6.13.2007

Blaming the 911 dispatcher

Wow. I can't believe they are blaming the 911 dispatchers for not sending an ambulance to the ER waiting room. Should they have? And taken her where?

I'm having trouble blaming them. Afterall, EMS is already stretched thin in the hood...therefore we need to allow the dispatchers to use discretion. And sending a rig to an ER waiting room...kinda doesn't sound like a great use of limited resources. Things are always more clear when we look thru retrospectoscopes, and this is no exception. Why should be blame the 911 dispatchers for not mounting the appropriate response when the triage nurse (who is trained to identify emergencies) and the King police officers were right there with her, and seemingly unimpressed....in a hospital ER!! Maybe they (the boyfriend) should have moved Ms. Edith Isabel Rodriguez out of the ER, to the McDonald's parking lot across the street...then called 911. At least she would have been brought to the back for an MD evaluation.

There are lots of things wrong with our healthcare system. But blaming individuals solves nothing. Maybe it appeases the public, but in reality, it is a very temporary solution at best. They can replace the triage nurse...fire the CEO...and reprimand 911 dispatchers, but this will result in 2 things:

1) a new policy will be written stating that "everyone with abdominal pain should be triaged at top priority."

2) 911 dispatchers will send rigs out to every nut who calls and requests one.

The repercussions of this include
1) a teenager with 'menstrual cramps' will go back, while a 3 year old seizing child will have to wait. Afterall, taking "all abdominal pains right back" comes at a price. Patients don't bring beds, nurses, or doctors with them. And in the ER, with limited resources....triaging based on chief complaint vs illness severity is not a good idea.
2) If things were bad in the hood *before* with EMS response times....imagine the outrage when there are no firefighter/paramedics to respond to a crash on the 105 freeway, and rich people die as a result.

What happened to Ms. Rodriguez is outrageous - and (thankfully) I wasn't there!! I'd be plenty pissed if she were my family member. And I'm not defending the triage nurse (because she was partially at fault), nor the hospital (because it has been completely reactionary and wholly concerned about maintaining "Black" leadership, just for the sake of Black, at the expense of patient care); therefore, I do believe they should shut the hospital down. But, for the media to turn the public focus on the 911 dispatcher (who was perhaps a bit rude, did nothing wrong), seems...off base.

The types of issues being uncovered at King are issues in every major metropolitan hospital in our country. We should focus on solutions...

...and firing a nurse, a CEO, and a 911 dispatcher isn't a solution.

6.07.2007

"They don't care about us..."

"They don't care about us...the paramedics take 20 minutes to get here, and they're just up the street...if this were 'Rich City America', they'd have been here by now..."


Anyone who works, lives, or otherwise visits the hood, has probably heard this before. Perhaps even experienced it. I've seen people get shot, 911 called...and, after 20 minutes bystanders/friends/whomever decide to just load the victim up into someone's truck and drive them to the nearest ER (nevermind it's not a trauma center...and bringing a trauma patient to a non-trauma ED is probably worse than just letting them sit on the street corner waiting...). This is the way my own father died, actually. So, I do know.
***

My sister was at In-N-Out one day. And a lady fell down seizing in the parking lot. Bystanders, including my sister, decided to 'help out'. She called me from her cell. "Sister, there's this lady here, I think she's having a seizure because she not responsive and she's shaking...what should we do?"

My first question is "Do you know her?"

Sister: "no."

So (I think to myself), let me make sure I'm understanding the situation correctly: some random lady 'fell out' in the hood somewhere...and you're calling *me* for medical advice?

My advice..."call 911."

Sister: "We called them 15 minutes ago...and no sign of help. Typical. If we lived in 'Rich City America' they'd be here by now. Why do they take so long on this side of the city?
***

I'll tell you why. Over there, people tend to...(how can I say this tactfully?)...be less concerned about others. They're about "getting rich, or die tryin." Nevermind what this does to the community. And 'the community' doesn't hold it's own accountable...(but that's a rant for another day).

Anyway...let me tell you what was (hypothetically) happening during that same timeframe, while my sister waited for an ambulance, with a random lady in the parking lot...

The players:
There's a guy named Bob, who frequents the ER at the Kingdom. He comes up with various complaints depending on the day. He lives in the ER waiting room, all of his 'stuff' is there. His basket, his bags, his trash. He'll sleep on the floor, in the corner at night. But in the day, security makes him leave 'unless he wants to see the doctor.' Well, if it's cold, or raining...or if he's just hungry, he'll make up a chief complaint...so he can 'wait and see the doctor.' The wait times at King are typically 12-14 hours...so he's good all day. But, at some point, he does get back to see us. And after running thousands of dollars worth of unnecessary tests (at your expense), he is discharged back to the street.

