Strictly subjective pain scales are of no use when used to triage patients in the Emergency Department. Almost every person who sits down at the triage assessment desk rates there pain an 8-9-10 on a 1-10 scale. They do this because they know that if they rate their pain at greater than 8, then they cannot be screened out as non-emergent and requested to accept financial responsibility for at least SOME of their visit.
Nurses are discouraged from using non-subjective pain scales on adults, actually, they're forbidden to do so. So, over and over again people who complain of a toothache, a headache, or finger pain must be triaged as emergent and seen by the ER physician. They take up valuable time and resources, and they cost hospitals around the country which are already strapped to the point of closure, millions of dollars a year. It's ridiculous.
As hospitals across the country have developed policies to screen out non-emergent patients seeking to use the ER as their personal drug dealers, these patients have become more and more adept at making sure they get past the triage nurse where they have a shot at getting the ER Doctor to give them what they are there to get. Drugs.
Here's my point. On the following scale, where would you objectively place someone sitting at triage, chewing gum, smiling, and eating cheetos?
Rating 1-3 Minor Pain (Does not interfere with most activities. Able to adapt to pain psychologically and with medication or devices such as cushions.)
Rating 4-6 Moderate Pain (Interferes with many activities. Requires lifestyle changes but patient remains independent. Unable to adapt to pain.)
Rating 7-10 Severe Pain (Unable to engage in normal activities. Patient is disabled and unable to function independently)
I would rate this person in the 1-3 range objectively, and would even accept that their own perceptions may place them in the 4-6 range. But 7-10? No way. But that's where they land over and over again, because ER abusers all know that if they rate at greater than 8, they can't be screened out.
Even if your not a medical person who has to deal with these patients on a daily basis, you're affected. Every time you pay your taxes. These people are a BIG part of the reason that healthcare costs are skyrocketing. They use the ER as a clinic, or as their personal drug dealers. They don't pay their bill, so guess who has to. You do, every time you get your check and see those income and medicare taxes.
The assumption is that nurses and physicians might be "unfair" to patients if they were allowed to use objective measures of pain. Well, the scale above is one that is given to chronic pain patients that they are encouraged to rate THEIR OWN pain. Think they would use it with any degree of truthfulness or accuracy? Well, some actually do. Out of the hundreds of patients that I triage in a month, maybe somewhere less than 10% ever rate their pain less than 8. Occasionally someone will surprise me with a 7 or even a 5, but not very often. When someone does, I generally traige them as emergent, because someone who is genuinely reporting a pain level of 5-7 is usually in severe pain. Most of the time, there are obvious objective signs that correlate with a high level of pain. A facial grimace, guarding, sweating, tachycardia, tachypnea, SOMETHING. Not chewing gum, texting on their phones and smiling at me!
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Monday, November 21, 2011
Wednesday, September 7, 2011
Slow ER Doc's
Is there ANYTHING more frustrating to an ER nurse than a Doctor who can't make a decision? Ordering tests one at a time, so that the patients sit in the rooms for hours before you even have results, and then once everything (and I mean EVERYTHING) is back, still no answer!! Patients angry because they're tired of waiting, families up in your face constantly for answers you can't give them, and more and more patients piling up in the waiting room because you can't get anyone admitted or discharged?
Of course, it's all the Nurse's fault. The one person who has no control over it, and wants nothing more than to make the ER flow, is blamed for the whole thing! Takes the abuse from the family, gets the complaints, which of course the administrators believe.
Not every migrain headache needs a Lumbar puncture!! Not every diarrhea needs a CT!! Come on Doc!! Please!!
Of course, it's all the Nurse's fault. The one person who has no control over it, and wants nothing more than to make the ER flow, is blamed for the whole thing! Takes the abuse from the family, gets the complaints, which of course the administrators believe.
Not every migrain headache needs a Lumbar puncture!! Not every diarrhea needs a CT!! Come on Doc!! Please!!
