I hear many, many people complaining about how long they have to wait to be seen in the Emergency Department. Here is the simple reality about the reasons you might wait, straight from an ED nurse:
1. We can only go as fast as the number of available beds allows. You may not know this, but state-of-the-art emergency rooms happen to be just a skosh expensive to build and equip, and they also take a little time to build. Then you have to staff them. My bedroom-community ED is operating at over 200% capacity because of the massive exodus of people out of the metro area. On a positive note, we are getting a new ED with twice the capacity of our present ED and with a better patient flow design. But that means that when it opens, we will start at 100% capacity. Why did we not build a bigger ED when we knew we would still be behind the curve? Behold, the simple economics of public funding: The taxpayers demand we build a new ED, but they'll be damned if they spend one dime for it. We can only build what we can afford. Sorry about that.
2. I don't care if a person is from Mexico, China, Haiti, Canada, Pakistan, or Lower Slobovia. I don't care if they are legal or not. I know full well how much it costs to provide healthcare to people who won't pay for it. It pisses me off too. But if they are sicker than you, they get in first. Sorry about that. Does treating illegals make things more expensive for us? Yes, it does. But they are also human beings. That takes precedence over legal status when a person is blue and pulseless. Turning deathly ill persons away because they are of questionable legal status or uninsured ain't in my job description, pal. And think about it: would you want to face me in triage if it was?
3. People using the ED as a family clinic is not a practice exclusive to the uninsured or to Mexican immigrants. More Caucasian, English-speaking, insured families follow that practice in my ED than any other demographic. Why? Because they seem to think that if they come to an ED with a toothache or a head cold, they will be seen sooner. After all, we're an ED- right? We must naturally assume that anyone who comes into an ED must certainly have a real emergency- right? Wrong. Take your headcold to the local drug store, buy some Nyquil, some Vick's Vapor Rub, some saline nose spray, and some chicken soup and then go home and deal with it. Don't waste space in my ED if you aren't bleeding, puking your everlovin' guts out, convulsing, febrile over 102 degrees, or if you don't have a bone sticking out, don't have a kidney stone that feels like it's the size of a cinder block, have not been in a car accident or have not been or are not now blue and pulseless. Those are emergencies. Your ingrown toenail is not. Sorry about that. And no, I will not look at your little Jimmy's splinter or your mother-in-law's corns since they are in the room with you anyway. They'll have to go through triage just like everyone else. You can find family price packages at the ballpark, not in my ED.
4. I am a highly trained medical professional with years of state-of-the-art education (graduated Magna cum Laude) and further years of ED experience behind me. When you come into my ED, you will get the best I have to give, no exceptions. So please do not come busting into my ED on your own two feet and tell me you are having a stroke, a heart attack , or kidney stones. I ruled all three of those out when I watched you get out of your car and briskly walk the 100 yards between your car and my door smoking that cigarette and putting it out in the faux-marble birdbath that I put out there with my own frigging money. I ain't buying. Sorry about that.
5. I try to get you in as fast as I can. I really do. Sometimes things happen that make you wait a little longer- a five-car pileup on the interstate; a barbecue explosion; a father of three whose heart has the gall to stop beating while he is playing ball with his kids; a pregnant woman who starts hemorrhaging and bleeds through six maxi-pads in a half hour. If those come through my door, you may have to wait a while longer. Please do not stomp up to the triage station and ask me if I know just how frigging long you have been waiting. Yes, I know how frigging long you have been waiting. I wrote down the time you came in. And when I apologize and tell you that you will have to wait just a little longer, please do not call me whatever filthy name strikes your fancy. Please do not threaten to wait for me outside the ED and beat me to death with a tire iron or cut my throat when I leave. It's been done. Believe me, pal- I have heard them all, even from upper middle-class people who speak marvelous English. I really do care. I wish I could get you in faster, but I can't. On that note:
6. If you can physically stomp up to my triage station after two or more hours of waiting and be loud and belligerent, then I can instantly deduce that you have the lung capacity and the cardiac capacity to keep that brain of yours perfused for a little while longer. I keep an eye on my triage patients, and I make a point of coming out to the waiting area and checking on folks who have to wait, just to let them know I have not forgotten about them and to recheck a blood pressure or temperature or two. In my ED, if you are really sick you can bet your ass I will move heaven and earth to try to get you seen. It's like that in almost every other ED in this country. Not all, unfortunately, but nearly all. But you don't hear about those. You only hear about the bad ones. They are not all bad. Most are pretty damn good. I know- I have been a customer in more than one of them. And yeah- I had to wait, too.
