Lost Art

So one interesting aspect of my job is that I can operate in any number of the areas of the emergency room; most EDs are set up so that different types of patients go to different physical areas of the department. For instance, there is fast track, which is like urgent care. On the days of being fast track nurse, I am kind of a pill-and-education giver, often dealing with minor complaints that seem very major to the patient. This means that their ire is often focused on me, the bearer of bad news (nope, nothing’s really wrong, you can go, nope, no extensive narcotics needed). Some days I enjoy this–patient education can be really fun, and I am sufficiently armored against the abuse by a deep and profound ability not to take it personally. Because it is rarely about me, and people’s lives are difficult in ways I can’t always understand in our brief encounters.

The next possibility is the exam hallway, which is where the majority of patients end up. These patients need some working up, but are not in imminent danger. Unless other areas of the department are full, in which case I could have very sick patients. When this occurs, it sucks. Depending on which half of the exam hallway I’m responsible for, and how many psych patients need the “quiet rooms,” I can have up to 6 patients. This is too many, generally, for totally effective nursing. That said, the exam hallway is both horrifying and fun, depending on how up for the challenge I am that day. Also it depends greatly on how many and which techs are working. Also it depends on the docs–are they the quick ones or the extensive worker uppers? Anyway, exams is a crapshoot. Sometimes literally. Code Brown.

The third possibility is the critical zone, where the sickest patients go. Some days it’s three people who are all touch and go, and sometimes it’s just steady, ill-but-stable people. Occasionally a gunshot wound or code (note to self: it is not wishing harm on the world, exactly, to be looking forward to trying out one’s new trauma shears that were an excellent find in one’s Christmas stocking). Crit zones are fun, in the emergency medicine sense, sometimes.

The final possibility (all right, there are a few others, like float and CCA and ST but those are all just variations of exam hallway, kind of) is triage. Triage is what happens when the patient first arrives in the hospital–they speak to a nurse who assesses (quickly) if they are urgently ill or not. This requires fairly strong critical thinking, to ask the right questions without wasting time. On a day when there are 30 people in the lobby, one does not want to waste time. Because one’s time will inevitably be interrupted by patients asking how much longer they must wait. In a polite, non-demanding manner, always. <——-Inaccurate

A while ago I noted that some nurses’ triage notes were hilarious, and chose to embrace the art. Before I was put out in triage (it requires a certain amount of experience) I expressed myself through the notes part of patient charting. It engaged my creative side; I could write things like “Patient disenchanted with plan of care, expresses fury at ‘being treated like shit in this fucking hospital.’ Support provided.” It is important to document patient’s responses to things. I choose to do this with flair, a bit of joy in what sometimes can be a dark, draining place. Every now and then someone catches these notes, and it seems to perk them up as well.

In triage, however, the note is everything–Why is the patient here? How do they look? Does what they are saying match with how they are acting? Why is their complaint of concern (past history makes a headache totally nothing in one person, totally emergent in another)? It is my mission to make these notes sing.

For instance (and these are modified a bit to remove identifiers):

(After main complaint of patient): Patient waxing nostalgic at times about previous life path. Is easily redirected.

Patient smashed first finger (describe describe blah blah). Soldiered on in spite of pain to complete shift. Patient moving finger freely in triage, able to grasp and use phone. No swelling or deformity noted.

Patient unable to obtain psych meds due to complex scenario involving case manager, vengeful girlfriend, and rent money.

Patient reports “just feeling terrible”; irate at possibility of having to wait for room. In NAD (No Apparent Distress) in triage; ambulates well from chair to triage booth to vending machine to bathroom to triage booth to other triage booth.

Pt groaning loudly in lobby due to pain in foot. Pt unable to remove bulky outerwear jacket for vital signs due to foot pain. Support and encouragement provided.

 

Overall I feel that as long as I am triaging accurately, respectfully, and well, there is no reason that the notes should not contain some essence of the situation at hand. Painting a picture, is what I’m aiming for here. In a place where dark, desperate, sad, lonely, and just….humanity regularly assert themselves as common features of the landscape, a little levity now and then balances things, for just a moment.