How to aggravate a triage nurse.

This week I spent 48 hours working in the ER, and because of a shortage of triage nurses over the weekend, spent half of those hours in triage.  This is just one job I do in role as ER nurse.  It isn't my favorite one, or my least favorite.  My least favorite, and one I rarely have to do because a) I am not very good at it and b) my boss has mercy on me and gives me other "leadership" stuff to do instead, is being charge nurse.   That crap will make you crazy.  I would rather be in triage, or doing chart reviews or building Meditech menus, or even working in Fast Track.  What I absolutely prefer to anything else is just patient care.  From hangnails to heart attacks, that is what I like to do best.  But I do spent a lot of time in triage.  It isn't so bad.  Sometimes it is funny.  A lot of times it is just mentally exhausting.

For those of you who don't know, the triage nurse is the one in the little room, or at the little desk in the ER who first sees you, takes your history, bandages the bleeding, gets your vital signs and so forth.    It usually takes about 5-10 minutes per patient.  Sounds like an easy job, huh? Not particularly hard or stressful or important.  No need to be polite, truthful or even reasonably civilized to this person.  He or she is just the person who checks you in.  But you might try being very dramatic or obnoxious to her, because that might get you to a room faster.

Right.  I can hear the laughter of ER nurses and medics everywhere.   For those of you who don't get it, let me explain.   The triage nurse is St Peter.  That's right, we are at the gate, and we decide who gets in.  Not the ER docs.  They are busy taking care of other people who have already been assigned a room and seen by a nurse. They have a patient to assess, three sets of lab to review, someone that needs stitching, a set of admit orders to write and two patients to be discharged. They don't care who gets in first because they are too busy to care and are happy to leave those decisions up to the triage nurse. The charge nurse doesn't decide either.  She only has a certain amount of rooms, nurses, techs and docs to share among 4 times that many patients and she is trying to monitor all  87 of these people to make sure they have the care they need. Patients get good medical care, doctors get tests results on time, nurses get to go pee every 4-6 hours. She has to answer about seven gazillion questions a day.  She is happy to let the triage nurse  decide who needs care the soonest.  Your family doctor who "sent you here" or called ahead most definitely does not get to decide. For one thing, he only sent you here because he didn't have the time, inclination or resources to deal with you today and wanted you to go away.  Not because he really thought you had an emergency.  Even if he did call ahead, which he probably didn't, he has no ability to judge the level of insanity currently going on in the ER and your appropriate place in it.  That is what the triage nurse does.

Last but certainly not least, neither you, your mom who is an RN in a foot clinic, or your brother-in-law who is a medic, gets to decide.  You may be in pain, feel like crap, be scared to death and think you are dying.  I get that, don't doubt it.  But you don't actually know how sick you are (or aren't), much less know about the other 12 people waiting.  So you don't get to decide.  The triage nurse decides.  That is her job.  She is very well trained for it.  She has years of nursing experience and judgement and education and the guidelines of the department and if needed, the second opinion of her coworkers.  She can do 75% of a head-to-toe primary assessment just watching you walk in the door, sit down and state your name and date of birth.  Her powers are limited.  Even if you are pretty sick or in a lot of pain, she cannot get you into an already-full ER immediately when 5 other just-as-sick people are ahead of you.  Because of her nursing ethics and conscience, she will not put you in a less-critical category than appropriate just because you are obnoxious.  But this is the person who decides into what category you fall. This is the person who might bump you up in line if you are really sick or miserable.  Think about that before you insult, try to intimidate, or aggravate her.

Please don't get the impression that every patient that comes into triage is being rude or melodramatic.  In fact, about 90% are reasonably pleasant people.  Some of them are delightful.  A lot of them are funny.  They may be scared, sick, upset, mad, wet or muddy, bloody, ignorant of all things medical or a medical person themselves, hysterical, stoic, or terrified. But most people do the best they can to behave decently and reasonably even in trying circumstances.  It's that ten percent that can make triage a more frustrating, aggravating, infuriating job.