7. I have studied in hospitals from here to Taiwan and have performed comparative research about the healthcare systems in dozens of countries incoluding America; and I can tell you that all this talk about socialized medicine being superior to American healthcare is by and large a trainload of horsefeathers. They are most certainly not any better than what we have to offer. And the wait is at least as long. There are exceptions, but that's all they are. American healthcare is flawed, but I'd still take my kid to an American hospital first.
I mean no disrespect to anyone when I say this, but it must be said because it is the absolute bottom line, and there is no getting around it: If you want bigger, better, faster, sexier hospitals, then you will have to accept the unsavory fact that you are going to have to pay for them. Ours is a consumer-driven society, and our healthcare system reflects that. If you expect Bugatti quality for the price of a Yugo, you are going to be very, very disappointed. That may not be palatable, but it is the truth. Sorry about that.
Posted by ERNurse at September 19, 2006 06:14 PM | Email ThisAs a former nozzle head (firefighter) and EMT I had a simple first pass triage method. If you're screaming in pain, you're conscience breathing and have a good heart rate, I'm check on the quiet ones first.
On illegals -- bill the country of origin or take it out of that fat foreign aid.
On no payers in this country we should be more aggressive in collecting, I can't tell you how many welfare homes I've been in with the big screen TV cable TV, cell phones, Xboxes and what not yet they "can't" afford health care.
Posted by: JCM on September 19, 2006 07:08 PMI personally think socialized healthcare is a bad idea. What we have isn't perfect by a long shot either. But considering how frivolous lawsuits and bloodsucking ambulance-chasing parasitic bastard attorneys a la Jonathan Edwards have jacked up healthcare prices, I can confidently say that America has simply gotten what it has asked for already, and now the Me Generation has to pay for what it asked for. Sorry about that.
Posted by: ERNurse on September 19, 2006 08:42 PMThe problem with healthcare is that the customer is usually not the person who pays the bill. And that works both ways. The patient doesn't know how much it costs and could care less in making sure they get a good deal. You are right, socialized medicine would make it worse than it already is.
And we need far more preventitive medicine up front. I'm starting to see these buses loaded with equipment that will do basic blood tests and screenings for a fee. This will be a great thing for healthcare because it will be far better if we can catch some of this stuff early so that we don't have to spend thousands slicing someone open in an emergency heart failure when we could have just seen the problem coming a year earlier.
If we moved towards a screening model, we could all pay a moderate fee for a comprehensive screening every six months to a year, which would catch a lot of really bad stuff in advance. This would free up surgery and emergency resources and the resultant insurance costs for where they are actually needed and lower premiums for all.
We take our cars in on a regular basis to get them checked with all sorts of diagnostic equipment. The same should be true for our bodies.
And yeah, lawyers are a big part of the problem. My Dad is a lawyer, and I'm embarassed to admit that he scammed the medical system for a disability insurance payout. But it was all done by the book, so there's nothing anyone can do to stop parasites willing to exploit the system. Tort reform is needed.
Posted by: Jeff B. on September 19, 2006 11:29 PMOne solution I think is to push to Health Savings accounts, which makes the consumer more aware of costs.
We also have redefined health care as a right, you have a right to access health care, but no right to free health care.
If we were more aggressive in making people actually pay for services, not let them walk into a ER and get treated and then allowed to walk away, that would help also, make people think twice about taking up ER space for a cold.
If she had come on an aid car, she would have been treated right away.
As it was she sat freezing, dehydrated and a disruptive heart, hardly conscious with a septic bladder infection. After treatment a couple of days later she walked out. But, not before the doctor gave us a 5 minute to dying prognosis the morning after (emergency room waste).
Posted by: swatter on September 20, 2006 08:18 AMYour mother might have been five minutes to death, but that sounds like a bit of hyperbole on either your part or the part of the doctor. Was it actually five minutes, or might it have been longer, and what are the exact reasons for that statement?
The point of the post, and a good point at that, is that the ED is vastly abused by those who have no business in a place reserved for true emergencies. If indeed you mother was a case of a true emergency, then as the voice mail greetings all say, you should have hung up and dialed 911. If anything, a failure to present the conditions of real emergency works against you as you have noted.