He goes outside...it's still cold...he turns around and checks in again. "I need to see the doctor."

After this happens a few times...he is not allowed to come back in (and, yes, he just might die of something totally random and unrelated, of course it'll make news...and everyone will think that the triage nurses are heartless..."how could this 'poor guy' not be allowed into the ER to see a doctor" and so forth and so on...). So, he goes to Burger King across the street, and calls 911. They dispatch a full response...and homeless dude is brought back to our ED. But...there are no ED gurneys. So the paramedics have to sit...and wait. 'Ambulance crews have waited for as long as 5 1/2 hours to transfer patients to the care of emergency-room staff.'

Then there's the very young mother and her 6 month old son. She calls 911 from her project across the street because she (and I quote) "doesn't want to wait" in the waiting room. The firefighter/paramedic brings the patient straight back, "This is a healthy 6 month old boy who, according to mom, hasn't slept in 4 hours" they report.

I look down on the gurney. In the infant carrier is a healthy looking *sleeping* baby (with 2 large fake diamond stud earrings, and a gold chain around his neck that reads "Lil'bit"). I look at the firefighter, he shrugs and says "baby has been sleeping the entire time." I then look at this mother, confused. She says "I just wanted to get him checked out." I cringe, and try to silence the little voice in my mind that is chanting "PLEASE. CHOKE. HER."

So...I send her, and her baby, out to the waiting room. Just because you come in by EMS, doesn't mean you're the sickest person waiting. Also, why keep this paramedic crew tied up for a healthy baby? She's upset..."I didn't call 911 to wait. This isn't fair, I hate this hospital..."

She storms out of the ER, pissed because she couldn't just...have things her way (I'm sure she filed a complaint with admin that will result in a 'conference', and 4 hours of "sensitivity training"). She left the ER, and got into her baby daddy's car...the car that followed the paramedics to the hospital from across the street.

Then, there's the pissed off wife, who calls 911 everytime her husband gets drunk...so she doesn't have to deal with him. "but he passed out." Yeah...that's what drunks do. How else would they ever stop drinking?

Then there's the family who dumps 'Mama' in the ER everytime they all want to go out and see a movie. "I think her sugar is acting up again" they say as they push her wheelchair thru the back door, and promptly disappear.

Then there's the drunk that the cops keep bringing in.
"Why can't you guys just take him to jail?"
They say, "Because he might have something else wrong with him."
I say, that's the price you pay when you get drunk in public, and piss on someone elses front porch. You go to jail with a the potential of having "something else" wrong with you that no one figures out until you sober up.

Or the felon who cries "chestpain" when he gets caught robbing a liquor store. Apparently they can't just take people to jail...taxpayers have to provide a full physical examination in the ED...and we have to sign a form as doctors saying "it's okay to book this patient." As if, in 1-2 hours we can determine if this guy is indeed "okay." As if, a 'normal' person would be allowed a 12 hour ER stay, food and a show, at someone else's expense...if they did something that required them to be "booked." I guess we should all learn that making up a "medical illness" may be worthwhile if we face the prospect of serving jail time (just ask Ms. Paris Hilton).

All ER docs are sure to have examples of blatant abuse of emergency services that society pays so dearly for.

Because of this very inappropriate use of the ED (some understandable, most not), we have no beds...no nursing...no resources to deal with emergencies. Paramedics have no place to drop off sick patients, so they sit at King for hours. Then, when the local EMS team is at 'the young mothers' place, cuz 'she doesn't want to wait,' ....a person with a *real* emergency has no EMS nearby available to respond.

Understand, that the little firehouse on the corner...depending on the area of the city...has no firefighters in it. They are at King, or in the adjacent city 'helping' those communities with their EMS needs. Afterall, we (the dispatcher, the medics) can't just tell people "no, you don't need a paramedic, we're not going to transfer you to the hospital". So, EMS brings us all this bullshit. Bullshit, that shouldn't have passed 'GO.' Bullshit that clogs our system. Bullshit that prevents us from identifying and treating true emergencies. We, as a society, do not hold people accountable (in any way) for calling EMS, for inappropriate use of social services. If there were some consequences...perhaps the right/privilege (however you see it) to utilize the ER...maybe things would be a bit better.
***

Getting back to the In-N-Out in on the 'wrong side of town'. 911 was called. The closest firehouse was empty as described. The next closest team is on the freeway, on it's way to the nearest open ER (transporting homeless dude)...which is 15 miles away. The next closest firehouse is...in the next city. It takes 30 minutes for them to reach the seizing woman. Where there is a high incidence of inappropriate use of resources...the ERs are more likely to be at capacity.... and, in turn there are no available resources for the average (good) citizen (or non-citizen). And it seems as if.....*they* don't care about folks unless they live in 'Rich City America'.