Even in a world of 100% sane, sensible people, triage would be a trying job.  It takes some mental effort to sort an infinite variety of illnesses/injuries into 5 simple categories. There is always something you might miss, which can be worrisome.  Rooms, nurses and docs are limited.  People who are sick, scared and miserable do sometimes have to wait a long time.  We, the ER staff, do not like that much better than the patients and families.  We feel bad for the ones who are truly sick or hurt.  We are anxious that something might go wrong(er) while they wait.  On very busy days you need to thing about reevaluating people after a couple of hours.  We are constantly bombarded by requests for food, water, blankets, buckets, ice packs and a place to lie down. (Which, once and for all, we do not have.  You left your couch at home to come here.  Our places to lie down are our exam rooms and they are full.  Requests to management for couches and/or stretchers in the lobby have been categorically and eye-rollingly denied. If you walked across the lobby to ask for a pillow you are not too sick to sit up.) People we encounter are often excited, upset, scared and generally freaked out.    We understand, but it can be hard on the nerves.  Our goal and our job is to keep everyone safe. We would like to keep them all happy and pain-free, but it isn't possible.   We are doing the best we can.  So be nice.  

The triage nurse needs to know what happened.  She needs to know when.  She needs to know your history.  She needs the patient to answer the questions as much as possible.  Yes, even when they are three, or ninety, demented or half-conscious.  It is part of the assessment. It is also rude to your 87-year-old grandma to answer for her just because she is slow. Hush!  Every vital sign we do and every question we ask has a purpose.  It takes five minutes.  Calm down and help us get it done.  If you are not the patient but need to feel as if you are having an influence on the situation, are just an asshat, or want some attention, be aware that every attempt to "rush" the triage nurse will only make things take longer.  Be aware that, as a patient or visitor,  you cannot insult the triage nurse because he/she doesn't give a tinker's damn about your opinion.  Know that the average triage nurse is about as easy to intimidate as a bull elephant, and if you do manage to make her consider you a threat, it may result in your having a conversation with our security staff, being expelled from the department, or being arrested.  Realize that a triage nurse has a bullshit meter like no one else on earth.  If you are lying or faking, we know it.  We probably won't call you on it, but we will word our assessment so that the other nurses and the doctors will understand that you are full of crap. If you just want to irritate the triage nurse, here are some ways to do it.

Burst into the triage room, ignoring the patient already in the chair,  and demand immediate attention for the cut on your finger.  Look insulted when the triage nurse asks you to have a seat and wait your turn.  Say indignantly and loudly that you are bleeding to death.  Wave the unbandaged finger around so you will drip blood in the floor.  This will demonstrate the rudeness of that nurse who is ignoring you in favor of the kid with the broken arm who was there first. 

Demand a stretcher to get a patient out of a car, in spite of the fact that they walked from their house TO the car.  Become indignant when the nurse brings a wheelchair instead.  Insist that the patient cannot stand or walk even while he is getting out of the car and into the wheelchair with minimal assistance.

Walk from the parking lot into the ER lobby, past a row of wheelchairs and collapse in front of the triage door, stating you can't walk.  Alternately, you can cling to the triage door and gasp that you have to sit down, instead of just sitting in the empty chair eighteen inches away, to which I am pointing.

Tell the triage nurse that you should be next because the other people waiting "don't look as sick as I am".  This makes you look like the selfish jerk you are.

Be as disgusting as possible. Cough in the nurse's face.  Poke your sores with a finger. Wipe your nose with the back of your hand.  Act completely astounded if she asks you to cover your mouth or disinfect your hands.  Spread as many germs as you can manage in your short visit to triage.

Tell the triage nurse that you (or the patient with you) is having a heart attack, a ruptured appendix, a massive stroke.  You don't know what they are having.  And if you really thought it was a heart attack, why didn't you call an ambulance?

Repeatedly walk into triage while the nurse is with another patient to ask for kleenex, a phone, ice, blankets and a place to lie down.  Behave as if that patient doesn't exist, much less deserve a nurse's undivided attention.  Do not say excuse me,  or thank you. Ever.

Argue with the patient. Or, if you are the patient, argue with the people with you.  Don't worry about what the triage nurse is trying to do or the three people waiting behind you.  We all have time for you to air your dirty laundry in public.  It's classy.

Deliberately slump out of the chair or wheelchair while stating you are going to pass out.  Yell at anyone who tries to get you to sit up or to support you.  Yell and curse at the triage nurse when she uses ammonia to revive you.   Flail your arms around and give her a good cussing.  Then slump back over.  Yeah, that seemed realistic.

Keep your head down and mumble at the nurse because you are too sick to answer.  Again, yell and curse when the nurse keeps repeating the questions.  Even better if you jump out of the chair and stomp out the door.  You were just too sick too cooperate with that nurse.  Glad you feel better now.

