wait!

    I fall into the camp of having to be dragged to the ER (at least for physical stuff.) For psych problems I'm pretty good. I know when I'm off my rocker *grin* But if my body is sick, you really have to haul me into the ER. And when I've gone, it's usually turned out to be nothing which I suppose is good...but I guess it's also good that I've gone (in the most recent past it's been concerns about appendicitis with wacky gastro issues happening.)

  20. Anonymous8:50 AM

    As a primary care doctor, mainly what we ask of patients is, before you pack up and go to the EMERGENCY ROOM, ask yourself, seriously, "Is this an emergency?"
    If the answer is uncertain, or most likely yes, then by all means go.
    If you're pretty sure it's not, then just use some common sense and see how it progresses. If you're smart enough to be on this message board, you should be smart enough to know when all you have is a cold or allergies.
    We don't ask nonmedical people to know everything, just don't be apathetic about how much unneeded visits cost, especially when you're on government(taxpayer) sponsored healthcare.


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