I certainly don't want to imply that your mother's health is not of great importance to all concerned, but the reality is that the ED is often abused. And that makes those who really need it subject to great risk and all of us subject to great cost.
Posted by: Jeff B. on September 20, 2006 10:50 AMI have relatives who do think health care and other perks are a God given right and won't ever pay a dime towards it. Yet they have the big screen TV, deluxe cable package, etc. Because they don't have insurance (they either choose not to pay or choose jobs without benefits), they don't think twice about using the ER as their primary care facility.
Swatter, any time a loved one is seriously ill we naturally think that things need to be tended to at once. Going by ambulance is not going to change how fast any one is seen by the doctor. When my mom had her heart attack, we drove her to the hospital (911 can be slow in Seattle) and the ER nurse took one look at her and the next thing we knew Mom was tossed on a gurney and rushed down the hall for immediate attention. When my dad went in because of breathing difficulties it was a three hour wait because others were in much worse shape but a nurse did stop by every 15 minutes or so just to make sure my dad's condition had not worsened.
Socialized medicine is not the answer. Paul McCartney brought his wife to the US for cancer treatment and this is one dude who could afford to see any of the Harley Street physicians. Getting the lawyers out of health care is the first step.
Posted by: Burdabee on September 20, 2006 05:39 PMYour chances of avoiding pain are better when you negotiate with a terrorist. ;oD
Posted by: ERNurse on September 20, 2006 06:49 PMA well-trained, experienced Triage RN comes replete with a highly-sensitized BS filter. I had a patient BS her way into being seen first by calling 911 and having the medics transport her to my ER. Her complaint? Same as the last 50 times she showed up in the last four months: migraine. How did I know this? We keep records and I pulled hers up at my desk.
The next night I was Triage RN, and we were just friggin' packed. It was a really, really bad night. Our charge nurse came out and told me that the one room that I was needing was being reserved for an incoming medic unit. I asked what was coming in and he told me.
I kid you not- it was the same woman who pulled that trick on us last night, and I was the RN who treated her then.
I said, "You know, [so-and-so] pulled this trick on us last night."
The charge RN says, "Oh, did she?"
I said, "Oh, yes. In fact, I treated her."
So the charge RN says, "Well, I'm glad I talked to you."
When the medic unit pulled up, the charge RN met the patient as the medics pulled her out of the unit, performed a neuro assessment (which she passed with flying colors), had them unstrap her, and marched her straight to the triage area. When she entered the triage area, she saw me and went pale. I gave her a little waggly-fingers "princess" wave, pulled out my triage sheet, wrote her name down by memory, and told her to have a seat and I would call her when it was her turn. The charge RN sat her down and told her, "Now I know you. Don't ever pull that stunt in my ER again." The patient got straight up, offered her pointed opinions about my parentage and my masculinity in language that would have made a Marine Gunnery Sergeant turn deathly pale, and she stormed out of the ER, nearly knocking over an elderly couple on her way out.
We never saw her again, but about three weeks later another area hospital called us about her, because her name showed up on the frequent flier/drug seeker alert that our area hospitals occasionally share.
She came into their ER by medic unit, complaining of a migraine.
Posted by: ERNurse on September 20, 2006 07:04 PMThe ER itself is a model of efficiency. We were cared for quickly and well.
My complaint is when they had occasion to send us across the drive to Ambulatory Care... GOOD GOD, it's medicine in a closet, waiting in a smaller closet and wholly understaffed!
It seems to me that the idea of AC is a wonderful adjuct to the ER and I admit they probably see far more patients than ER after the initial triage... but please, please please, tell me why they can't be at least AS efficient as the ER.
Posted by: Cheryl on September 20, 2006 07:18 PMThe primary reason that Acute Care is so much more overwhelmed than the primary ED is that more and more people are using the ED for non-emergent cases- toothaches, running out of medications, headaches, bad colds, etc. Having an Acute Care area is a good ide because it gets the non-emergent cases out of the main ED and keeps it clear for the really bad stuff. On the other hand, since more people are using the ED for non-emergent reasons, consequently the Acute Care areas become packed with patients.
Staffing is driven by averages. You take the total number of patients seen in the previous year, look for trends, and then staff accordingly. Most of the time it works, but it isn't perfect because it cannot predict the five-car pileup or the outbreak of viral gastroentritis at the local University.
