What do you do with a Drunken Sailor?

The post 'Minor Complaints' at 'Rickety Contrivances of Doing Good' has spurred me to write a response (which has unfortunately taken me 4 weeks to complete...).

I read Susan's post 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.

I would like to remind my regular readers (all three of you... Hi Dad, Hi Tracy, Hi Robin) that my blog is only one aspect of my nursing persona - I use it as an opportunity to blow off steam in a creative way. The frustration I show here would never be displayed to the patient or family in front of me. My goal when I speak to a patient is to treat them as I would want my family member to be treated, or how I would like to be treated myself. I have had some excellent experiences as a patient and family member, and I've had some really not so nice ones. They have all shaped the nurse I am.

The most recent experience I had as a patient was when I had a herniated disc. Next to having labour this was the most pain I have ever had. Now, I am stubborn, and I will carry on through most illnesses (fever, cough, cold, pneumonia, gastro), but this was completely beyond what I could work through. I could not move, and I certainly couldn't care for patients. My family, co-workers, chiropractor and massage therapist understood, but my doctor minimized it completely

"I don't think it's a disc - your symptoms are not severe enough."

and then once it was diagnosed on CT as a disc,

"It's only a small protrusion - you'll be fine."

I found this infuriating! I am telling you how I feel and you are telling me that I am not feeling what I say I'm feeling. I'm telling you that this really hurts and you're telling me it isn't. I'm telling you that this is interfering with my daily living and you are poo-pooing me.

This very small event reminded and reinforced for me that every patient who presents to Emergency does so because they perceive they have an emergency. It is my job to determine if it actually is an emergency or not. That is why I have taken all those physical assessment courses and have had all those workshops on triage. I don't come by this naturally - this is a learned skill I have, this ability to determine who is really sick and who is sick but can wait.

For some, it is a lack of knowledge that makes their non-emergency bigger in their eyes.

"I knew when her fever hit 104 that I had to rush her here before she had brain damage!"

These are sometimes the easiest and the hardest patients/families to care for. Most will listen to your reassurance and explanation and relax a bit. Others just think you are brushing off their concern, and obviously don't know what you are talking about "because my mother's brother's wife's sister-in-law's aunt's baby had brain damage after a fever!" Is this the way that the information is delivered to them or is it their fear making them unable to hear the information? Maybe both. I have no doubt that my physician was not meaning to put me down or minimize my concern - she was trying to reassure me that I would be OK. Even when she was wrong (it was a disc) she was right - I have recovered.

For some the emergency is acknowledged at the beginning as a non-emergency

"I know this isn't really an emergency but I didn't know where else to go - I called my family doc on Friday and I have an appointment booked for next Thursday, but this is getting worse and I didn't know were else to go!"

These are the people I feel for. They know that they are not critically ill but they do have symptoms worthy of assessment by a physician. They have tried to go the appropriate route but have been turned away or put off and are left with us as a path of last resort. They know that they are looking at hours of waiting for something that is clearly non-urgent, but still requires a physician's care.

Then there are those in pain. Pain is a hard one because it is so individual. Your broken toe may be as painful to you as my herniated disc was to me. Who am I to judge your pain? Again, I try hard to treat your pain and to acknowledge that you have it (I freely give out tylenol, advil, and ice packs in triage) while still placing you appropriately in the triage system. No matter how annoying your lacerated finger is, it is not a life threatening injury, and those with potential heart problems, breathing issues, broken long or joint bones, blocked bowels, dehydration, seizures and intractable cancer pain and many other concerns must all go ahead of you.

I find myself very annoyed with the people who while expressing frustration with their wait say things like:

"It's good this isn't a real emergency - if it was I'd be dead now!!"

These are the people who have come in with an acknowledged less-urgent concern and who are frustrated with their four or six or eight hour wait. The snappy response would be

"No, if this was a real emergency you'd be being treated by now. The fact that you're still here bugging me is a clear indication that you aren't sick!!"

However I bite my tongue and nicely reassure them that the reason for their wait is that we treat people based on acuity, but that we are still taking their concern seriously. I remember clearly one father who, after watching a child have a full-blown grand-mal seizure in the waiting room, stated

"I wish my kid would do that so we can get seen!"

I was definitely not at my professional best that night because I laughed out loud and said

"No you don't, silly man! You're lucky your child is well enough to wait to be seen!"

Luckily he saw the humour too and laughed with me, responding

"You're right. It's just so hard to wait."

And it is. Waiting is absolutely painful! In North America we are a culture of people who are used to getting what we want and right away. We have internet access to any information we want. We have cell phones and email for communication. We have fast food 'Your way. Right away!' We do not know how to wait. We would never survive in a bread line in Russia - imagine waiting five hours to purchase a loaf of bread! So after living our lives with instant gratification we are asked to wait what seems like an interminable length of time for care, at a time when we are feeling our worst and most vulnerable. We are scared, nauseated, dizzy, in pain. Every second we wait makes our symptoms seem worse and makes our fear grow.

So what is my point? Only this - the less urgent concerns are still the bread and butter of Emergency Nursing. Without these patients 60% of us would not have jobs. I'm happy to care for you. Please just recognize that I am doing the best I can with the resources available to me.

And lets agree to be mutually respectful. Deal?



For a real-time example of how I really respond, you can read (or re-read if you were already there, as there is an addendum) my post 'What to do?'.