Sunday, April 24, 2011
A generation of tough love, the only cure for an entitled society
I've been talking to friends lately about the abuse of medicaid in the ER, and what could be done to fix a system that not only allows people to abuse it, but encourages it. While we were talking, we realized that so many of our friends and family who aren't in the medical profession, really have no idea how much abuse of this entitlement program that there really is.
You have to wonder if the lay public knows that medicaid recipients are using the ER's in this country as their personal physician's, and not because they don't have another option, but because in their view it's free. Well, in a sense, it IS free for them. They can present to the ER with their toothache, headache, cold symptoms, sprained ankles and the like rather going to the community clinics and private physician's out there that take medicaid (but require them to pay their co-pay), and they simply tell the hospital sorry, I don't have any money to pay for this. So, rather than pay a $20 copayment at the clinic, or in some cases nothing at all, they come to the ER and cost you and I $500 to $1000 a visit. Why? Because they can't be forced to pay it, and public policy makes it difficult for ER's to tell these people that they are not having an emergency and can wait to be seen at the clinic or at their Doctor's office.
I recently had a medicaid mother check in with 4 children, one of whom had a cold. She checked her other children in stating "I just want to get them checked out since we're here". Because the hospital doesn't screen out non-emergent patients from the ER to the clinic, her one child which had a cold was seen, and her 3 other children with NO symptoms at all were also seen. Want to know how much those three visits for NOTHING cost you and I? A lot.
Medicaid has become a feather bed for the entitled to lay in at our expense. Instead of a program to make sure that the poor have access to appropriate health care, it's become a free ticket to the most expensive care available for non-emergency conditions - a trip to the ER.
The same can be said for those with no coverage at all. While every American should have access to emergency health care irregardless of theit ability to pay, that does not mean that they should be allowed to cost those of us who work hard and pay taxes massive amounts of money simply because they would rather not pay a nominal fee to go to a clinic, or don't want to take the time to make an appointment at the clinic and wait to be seen. It's very frustrating to take care of someone who is a self pay who comes into the ER for a simple rash, have them tell you they don't have enough money to go to the clinic, and then tell you as a part of their history that they smoke a pack and a half of cigarettes a day.
Until Medicaid and the Medical system in this country realizes that it IS politically correct to demand personal responsibility from people, this wasteful drain on the funds that are set aside to provide health care to those that truly need it will never stop.
Until we find the guts to tell young women that the rest of the country is not responsible for supporting her for the next 18 years every time she decides to have another child out of marriage. One child, perhaps, but five or six? Really? How is it that I am forced to support through my taxes someone who can actually make a living by having children that they can't afford to raise off of public assistance. Tough love for an entire generation, that's the only way we will ever change it. Telling these women that the cap on funds for unwed mothers stops at one child. If you can't afford to provide for the next one, or the next, then there are thousands of families out there who want to adopt and have the means to provide for these children. It's a tough thing to do, to implement, and to live with for the generation it will take to convince people that childbirth is no longer a means of employment at the expense of others.
A generation of tough love is the only cure for an entitled society, and the only way to bring personal responsibility back. Taking away Social Security benefits from those people who have contributed to society their entire lives to continue to pay people to sit home and do nothing is not the answer.
You have to wonder if the lay public knows that medicaid recipients are using the ER's in this country as their personal physician's, and not because they don't have another option, but because in their view it's free. Well, in a sense, it IS free for them. They can present to the ER with their toothache, headache, cold symptoms, sprained ankles and the like rather going to the community clinics and private physician's out there that take medicaid (but require them to pay their co-pay), and they simply tell the hospital sorry, I don't have any money to pay for this. So, rather than pay a $20 copayment at the clinic, or in some cases nothing at all, they come to the ER and cost you and I $500 to $1000 a visit. Why? Because they can't be forced to pay it, and public policy makes it difficult for ER's to tell these people that they are not having an emergency and can wait to be seen at the clinic or at their Doctor's office.
