Multitasking (and why migraine patients wait)
At any given moment during the typical shift in the ER, here is what is happening:
- There are 10-20 patients in the waiting room. Some have been waiting 6 hours. A couple of them have ankle sprains and were already X-rayed, and their X-rays were already read by the Radiologist as "no bony abnormality, soft tissue swelling." They would like to leave without being seen. We don't argue too much.
- I'm waiting on a callback from a specialist, and I have two more calls to make after that one. If I paged them all at once, they would all call back at the same time, then two of them would hang up before I was finished talking with the first one. They would be understandably angry when they were repaged, and they would take an hour to call back the second time. So I page them one at a time. As soon as I introduce myself to the next patient I see, the first one will call back.
- I have one patient in the CT scanner and two more patients drinking contrast waiting their turn to get scanned. One of them just vomited, and will need some more antiemetic (and some more contrast). The other one wants more pain medication. One of these will need to be admitted for surgery, another will need to be admitted for IV antibiotics, and the other can be discharged after several hours of medical management and serial evaluations in the ER.
- I'm waiting on the Radiologist to interpret the head CT scan and X-rays of the lady that passed out and fell down the stairs. I need to see her blood tests too, but the lab is taking longer than normal. I still need to suture her lacerated lip and eyebrow.
- I have a dialysis patient who has missed his last couple of dialysis treatments, preferring to go to the crack house instead. His blood pressure is dangerously elevated, he has chest pain, his lungs are full of fluid, and his potassium is dangerously high. It initially appeared that he might need to be intubated, but after 20 minutes of aggressive medical management he is starting to breathe a bit easier. There are no ICU beds available, so he requires a nurse to give one-on-one care until he is stabilized.
- There is a homeless patient who is "suicidal" after running out of money to buy crack who is taking up an ER room (and a tech to act as a sitter) while waiting for his transfer to the first Psychiatric facility that will take him. No facility will accept him during my shift, and he will be turned over to the next doctor in the morning.
- One elderly patient with chest pain and known coronary disease is waiting to be admitted to a telemetry bed, and a nurse is standing behind me (as I am charting on someone else) asking me for a Tylenol order because he has a nitro headache, and by the way, his blood pressure is still high. Two other new patients with chest pain are still waiting to be seen. I need to look at their medical records to see what their last cardiac admissions revealed, and to see who admitted them the last time. The tech is standing next to me waiting to show me their ECGs.
- I can hear a toddler screaming with a fever of 103 and (hopefully) an ear infection. I would love to see him quickly and get him out of the ER ASAP, but I have to pop in to see the new chest painers first. His nurse is taking care of the dialysis patient, so the kid still hasn't gotten the Motrin I ordered half an hour ago. His father is standing angrily at the door with arms crossed, glaring at all who pass by.
- EMS just brought in a drunk guy on a backboard who is now in the hallway because there are no rooms to put him in. He's cursing and trying to take off his cervical collar. I'm going to have to quickly look him over before I see the two chest painers. But he will have to wait a minute, because...
- EMS is transferring a frail nursing home resident with fever and mental status changes onto our stretcher. Her mouth is open, her tongue is as dry as the Sahara, dried feces is caked on her legs and fingernails, and she smells strongly of urine. She doesn't speak, staring blankly at the ceiling. Her blood pressure is low, and she is pale. No family is present, and she has never been to our facility before. She usually goes to Big City Hospital, but they are on drive-by. I wonder for a second why we aren't, then I remember that we are. It doesn't matter. She's our patient now.
- A patient who was admitted by the doctor I replaced is waiting on an inpatient bed, and her family keeps coming up to the nurses' station to ask for an extra pillow, a cup of ice, somebody to come help them lower the head of the bed, and the all-important "how much longer?" Oh, and the IV machine is beeping again. All the nurses are taking care of other patients, and since I am stuck at the desk charting, I am the default question-answerer. I tell them I'll ask their nurse to come in as soon as I can, but I am quickly sidetracked with other concerns and never do so.
- A migraine patient was brought into her darkened room 30 minutes ago, not because she was necessarily the most acute patient in the waiting room, but because she had already been waiting for 6 hours. Her concerned mother had been pestering the triage nurse relentlessly. Mom is standing in line behind the other people who are asking me questions, ready to ask me "How much longer? She's really hurting." This is her tenth ER visit this year for the same complaint.