But, wait time to paramedic arrival is only the outcome of a complicated problem that disproportionally affects cities (or parts of the city) where there's a higher percentage of poverty.

6.02.2007

The Rules

The Rules**

If it requires the ambulance team and entire truck of firefighters to transport you and safely place you on a hospital stretcher, it is time to go on a diet.

When you present to the triage nurse, do not tell him/her that your doctor called ahead. If you survey our waiting area, probably 50% of the people waiting said the same thing and the other 50% use the ER as their regular doctor.

Never start out by saying, "I was searching the Internet.....

"When asked how much you weigh, please do not give the deer in the headlights look, and tell us you really don't know. It's a simple question, simple answer.

Just because you have a phone and know how to call 911, we are not impressed by your arrival on an ambulance stretcher. You had better be sick. If you came escorted via EMS for multiple complaints that started more than one week ago and your entire family followed the ambulance to the hospital, you will be labeled a pussy and treated like one. Enjoy the waiting area with your family.

One complaint/ailment per visit, please.

Just because you came in on an ambulance, doesn't mean you're going home on one. You better start making arrangements, now. I am not driving you home, or figuring out how to get you home. Cab vouchers are not an option.

If you have one of these four, go to your own doctor in the morning: a migraine, the flu, a stomach virus, or a stuffy nose.

Do not ask us how long it will be. We don't know. I don't know what is coming through my door 30 seconds from now and so I sure as hell don't know when you're getting a room. We have priorities. We understand that you have been waiting for two hours in the waiting room. If you don't want to wait, make an appointment with a doctor. The little old lady that just walked in looking OK to you is probably having a massive heart attack. That is why she goes first.

If your mother is a patient and we ask her a question, let her answer it.

If your child has a fever, you had damn well better give it Tylenol before coming in. DO NOT let the fever remain high just so I will believe the child has a fever. Do you want your child to have a seizure? Do you?

If you are well enough to complain about the wait, you are well enough to go home.

Do not utter the words "It is in my chart." I don't have your chart, and I don't have the time to call and get it. Just tell me.

We know how many times you've been to an ER. We can usually tell if you are faking it during the first 5 seconds of talking to you. Do not lie to us. If you lie about one thing, we will assume you are lying about everything. You don't want that.

If you have diabetes and do not control it, you are committing slow suicide.

If you are a female between 16 and 42 and your last period was between 28-35 days ago, and you are here for abdominal pain and vaginal bleeding, guess what? You got your period. Again.

Do not bring your entire posse with you. One person at the bedside is all you need. It is really difficult to get around seven people in the event that you are really sick.

Every time I ask you a question, I learn more about what is wrong with you. I don't care if I asked you what day it is four different times. Each time I ask, it is for a reason. Just answer the questions, regardless whether you have answered them before.

If you want something, be nice. I will go out of my way to piss off rude people.

Our definition of sick is not your definition of sick. If a member of the ER staff says that someone is sick, it means that they are in the process of DYING. They have had a massive stroke, are bleeding out, having a heart attack, or shot. We don't consider a kidney stone sick. Painful, yes. Sick, no.

At any given time, one nurse has four patients. One doctor has up to 15. There is a law (similar to Murphy's) in the ER. If you have four patients: one of them will be sick (see above for definition); one of them will be whining constantly; one of them will be homeless; and one of them will a delightful patient. Don't be the whiner. Please.

If you see someone pushing a big cart down the hall at full speed and you hear bells going off, do not ask for a cup of coffee. Someone is dying, you inconsiderate asshole.

In the ER, bells don't ring for nothing. Sit down, shut up, and let us work. If you can bitch about the blood pressure cuff being too tight, or the IV hurting, you are not in that much pain.

Physicians and nurses are not waiters. We are not customer service representatives. This is not McDonalds, and you very well may NOT have it your way. Our job is to save your life, or at least make you feel better. If you want a pillow, two blankets and the lights dimmed, go to the Ramada.

If you have any sort of stomach pain and you ask for something to eat, you are not sick.

Do not talk shit about the other members of staff I work with. The doctor that you hate? I work with him every day, and I know that he knows what he is doing. I trust him a lot more that I trust you. I am not here to be your friend, and neither is he. I will tell him what you said, and we will laugh about it. If you want a buddy, go somewhere else.