I recently had a medicaid mother check in with 4 children, one of whom had a cold. She checked her other children in stating "I just want to get them checked out since we're here". Because the hospital doesn't screen out non-emergent patients from the ER to the clinic, her one child which had a cold was seen, and her 3 other children with NO symptoms at all were also seen. Want to know how much those three visits for NOTHING cost you and I? A lot.
Medicaid has become a feather bed for the entitled to lay in at our expense. Instead of a program to make sure that the poor have access to appropriate health care, it's become a free ticket to the most expensive care available for non-emergency conditions - a trip to the ER.
The same can be said for those with no coverage at all. While every American should have access to emergency health care irregardless of theit ability to pay, that does not mean that they should be allowed to cost those of us who work hard and pay taxes massive amounts of money simply because they would rather not pay a nominal fee to go to a clinic, or don't want to take the time to make an appointment at the clinic and wait to be seen. It's very frustrating to take care of someone who is a self pay who comes into the ER for a simple rash, have them tell you they don't have enough money to go to the clinic, and then tell you as a part of their history that they smoke a pack and a half of cigarettes a day.
Until Medicaid and the Medical system in this country realizes that it IS politically correct to demand personal responsibility from people, this wasteful drain on the funds that are set aside to provide health care to those that truly need it will never stop.
Until we find the guts to tell young women that the rest of the country is not responsible for supporting her for the next 18 years every time she decides to have another child out of marriage. One child, perhaps, but five or six? Really? How is it that I am forced to support through my taxes someone who can actually make a living by having children that they can't afford to raise off of public assistance. Tough love for an entire generation, that's the only way we will ever change it. Telling these women that the cap on funds for unwed mothers stops at one child. If you can't afford to provide for the next one, or the next, then there are thousands of families out there who want to adopt and have the means to provide for these children. It's a tough thing to do, to implement, and to live with for the generation it will take to convince people that childbirth is no longer a means of employment at the expense of others.
A generation of tough love is the only cure for an entitled society, and the only way to bring personal responsibility back. Taking away Social Security benefits from those people who have contributed to society their entire lives to continue to pay people to sit home and do nothing is not the answer.
Friday, January 7, 2011
Long ER Wait Times are Getting EvenLonger
There's nothing more stressful as a nurse, than to walk into work in any ER in the country and be met immediately by angry gazes from patients waiting to see the doctor. It sets the tone for your entire night, and when it starts out that way, it usually just gets worse before it gets better.
The median amount of time between registering in the emergency department and being examined by a physician was 22 minutes in 1997, according to an analysis of more than 92,000 medical records in the National Hospital Ambulatory Medical Care Survey. By 2004, the median wait time was 30 minutes, the study says. Whether patients had insurance made no difference in how long they waited to see a doctor. Most patients who don't have insurance don't believe that, but it's true.
The longer wait times were tracked during a period when hospital emergency departments were being closed even though patient visits were going up, the authors say. Emergency visits climbed 78 percent from 1995 to 2003 but the number of emergency departments fell 12.4 percent from 1995 to 2003. Make sense? Of course not, but the reality is that most hospitals cannot operate at a deficit forever. Eventually, they will close if they can't make any money. It's sad fact of life that health care, like every other industry,
depends on profits in order to provide it's product to the community. Not great news when you consider that what insurance and the government will reimburse for health care provided keeps going down. The keys to the quality of health care in this country are held by rich insurance companies, and when I say rich I mean disgustingly wealthy. They arbitrarily decide what they will pay for YOUR health care, based on their profit margin desires.
Unfortunately, when it's you sitting the in the ER for hours waiting to be seen, you don't care WHO'S fault it is. You're going to take your stress and anger out on the person most accessible to you. The Nurse. The one person who has almost no control over the situation. Every night, I deal with people who feel that they aren't being taken seriously enough, or aren't being given the attention that they feel they deserve. I deal with these people as sensitively as possible, but it's difficult to be sensitive when someone with a toothache is cursing at you and disrupting the entire department with their tantrums as you are trying to care for someone with chest pain or stroke symptoms or trauma.