Never, ever attempt to control your children.  If they are the patient, allow them to wander around the room while the triage nurse is trying to assess them.  Ignore her repeated requests to "bring him over here please" or "hold him in your lap".  If they resist, allow them to flail and scream and kick the nurse without any restraint or reprimand.  This is acceptable behavior for a four-year-old.

If your kids are not patients, allow them to run in and out of triage while grandma is being assessed.  They shouldn't have to wait five minutes for sodas and coloring pages.  Let them grab any piece of equipment they want to examine with their dirty hands.  It's fine if they want to wander around into dual triage or the EKG area with other patients.

Tell the triage nurse that you have not given your child Tylenol or their prescription medicine or made them wear their splint or have their dressing changed because "he didn't want to".  A five-year-old's wishes are more important than his healthcare, and you as the parent are not responsible for making him do things for his own good.  The triage nurse will consider this a reasonable excuse for letting your child get a lot sicker.

If you seem frightened, the triage nurse may try to reassure you  that you (or your child) do not have life-threatening illness.  Be insulted by this and act as if she is trying to refuse to take care of you,  instead of having some compassion for your fears.  The fact that she said "we will take care of you" or "that will need some stitches"  was just a ruse to make you think that you would actually get appropriate care.

Be very annoyed when the nurse asks you what meds you take or what surgeries you have had.  This is not important, and she is just trying to be difficult.   She should not expect you to know the answer to these questions.  Maybe if you are rude enough, she will stop asking stupid questions.  

Sit or stand calmly in the waiting room until it is your turn for triage.  Then begin yelling, cursing, sobbing , gagging or flailing around like an octopus.  The more you can sob or yell while being assessed the better. This makes her believe you are sicker, because she is stupid, has no actual knowledge base to make an informed decision, and has never seen anyone as dramatic as you.  Be sure to call the nurse a stupid bitch when she attempts to apply a splint or bandage.  She meant for it to hurt.

Basically, just be as rude, dramatic, loud and disruptive as possible.  You are sick, that is an excuse for any obnoxious behavior.  No one is expected to be reasonable when they are sick.  The other people in the lobby are just stupid for waiting their turn and following instructions.  The ER staff aren't actually people trying to do their jobs.  They are just there to thwart you. Please make their job harder.

Never, ever, answer a simple question with a direct answer.  For instance, if the nurse asks if you have had surgery before, answer by saying that you have had several broken bones and an MRI of your back and the doctor thought you would need surgery but you went to the chiropractor instead.

If the nurse asks you what meds you are taking, do not tell her their names, give her a list, or let her see the med bottles.  Tell her you take a little blue pill for water and two round white ones for sugar.  Or better yet  "my wife keeps up with all that".

Conversations should go like this:

Nurse:  When did the pain start?
Patient:  I've been sick at my stomach every since three weeks ago. I went to see Dr Doolittle and he put me on some medicine but it didn't help
Nurse:  Okay.. but when did it start hurting?
Patient:  Well, after that I started throwing up and that made it hurt.
Nurse:  So that was what day?
Patient: Two days after I saw the doctor.
Nurse:  Right. But I don't know when you saw him. How many days has it been hurting?
Patient:  Well, okay, three or four days?

Nurse:  Are you dizzy?
Patient: I've had a headache for a few days.
Nurse: Uh huh.  But are you dizzy?
Patient: I've got a headache I tell you!
Nurse:  I know, sir.  Are you also dizzy?
Patient:  I keep having weird tingling in my hands.
Nurse: When did that start?
Patient:  When the headache started.
Nurse: Which was when?
Patient: Oh.... last week some time
Nurse: And are you dizzy as well?  
Patient: I just feel tired all the time
Nurse: So you've had fatigue.  Okay.  But I really need to know if you have been dizzy or lightheaded at all?
Patient: No! Why do you keep asking me that?

This kind of question-and-answer session will ensure that the nurse spends a lot of time with you. But if you are in a hurry, it might be better to just give simple, direct answers to the questions.

