Actual Triage Note

"...c/o right axillary cyst, pain to right shin, left arm pain, tingles to fingers, right eye pain, joint aches, can't sleep, feels like 'I can't breathe - someone sitting on my chest, having a hard time swallowing.' Pt sitting calmly dressed in PJs in no apparent distress. Pain to neck, feet, thighs, palms, headache to right eye, etc."

Yes, the triage note actually ended with "etc."

The doctor picked up the chart, read it through and said, "Well, I guess we'll just have to do one of everything."

I replied, "Hey, that can be your orders and your diagnosis all in one: one of everything!"

Breaking Up Is Hard To Do

His story started with, "I was in a car accident 6 months ago."

This is never a good start, and rarely relevant to an ER visit.

He didn't go to a doctor at the time, because it was his girlfriend's car and she'd already had several accidents and he didn't want her to lose her insurance. What a noble guy.

Now, six months later, they broke up so he wants to file a claim.

I'm not sure which is worse: the general story, or the idea that people really think something still counts as an "emergency" six months after the fact.

Parental PSA

Okay, stay with me on this one here, because it's a very difficult concept.

Ready?

One dose of Tylenol does not magically cure illness.

I know, I know: it's difficult to believe. But if your child has a fever, and you give him Tylenol, and then four hours later he has a fever again, this in and off itself is not a reason to bring him to the ER in a panic. This does not mean he is getting worse. It simply means that the Tylenol has worn off. Do you know what you need to do now?

YOU NEED TO GIVE HIM ANOTHER DOSE.

See how that works? Okay, let's try another one.

Your child had a fever yesterday. You gave him a dose of Tylenol yesterday. Today, he has a fever again.

He has not had any Tylenol since yesterday.

I'm going to leave this one up to you, parents. I know it's tough, but I have faith, deep down inside somewhere, that you can figure out what you need to do next.

Let's think about this here.

I triaged a patient tonight, who kept looking at me with that "I know you but I can't place you and it's bugging me" look.

Then, all of a sudden, she got this big grin on her face and said, "I've got it! Walmart! I saw you at Walmart yesterday!"

"No, I don't think so," I said, knowing I had not in fact been in Walmart any time in the recent past. The woman looked very perplexed.

"You don't work at Walmart?"

Umm....NO.

Now, I know that the economy is bad right now and people are trying to make ends meet any way that they can, but if times have gotten so tough that your ER nurses are moonlighting at Walmart, then we're all in a lot more trouble than I thought.

Conversely, if you think you're being triaged by someone with a skillset comparable to a Walmart employee, then that just might explain a lot of the problems in healthcare today.

The Lady and the Snake

It was a fairly typical evening in the ER, as much as that phrase can ever be used. Little did this nurse know the can of worms (::giggle::) which she would open simply by answering the phone.

"I have a snake inside of me. I can feel it moving around and biting me."

So of course the nurse who answered the phone (who wasn't me, thankfully!) asked, "Inside you, where?"

"Where babies come from."

The lady goes on about all of these snakes around her, and we basically figure this is either a crank call, or a certified wacko. So the nurse says you're welcome to come into the ER, but we really can't help you over the telephone. (Which is what we say to 98% of our phone calls anyway.)

We all had a good laugh over it.

About half an hour later...she showed up!

She wanted to know how were were going to lure the snake out of her. She suggested dangling a piece of chicken between her legs.

Then, when we told her that we would have to actually examine her, she refused to sign the treatment consent, started screaming that we had no idea what we were doing, and ran out of the ER.

We keep wondering if she will turn up again (somehow, they always do...) but so far, no Snake Lady.

It all started with a pair of handcuffs.

Some of the best stories do.

In this case, it was a middle-aged man who was brought in by the police. The officer told me that he was complaining of wrist pain caused by the handcuffs and had insisted on being brought to the ER. So, into triage we go.

Naturally, I started by asking the patient which wrist it was, and he told me it was the right one.

"Can you rate your pain on a scale of 0-10?"

"What? It doesn't hurt."

At this point, the officer interjected: "You told me your wrist hurt. You insisted on coming here. That's why you're here."

Patient: "It doesn't hurt. It's metal."

Me: "You mean you have pins in it?"

Patient: "No, my whole wrist. It's metal."

Oookay. By this point, I had figured out that the guy was absolutely filthy stinkin' drunk. But it gets better! Next I asked him about his medical history.

"I'm a mental health patient at the VA. I should be going there but he wants to take me to jail."

Ah. The pieces are starting to fall into place. He perseverated from there on the subject of being transfered to the VA to be seen for his mental health issues, which I flatly told him we were not going to do. He also denied any suicidal or homicidal ideation, so he didn't even fit the criteria for our emergency mental health evaluation; and aside from that, he was DRUNK, so no mental health counselor would speak to him in that condition anyway. Basically, he didn't want to go to jail. Tough luck, buddy. Not my call.

He also told me that he needed to self-catherize in order to urinate. Remember this point, because it will be important later.

AND he lied to me, in front of the officer, telling me that they wouldn't allow him to catherize himself. The officer called him on it right there: "That's not true. You cathed yourself at the station."

Then the officer made him apologize to me for lying, which I found amusing.

Anyway, I got him into a room and put him in for an x-ray of his wrist, which he kept insisting had been "bent" by the handcuffs. (He did actually have a metal plate in it, but there was absolutely nothing wrong with it.)

Throughout his entire visit, he kept insisting that he wanted a mental health evaluation, and I kept telling him it wasn't going to happen. You can't have a mental health evaluation when you're intoxicated. It just doesn't work.

So, the doc reviewed his x-ray and pronounced him fit for jail. I thought I was off the hook, but then she threw me a curve ball: "Oh, and he needs a catheter before he goes."

Damn it!

Well, you know what, buddy: you cath yourself all the time. There is absolutely no reason that I need to do this for you.

Patient: "But you're going to measure it, right?"

Me: "There's a bag in the kit with graduated markings. You can measure it yourself."

But Mr. VA Mental Patient had found something new to harp on that he thought would get him out of jail: "If I get more than 200cc in my bladder I become nephrotic!"

Um...you turn into a giant kidney?

I don't know what it means to "become nephrotic," and honestly, I don't really care. I gave him his catheter and directed him to the bathroom.

But this is almost to the best part of the story!

I went back to discharge him after he had cathed himself, and he was INSISTING that he had drained 900ml out of his bladder.

"I want that documented! They won't let me cath myself! I'm going to become nephrotic!"

There's that funny word again. I want to see you turn into a kidney. Really.

By this point, the officer and I were both done arguing with him. He had already assured me that the patient had not only cathed himself less than two hours ago at the police station, but that they had additional catheter supplies for him on hand. Neither one of us felt like continuing to point out to Mr. VA that he was lying.

Now: THIS is the best part of the story.

I went into the bathroom to clean up the catheter supplies. I found the drainage bag sitting in the sink. The patient had disconnected the catheter from it. Would you like to know why?

The patient had had to disconnect the catheter because HE HAD FILLED THE DRAINAGE BAG WITH TAP WATER.

I was done. I just burst out laughing. Have fun in jail, Mr. VA Mental Patient!

A girl and her mom walk into triage.

The girl was kicked in the shin while playing soccer at school.

...

Oh, sorry, were you looking for something more than that?

No bruising, no swelling, no deformity. The girl did not have a single mark on her. Not even the decency to walk with a limp.

I asked the mother what exactly she was looking for.

"I just want to make sure that she's okay."

Trust me: she's okay.