My hope is that no matter what ED you visit, the next time you go you will have a better understanding of how these things work from the nursing perspective. We don't like to make people wait any more than the patients like to wait. But we can't do anything about that. We are on your side. Unfortunately, I cannot speak for every nurse, but only for myself. I cannot guarantee that if you came to my ED you would get in any faster. No nurse can do that. But nearly every nurse will tell you that he or she will do everything within their abilities and influence to give you the best possible care. We don't go into nursing for the glamour or the money, which is not all that great when you consider the crap someone has to go through to get a nursing degree.
People don't throw containers of urine at CPAs or barf all over investment bankers- and those folks make a helluva lot more than nurses do. Nurses get barfed on, bled on, spat on and shat on, and we are paid less than public school teachers and are more open to assaults and lawsuits than almost any other profession. So the money is not what motivates us to do what we do. Nearly all of us do it because we think it worthwhile to make a career out of helping people get better.
Posted by: ERNurse on September 21, 2006 01:15 AMYou, sir, are full of it. Your general statements about all ERs are full of it. Unless you want to get the facts, keep the trap shut. The ER front room was full of incompetents and people that don't want to help people.
And the treatment was for life-threatening. This ER just screwed up. Sorry, but I can't be anymore blunt than that.
Once she got in the backroom she got good treatment and made an overnight (several day) stay at the hospital. No, this wasn't a toothache.
The doctor that had given her 5 minutes was the one who treated her a few months before. During the 3-4 day stay he told us his impressions of that moment I mentioned before.
I am not minimizing the work that RN's do by any means, but I do not think this statement is accurate. The median salary (excluding premium time) in the Seattle area for RN's is $65,312. RN's that I know can work a significant amount of overtime or can pick up extra shifts paid at overtime rates, and also get other shift premiums on top of that. The median salary for teachers is in the mid 40's.
Posted by: Palouse123 on September 25, 2006 04:02 PMLet's compare. We will use the base salary of a new ER nurse as our control, which is around $22.30/hour (gross). That's $42,816 annual. Not median, but actual. That's the going rate for factory-fresh ER nurses in the Seattle area. There is no median.
So, what does a new kindergartner teacher in the Seattle area? Try $52,451 or $27.32/hour. Without overtime.
Elementary school starting wages are the same.
Brand-new High school teachers start out at $28.00/hour, or 54,691 annually. Without overtime, with a couple months off thrown in.
And to put up numbers that are comparable to those, a new nurse would have to work 12 hour shifts plus extra shifts.
And then there is the workplace violence issue. And the blood and body fluids issue. And the exposure to unusual diseases issue. And the exposure to toxic chemicals and medications issue. And the exposure to raving lunatics issue. And the "losing the fight to save a 28-year-old mommy who was hit head on by a drunk driver and having to tell her husband and kids that she's dead" issue. They can never pay me enough for that sh*t, let me tell you.
No, I'd say schoolteachers get a lot more than ER nurses do for the work they put into their clientele.
Posted by: ERNurse on September 25, 2006 07:31 PMIn this article, it details starting salaries in the highest paid district in the state.
Everett has the highest teacher pay in Washington. Starting salary for a first-year teacher is $35,055. A teacher with seven years' experience earns $52,366, and a teacher with 15 years' experience and a master's degree earns $71,377
Full time RN's start at a BASE salary of $46,467, plus overtime and shift premiums. Again, the MEDIAN salaries for RN's is in the mid-60's, excluding overtime and premium pay, which they can easily achieve if they take evening or night or weekend shifts.
I am not arguing that RN's have a tougher job, they do, without question. And they are in higher demand than teachers. This is why they are compensated higher.
Just so others are aware, there are full time RN's who easily make six figures with the premium time they earn. Alot of RN's make an hourly rate equivalent of a salary in the 80's or 90's (>$40 per hour), but choose to work per diem so they do not work 40 hours per week.
Posted by: Palouse on September 26, 2006 09:30 AMLook. If you want to contest my position that teachers are better paid than nurses, that's cool. I'll take correction on that. But when you factor in the tangible hazards associated with ED nursing, that's another story. Schoolteachers don't face those hazards on a daily basis. ED nurses do. And being an ED nurse, I count that as part of the equation. Okay, so that's my personal position.
Posted by: ERNurse on September 26, 2006 05:37 PM