8.28.2015

Best Thing on the Worst Day

 via Library of Congress
It was a busy night.

That is saying a lot.

All of our Monday nights are busy these days, but this was bad even by our standards. We had our fastest night shift ER doc working and extra staff, but still the patient's kept pouring in all night long.

We had sick patients too.

It was so bad that we woke up the morning shift doc and brought him in at 4 am because the department and the waiting room were full and the night shift doc was still ten charts behind.

That wasn't the only thing that made it unusual.

It was that rare night in the Emergency Department when all my patients:

1) Have a good reason to be in the ED.
2) Actually appreciated my help.

A night like that can carry you for six months -- it usually has to since it is about as common as hen's teeth these days.

With the onset of the Affordable Care Act,  Emergency Departments have seen huge increases in patient volume. Many more people have access to health insurance under Obamacare, but there has not been a huge increase in primary care providers to see them.

Yet it is not just people with new access to insurance. A 2013 studies found that only about one third of the people who come to the emergency room require immediate attention and 70 percent at that time had private health insurance.

The emergency rooms are filled around the country with non-emergent conditions and unrealistic expectations. We don't dole out narcotics like candy. We don't solve mystery conditions that you've been to every specialist to see. We give toddlers with fevers over the counter medications that parents could have given at home. We get sent patients from clinics because they can't get a same day appointment -- or don't want to wait until morning. People call ambulances because they don't have gas money and don't want to pay for a taxi.

The least sick, it seems, are the most rude and impatient. It is tempting to be rude right back, but that's what they want. They want to start a fight, to get into a tug of war. Something to tell their friends and post on social media. The only way to win that sort of power struggle is to not engage, to not pick up the rope.

Moreover, these days nurses live in fear of the dreaded "Patient Satisfaction Survey." Federal insurers want to pay hospital based on patient satisfaction -- but it is a rigged game. It assumes the patient is a customer in a restaurant, but it is the doctor that places the order. Patient advocacy is the nurse's primary motivator, but sometimes what is best for a patient is not what the patient wants or expects -- because they aren't the medical experts and they don't always want what is best for their own well being.

When our surveys dropped a few years ago, our corporation ran us through a bunch of training to teach us how to be better service workers rather than professionals.

Unfortunately the first day of these classes they explained the methodology of the survey.  Satisfaction with care was rated on 1-10, but everything below an 8 was scored as a "0." The results were not randomized, sample sizes and response errors were big problems.  We were rigged to fail. Why? I suspect is has something to do with the fact that the companies that do these surveys also profit from the consultants and seminars and education products sold to hospital systems that panic at less than perfect scores.

So we are taught how to be kind and patient with people exhibiting behavior that would get them kicked out of the lowest dive bar in town.

This night was different.

My patients were sick. I had a brain damaged man having increased seizures because of a change in his medications. I had a cancer patient on chemotherapy with a fever -- he and his wife were kind and jolly despite a terminal diagnosis. He kept making jokes as I accessed his port and drew blood cultures.

"I'm terminal," he said. "What else is there left to do with my time, but laugh as much as possible?"

Late in the night I helped with a trauma patient. An elderly lady had fallen down a flight of stairs. She was on Warfarin and had a head bleed, broken ribs and hemo-pneumo that required a chest tube. She was deteriorating. We moved her to a trauma bay to get her chest tube in and possibly intubated for the flight to Portland.

The room was filled with nurses and techs -- so often when you have a sick patient, the staff appears when you need it most.

So I lingered to cover the other rooms and found myself standing with the woman's husband in the hall. I brought him a chair, which he leaned on, but did not want to sit.

This is nursing sometimes, standing with a family member while they come to realize how this night will never leave their memory.

The doctor came out -- and behind them, I saw the Lifeflight crew shouldering their bags and walking away. Our doc had got a call back from the receiving hospital. He was told by the neurologist that the prognosis was so poor that it was not worth risking a helicopter flight.

The doctor returned to the room to put in the chest tube and I stood with the husband as he started to cry. I just stayed there, stayed present with him and we talked.

He had bad nights before. He was a World War II veteran. He had been wounded twice and saw the war end while he was in Austria. The first time he had been wounded, he pulled the shrapnel out himself and kept going. He explained that if he was medivac'd out, he would have lost contact with this unit.

"Those were the guys you were fighting for," he said. "Those were the people who had your back. You didn't want to leave them. They're your family."

While nothing like combat, his story made me think of how the whole department pulled together when there was a disaster or trauma, or critically ill patient that needed extra hands, extra help.

In the room, three nurses and two techs helped the doctor secure the chest tube which quickly drained the blood from the woman's chest and allowed her lung to re-inflate.  The radiology tech stood by with the portable chest x-ray, respiratory therapists were at bedside.

All that staff in that one room meant that somewhere a call light wasn't being answered as quickly as would otherwise have been the case. Someone was waiting for a warm blanket. Other less acute patients were still waiting to be seen. Our critical care of this one patient would probably reduce our patient satisfaction surveys.

Most nights I'm the charge nurse, directing traffic and solving problems and rarely doing hands-on care. I love my one or two nights a month where I get to take care of patients. It reminds me why I got into this business in the first place.

When I first got into medicine -- as a volunteer EMT -- someone told me that I'd have the opportunity to be the best thing on the worst day of someone's life.

Being present doesn't have a billing code. Standing with a family member at a horrible moment during a tragic night might not move the needle on a patient satisfaction survey.

Yet sometimes, that's what nursing is.

-30-

Further Reading:
The Problem with Satisfied Patients
Seven Things You May Not Know About Press Ganney Statistics
Emergency Room Visits Continue to Climb
The Ten Types of ER Patients
The Yelp-ing of Emergency Rooms

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