Honestly, it is in your own best interest to cooperate with the triage nurse.  It will ensure that she gets the correct impression of your condition.  It will help your visit go faster. It will help prevent your getting the wrong medicines. It will also help prevent the triage nurse banging her head on the wall in a combination of exasperation, amusement and mental fatigue.  You don't want that. Because if the triage nurse goes bonkers and runs screaming out the door, that means some nurse in the back will have to divvy up her patients among her already overloaded coworkers and come be the triage nurse instead.  That means there are less nurses taking care of patients, which means slower turnover times. Which ultimately means YOU have to wait in the lobby longer.

If you want to make a triage nurse's day, it is easy.  Be as calm and reasonable as you can under the circumstance.  If we see you are making an effort, it will make us try harder for you.  Answer the questions as best you can, without evasion or embellishment. Listen to our instructions. They are for your benefit.  Let us help you by reassuring you, telling you what may happen, and providing ice, bandages and throw-up buckets.  We wouldn't be there if there wasn't some tiny remnant of our abused psyche that actually still wanted to help people.

Other weird religions

Why does no one seem to care that Mitt Romney is Mormon?  I have been asking myself that question for months, thinking that some wild-eyed fundamentalist Christian or some sarcastic atheist somewhere would surely bring it up.  But that hasn't happened, and it puzzles me.

I would be ecstatic to think that the majority of Americans have suddenly grown up and realized that a political figure does not have to share your religious values to be a good leader.  But that is moonshine and madness, we all know it.  The majority of Americans view any religion that varies two degrees from their own with extreme suspicion, frequent disdain, and all too often hostility.  We will skip for the moment the ridiculousness of that attitude, considering the "love and brotherhood" message of most religions in the whole dang world......  But I digress.

Here's the thing.... my personal beliefs aside, I have to say that ANY religion, viewed objectively, is just goofy.  If you just start reading the "what we believe" section of any religious group's website or handbook,  some of that stuff is just going to sound weird.   Yeah, even my own Sunday-school class made me occasionally think "say WHAT?" as a child.   You learn to take it on faith, because, hey. That's what makes it FAITH and not, you know.... science.  So I have no personal objections to Mormonism other than the ones I would have to any patriarchal, oppressive religious sect.

I have a strong personal belief in God, and almost none in organized religion.  Which is why, as a rule, I couldn't give a fig newton what religious background a person has, preferring to measure them by their own character and behaviors.  Unfortunately that is not, as I mentioned above, the view of most Americans. Witness, if you will, the uproar when a non-Protestant white boy was elected president in the sixties.   Then there is that whole piece of ridiculousness about our current president having ties to Islam.  Apparently any religion that varies from Christian Protestant is a big hairy deal.  Until it just isn't.  We got right over Kennedy being Catholic, and the uproar about Obama being a "secret Muslim" seems to have mercifully faded as well.  But at least during an election season, there was a small but vocal and somewhat vicious segment of the population that made a big noise about having a president with a different brand of religion.  So why is Romney getting a pass?

Folks, Mormonism is NOT mainstream middle-class Christianity.  It differs from regular old Bible Belt  Sunday School teaching as a pineapple differs from a watermelon.  Far more so than Catholicism from Protestant religions.  Equally as unlike as Christianity and Islam.  Yeah, I know, that is going to get a lot of panties in little wads.  But they are both Abrahamic religions, along with Judaism.   Despite the fact that followers of these three religions frequently declare themselves anathema to each other aside, they are fruits from the same family tree.  Dysfunctional siblings, if you will.  We can consider Mormonism a genetically drifted son of Protestant Christianity, and therefore a troublesome nephew to the other two.  But there are many more differences in cosmology between the three big guys and Mormonism, than there are between any two of them.  

Let me say again, I have no personal objection to it, but why is it NOT an issue for those who would normally be wild-eyed and bushy-tailed about it? Is it because it is considered an alternate form of Christianity?  Maybe, tho Catholicism didn't get a free pass.  Maybe it is because the people who would ordinarily make a big fat hairy deal out of it would rather have a rich white Republican in office with an admitted allegiance to an unusual religion, than a black Democrat with loose ties to another one.  Yeah, that IS ugly, isn't it?

I hope I'm wrong.  But the next time these same froth-brained tribal monkeys start screaming about some candidate's religious views being incompatible with the values of our country,  well, I guess we will know the truth, won't we?  Because if Mormonism is acceptable, there is no reason to object to any brand of Christianity, Islam, Judaism or even Scientology in a political candidate.  In other words, oh ye of so very much vociferous and vocal faith .... if you are going to let this go by without a squeak then you should shut the hell up for ever.  Because now we know.