Believe me, we understand that when you have no insurance, and you are in pain, the ER is your only recourse for relief from your toothache. We sympathize and are more than willing to help. But people have to understand that the EMERGENCY room is first and foremost a place where people who are experiencing life threatening events in their lives can rely of fast and professional care. If you're coming to the ER as a clinic because you think it's free.....you're going to have to wait. It's not the Nurse's rule, it's a national rule called triage, and that's the way it SHOULD be. Like it or not, the critically ill have to take precedence over those with minor complaints. When even the very sick are having to wait to be seen, that means that a minor complaint is going to have to wait even longer. Sometimes the wait is tremendous, we know that. But that's the price you pay for the convenience of using the ER as your personal clinic.
So don't blame the Nurse, don't curse at her, don't threaten her. Vote for people who are trying to change the way health care is provided. Demand your county to make accommodations for those who need minor care but have no financial means to pay for it. Be sensitive to the needs of others in your community who are in the ER because they are seriously ill or injured. Bottom line, wait your turn. We'll get to you just as fast as we can because believe me, we want nothing more than to get you in, and get you out as soon as possible while giving you the best care that is possible. That's how WE measure our performance. Not by the patient care satisfaction surveys that seem to be all that CEO's care about.
The median amount of time between registering in the emergency department and being examined by a physician was 22 minutes in 1997, according to an analysis of more than 92,000 medical records in the National Hospital Ambulatory Medical Care Survey. By 2004, the median wait time was 30 minutes, the study says. Whether patients had insurance made no difference in how long they waited to see a doctor. Most patients who don't have insurance don't believe that, but it's true.
The longer wait times were tracked during a period when hospital emergency departments were being closed even though patient visits were going up, the authors say. Emergency visits climbed 78 percent from 1995 to 2003 but the number of emergency departments fell 12.4 percent from 1995 to 2003. Make sense? Of course not, but the reality is that most hospitals cannot operate at a deficit forever. Eventually, they will close if they can't make any money. It's sad fact of life that health care, like every other industry,
depends on profits in order to provide it's product to the community. Not great news when you consider that what insurance and the government will reimburse for health care provided keeps going down. The keys to the quality of health care in this country are held by rich insurance companies, and when I say rich I mean disgustingly wealthy. They arbitrarily decide what they will pay for YOUR health care, based on their profit margin desires.
Unfortunately, when it's you sitting the in the ER for hours waiting to be seen, you don't care WHO'S fault it is. You're going to take your stress and anger out on the person most accessible to you. The Nurse. The one person who has almost no control over the situation. Every night, I deal with people who feel that they aren't being taken seriously enough, or aren't being given the attention that they feel they deserve. I deal with these people as sensitively as possible, but it's difficult to be sensitive when someone with a toothache is cursing at you and disrupting the entire department with their tantrums as you are trying to care for someone with chest pain or stroke symptoms or trauma.
Believe me, we understand that when you have no insurance, and you are in pain, the ER is your only recourse for relief from your toothache. We sympathize and are more than willing to help. But people have to understand that the EMERGENCY room is first and foremost a place where people who are experiencing life threatening events in their lives can rely of fast and professional care. If you're coming to the ER as a clinic because you think it's free.....you're going to have to wait. It's not the Nurse's rule, it's a national rule called triage, and that's the way it SHOULD be. Like it or not, the critically ill have to take precedence over those with minor complaints. When even the very sick are having to wait to be seen, that means that a minor complaint is going to have to wait even longer. Sometimes the wait is tremendous, we know that. But that's the price you pay for the convenience of using the ER as your personal clinic.