If you are homeless, don't ask for a bus token or cab voucher to get home. It just confuses the staff.

Please don't tell us how to do our job. Do we go to your place of business and tell you how to do your job?

Please don't bring in a show and tell. If you have to fish it out of the toilet, it's really not necessary to bring it in. We will take your word. If you did fish something out of the toilet, you may not use my pen.



**from another blog


6.01.2007

Coming to America

"I paid $1000 to come to America, hoping to get some medication to cure my illness"

The County hospitals notoriously have a number of patients who, for one reason or another, sneak into the country for medical care. Sometimes it's to give birth to an "American" baby. Other times it's because they have a weird disease and the resources of their home country won't allow for definitive treatments. But at the kingdom it's usually chronic diseases, that are hard to treat in Mexico...especially if you have no money.

The other day there was this girl, 19 years-old, who presented to the ED with a note from her PMD in Mexico:

"Patient with multi-drug resistant TB; medications taken to date are not effective. We have nothing more to offer. Go to America to a County hospital for further treatment."

In triage she's sitting among everyone for...30 minutes or so before her vitals are taken. Then, per protocol, she is taken thru the registration process. She changes her name a few times before settling on 'Maricella.'

After her vital signs reveal she's hypotensive and tachycardic (low BP and high heartrate), she is 'expedited.' At King, this means she gets the 'next bed'...which may be in 5 minutes, or it may be in 3 hours. In the meantime, she's hanging out with everyone in the waiting room.

Finally, she comes to the back. Because of her note, she is placed in 1 of 2 isolation rooms. This is when I meet her.

I peak thru the window on the door and see a very thin, wasted, silhouette, sitting on the edge of the bed with her hands clasped on her lap. She has on a mask, despite the fact that she's in isolation. And the monitor overhead is indicating that she's quite ill. I see her, talk with her...
...she is *really* 17 years old. Other family members in Mexico had already died of this TB, and she was dying as well. Her doctor in Mexico told her that her only chance to live was to sneak across the border and seek help in America. She passed San Diego since her perception of SD is that of hostility towards Mexicans. She saved $1000 over 9 months, begged, borrowed, and prostituted in Tijuana. Then, she met someone, who knew someone, who had a truck. She paid the driver the $1000 for a trip to just past the border. From there she hitchhiked. At the time of her ED presentation, she had traveled, non-stop, for 3 days. She was tired. She was very sick. But, she was very hopeful!!

My intern examines her, we order appropriate studies, initiate treatment, and subsequently consult medicine/ICU.

They see her, admit her to ICU, but...there are no isolation, ICU beds. So this girl sits in the ED isolation room for (count them) 6 shifts. That's 3 days!!

During this time, she decompensates. She becomes increasingly lethargic, tachycardic, hypotensive, is on pressors, and 4 TB meds. Eventually, we have to intubate her.

Herein lies the dilemma: The isolation room isn't a critical care area. There isn't enough room in this tiny closet of a space for a ventilator, crash cart, monitors, and her bed. Additionally, it's difficult for a nurse to tend to her since she's behind a closed door with only a tiny window.

So, we are told to move her to our critical area (by the "suits" who sit behind big desks, and have no understanding of the workings of the ER; those mighty people who never see a patient face to face, and are not risking their own well being by 'just moving her to the critical area'). The critical area is an open space separated by curtains. This area is where the febrile seizure kids go. This is the area where babies are born (if they didn't make it to L&D). This is an area where all the air is shared, with no isolation capability.

So we fight. We throw a tantrum. We refuse to move her.

"but she will die in there"

But she'll take us all with her...and our families...and our friends...if she contaminates the entire ER. Can you imagine coming into the ED with an arm laceration...and leave with multi-drug resistant TB?

This was a recurring theme at the Kingdom. Inadequate number of isolation rooms, and lack of critical care isolation space. We wrote letters, called hospital chiefs/CEOs, etc. We even threatened to call the press...(I think someone may *have* called the press...and eventually lots of 'someones' called the press)...

...eventually she did die...but not in the ED. After 5 days, she was finally moved to the ICU (after the other critical isolation patient in the ICU finally died).

Given Maricella's circumstances, most of us would have done something similar to what she did. It's not appropriate to punish individuals for systemic failure.

However...
...it is concerning that in an era post 9-11, our government has decided to not deal with the issue of 'safe' immigration.
...it's concerning that in an era post 9-11, and the threat of SARS, bird flu, etc., that in a major, busy hospital ED, in a major metropolis, we cannot isolate 1 patient!!

The real threat to national security...