So don't blame the Nurse, don't curse at her, don't threaten her. Vote for people who are trying to change the way health care is provided. Demand your county to make accommodations for those who need minor care but have no financial means to pay for it. Be sensitive to the needs of others in your community who are in the ER because they are seriously ill or injured. Bottom line, wait your turn. We'll get to you just as fast as we can because believe me, we want nothing more than to get you in, and get you out as soon as possible while giving you the best care that is possible. That's how WE measure our performance. Not by the patient care satisfaction surveys that seem to be all that CEO's care about.
Monday, October 18, 2010
Happy ER Nurses Week!!
Just a quick note to all my friends in the trenches. I hope you have a fantastic week, I salute you, and I appreciate you. Here's to you (holding up my cold beer) !!
Sunday, September 5, 2010
Compassion Failure? You bet, it's caused by Hydrocodone.
Is the whole freakin world addicted to Hydrocodone. Would there even be any need for an ER anymore if it weren't for drug seeking people who bombard the ER 24 hours a day looking for their next fix. How many ER's a day are these people visiting and just how many of the pills they get prescriptions for are they actually taking, versus how many their selling to Kids so that we can have another whole generation of pathetic drug addicted society abusers to fill the ER's of the future.
Remember when you used to take tylenol or motrin for a sprained ankle? Not any more!! Now they start kids, YOUNG kids, off on prescriptions for Hydrocodone for a little sprained ankle or tiny little laceration that the Physician has already sewn up. We wonder why so many people are addicted to these powerful pain medications. Well, look at the medical community and it's governing bodies. The AMA, the State Boards of Nursing, the Nursing Societies.....all of them encourage liberal use of narcotics for any and all pain and tell physician's and nurses that if they aren't giving these medications, they aren't treating their patients.
I have news for you people, patients DO lie to get narcotics, and they lie ALOT. The lies cause huge expenditures in unneccsary tests. You would be shocked how many times we get calls from pharmacies telling us that the person we just discharged with a new prescription for Vicodin, has filled TWELVE of the same prescription in the past 2-3 days. All from different Doctors and ER's. There are people who get literally thousands of pills of hydrocodone a month in prescriptions from multiple doctor's. They aren't personally taking these medications. What do YOU think they're doing with them? Whose child is going to get them at school next?
I am so sick and tired of Nursing leaders in this country saying that patients don't lie, that addiction isn't our concern in the ER, and that no professional has the right to use objective observation to assess a patients pain. Come work with us in the trenches of hell you've created and tell us that to our faces. Next time you're sick and need a bed in the ER that's full of various undiagnosable pain complaints, tell me that the 22 year old here for the 12th time in 2 weeks for chronic foot pain that he rates at a 10 out of 10 and is out of his hydrocodone should be an emergent patient and taken ahead of you! Get real, we're creating an entire generation, multiple generations actually, of addicts who are going to spend their lives paying for your unwillingness to admit that your policy on pain is a complete failure and is killing people.
Remember when you used to take tylenol or motrin for a sprained ankle? Not any more!! Now they start kids, YOUNG kids, off on prescriptions for Hydrocodone for a little sprained ankle or tiny little laceration that the Physician has already sewn up. We wonder why so many people are addicted to these powerful pain medications. Well, look at the medical community and it's governing bodies. The AMA, the State Boards of Nursing, the Nursing Societies.....all of them encourage liberal use of narcotics for any and all pain and tell physician's and nurses that if they aren't giving these medications, they aren't treating their patients.
I have news for you people, patients DO lie to get narcotics, and they lie ALOT. The lies cause huge expenditures in unneccsary tests. You would be shocked how many times we get calls from pharmacies telling us that the person we just discharged with a new prescription for Vicodin, has filled TWELVE of the same prescription in the past 2-3 days. All from different Doctors and ER's. There are people who get literally thousands of pills of hydrocodone a month in prescriptions from multiple doctor's. They aren't personally taking these medications. What do YOU think they're doing with them? Whose child is going to get them at school next?
I am so sick and tired of Nursing leaders in this country saying that patients don't lie, that addiction isn't our concern in the ER, and that no professional has the right to use objective observation to assess a patients pain. Come work with us in the trenches of hell you've created and tell us that to our faces. Next time you're sick and need a bed in the ER that's full of various undiagnosable pain complaints, tell me that the 22 year old here for the 12th time in 2 weeks for chronic foot pain that he rates at a 10 out of 10 and is out of his hydrocodone should be an emergent patient and taken ahead of you! Get real, we're creating an entire generation, multiple generations actually, of addicts who are going to spend their lives paying for your unwillingness to admit that your policy on pain is a complete failure and is killing people.
Tuesday, December 15, 2009
Crack rocks on the corner, or Vicodin in the ER : Pushing Drugs is Pushin Drugs
I read this news article that was published in the SunSentinel.com. It was written in 2003, but is just as relevant today, if not more so, than it was at that time. It discusses the amount of Medicaid funds that are spent yearly on prescription pain medications, and how a small percentage of physicians write for a huge number of those prescriptions. I highly recommend that anyone who is concerned about drug abuse and addiction, and wastefull government spending read this article. http://www.sun-sentinel.com/news/sfl-drugmain1nov30,0,3963215.storyThose of us who work in ER's around the country can attest to the fact that the face of addiction is changing in this country. It isn't the guy standing out of the corner selling crack rocks that is spending medicaid dollars like they will never run out, and the typical addict isn't a young homeless person who's shooting up in an alley anymore. If you don't already know this, then you should, your tax dollars are being spent every day to create addictions, fuel them, and deal with the aftermath caused by desperate people who need to get their fix. Most of these addicts don't even see themselves as addicts. They get their drugs from Doctor's, either in the ER or at their primary care office, and think that if they get their 'medication' that way, then there's nothing wrong with it.
It makes me sick to see an ER Doctor write a prescription for a 16 year old kid with a sprain ankle for Vicodin. Not tylenol, not motrin, not alieve.....Vicodin. Remember when the treatment for a sprain was ice, elevation, and some kind of anti-inflammatory? Well, no more. The medical and nursing leadership in the country have demanded more and more aggressive treatment of pain, until Doctor's feel obligated now to pacify a patients desires, rather than their needs.
Add to that the fact that hospital administrators care more about patient satisfaction surverys, than they do the quality of a patients care, and you get a dangerous mixture of ambiguous physicians and a patient population that is increasingly craving strong narcotic pain relievers for minor aches and pains.
Some ER Doctor's fight the good fight, and refuse to pass out Narcotics like candy on halloween, but they are often berated by administrators when drug seeking patients who don't get what they want, return surveys saying they weren't 'satisfied' with their care. But what is that Doctor's first responsibility? To give good care, or to give them what they want even if it's NOT good for them?
I've worked with more than one Doctor who lost his job for not handing out narcotics. I've worked with Dozens who pass out narcotics all night, every night, to anyone with any complaint. I work with one, who will give a prescription for Vicodin at any patients request. Literally, all you have to do is ask, and he will not only give you a prescription for Hydrocodone, but a take home pack to get you started on the way home. We have patients at triage, requesting him by name, as you can imagine.
What makes me sick is that I'm paying for many of these prescriptions with my taxes. So many of these patients are on public assistance programs, and my tax dollars pay for their ER visits for toothaces, sprained everything (new sprain every other week), chronic back pain, chronic headaches, undiagnosable abdominal pain for 12th visit. Lastly, my tax dollars pay for their care when they come in overdosed on their legally obtained prescription narcotics, or when they drive impaired on them and wreck into other people unlucky enough to be on the same road with them.
I keep hearing about healthcare reform, but I don't see ER expenditures getting any better until the culture of pushing drugs in healthcare changes. Throwing crack rocks, or writing a kid his first prescription for vicodin when he has a bruise on his knee. To me, it's both the same thing. Pushing drugs, is pushing drugs.
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