Techno Auld Lang Syne

Nurse K likely* has some exciting stuff coming up in 2009 not related to this blog. I probably will tell you nothing about any of it. Happy New Years everyone and thanks for humoring me yet another year. Hope your 2009 will be as great as mine likely* will be.

* It's me, I don't want to be too optimistic, but I'm pretty damn sure.

Recession-unfriendly union rule

In any hospital in America, you'll find tons of nursing students working in ancillary-type positions: Aides/CNAs, EMTs in the ER, and secretaries mainly. It's helpful to be in the "milieu" of a hospital, to say the least. Most of these were easily hired into an open nursing position in the hospital upon graduation.

The aides in my hospital are all in a union. Many of them, especially in the emergency department, are in nursing school. In previous years, there wasn't a big union/nursing student conflict because most nursing students had jobs lined up upon graduation. My job was secured in February, and I didn't even graduate until the end of June! It wasn't a big deal that you hadn't passed your NCLEX yet because you could work as a "graduate nurse (GN)" and train on your floor at the same time while studying for boards for a couple months or so. You just had to have another nurse co-sign your assessments and meds which isn't a big deal because you were with a preceptor for your first 12 weeks anyway.

HOWEVER

Our aides have been hit with an obscure union rule that says you will automatically be terminated when you pass your NCLEX board exam for LPN or RN. This rule has been around forever, in order to keep aides from being forced to work as nurses with no nurse pay, I guess.

The last batch of nursing student emergency department employees, however, are trying to get jobs in a recession economy. Our hospital was hiring NO new graduate nurses and laid off 10% of the staff nurses. Yeah, ten percent! Other hospitals are experiencing the same thing. Not a single emergency-department aide in my hospital was accepted into a nursing position while still in school as I was because the new trend is to not hire anyone who hasn't passed the board exam yet because, with an influx of all these laid-off nurses into the job market along with new graduates, why risk that your new hire won't pass the boards? Why hire a new grad when dozens of laid-off, experienced nurses are applying too?

So, enter the stupid union rule. If you pass boards, you lose your job as an aide the second that NCLEX result hits the registry. If you haven't taken boards yet, you can't even get your application looked at. Ergo, you have to voluntarily go unemployed to look for a nursing job, which may or may not ever come then risk being laid off as a low-seniority nurse anyway.

One girl started at a nursing home (a rarity earlier this decade for new-grad RNs since hospital jobs pay more and were plentiful). Another up and moved to a different state with a couple of her classmates since they were all experiencing the same problem. Another started in a clinic for just barely more than she made as an ER EMT. The 4th has three kids and is still working as an aide 6 months after graduation because she has to be able to save up enough money to live unemployed for 2-3 months while she searches for a job in this lay-off job market.

So, FU obscure union rule. New graduate nurses shouldn't have to be unemployed while looking for a job.

New move from a chick who likes to be sick

If you're in the ER > 1 time per week with somatic complaints, I assume you get off on being sick.

After the 50th question asking for inappropriate interventions such as narcotics for a cough: "I talked to the doctor, and the plan is to check your blood and send you home assuming everything is normal once this fluid goes in."

I had the bag-o-fluid hanging to gravity, and, hm, I come back to check to see if the bag was done and--huh--like only 200 cc had infused when the whole bag should have been in by then.

Come to see the roller clamp was tightened up, causing the fluid to trickle in, instead of running at wide-open speed as I'd set it.

Given that she had no tests and no other nurse would just arbitrarily slow down a fluid rate, I came to the conclusion that the chick slowed her own fluid rate down in order to be able to stay longer. LAME, but certainly not shocking. C-R-A-Y-Z-E-E!!!

Party game idea

Pictionary? Trivial Pursuit? Scattegories?

Hell no.

I have a suggestion for your next get-together, and it's called:

Plastic Surgeon Hunt

It's fun!!! You can scour the city on a scavenger hunt-of-sorts, making phone call after phone call to numbers that are out of service, have people pass you off on someone else, and still have somedood chillin there with slashed-up cartilage dangling out of his head at the end of the whole thing.

If you master the game, up the ante a bit and add "uninsured" into the mix.

Challenging. Frustrating. It's Plastic Surgeon Hunt. Do you have what it takes to find a plastic surgeon taking ER call at night?

Ominous sign

You know it's going to be a bad night when the frequent-flying Bong Resin Girl hits us on the telephone to talk to another frequent flyer who is there. It seems they've become friends from seeing each other in the hospital lobby so much and having ill-defined pain syndromes SO SEVERE that they require several doctor visits per month. How quaint.

Hyperbolic pain scale ratios

Me: What's your pain on a scale of 0-10 if 10 is the worst you can imagine for any reason?

Patient: 246!

Me: Come on, we're doing 0-10 here. What's your pain from 0-10?

Patient: Oh, about an 8.

Me: [Turns head, rolls eyes]
----

So, kids, let's set this up in the form of an equation. If 246 is the equivalent of an "8" to this patient, how would the patient rate the pain if it is a 10/10, assuming a linear progression?

246/8 = x/10

So first we cross-multiply 246 x 10 to get 2460.
Then we make an equation to determine the value of X by cross-multiplying.

8x=2460

Then we divide by 8 to find X:

2460/8 = 307.5

So, for this patient, a pain score of 307.5 would be the equivalent of 10/10.

Christ child

We see a frequent flying EtOHeur rolling in by ambulance...

Charge nurse: It must be Christmas...the Christ Child has arrived!

Aide: Christ child?

Charge nurse: Yeah, because every time he shows up everyone always mumbles "JEE-SUS CHRIST!"

Another one I haven't heard

A "chronic pain" (addicted) patient younger than I comes in at an ungodly time of the night asking for a refill on his oxycontin, 200 mg BID for...chronic abdominal pain of unknown origin. I shit you not. If you're doing the math, that means he takes the equivalent of 80 5mg oxycodone tabs daily for pain with "no known cause identified". No cancer, no abdominal surgeries, no abnormalities seen on multiple imaging studies.

"My doctor just lost his license for over-prescribing narcotics, so I need a refill on my oxy! I can't get any other doctors to take me on as a patient!"

We fired up the medical board website, and, yes, he had recently lost his license for that and being addicted to pain pills himself.

The patient was also was addicted to and on high-dose benzodiazepines, and the the doc agreed to give him some of those to prevent withdrawal seizures, but nooooo oxycontin, sorry. Have a nice night, drug-addicted dood whose doctor is also an addict.

When your life is your deathbed

There are some people out there who are around my age (not that old, and don't you forget it) that are on their deathbeds all day everyday. Every day could be their last; you know this and, deep down, they know this too. They don't have cancer nor a rare deadly disease for which there is no cure that brings out crowds from the internal medicine residency program to "learn" from you.

They're the hardcore drug addicts.

Sure, I ramble on and on about how irritating it is to be burdened with someone coming in high as Cheech and Chong in a hot air balloon or looking for some pills for their addiction or making up some sort of N/V/D with 10/10 pain story about bad chicken to stave off the withdrawals, but with the advent of the integrated electronic medical record (emergency, clinics, social work and psychiatry sessions et al.), you can see some really depressing stuff.

You see scanned-in copies of inquiry after inquiry from child protective services, then, scroll up a few visits, and a few therapy appointments talking about how the kids were taken away when the patient was on a crack binge. The patient leaves the children at home to prostitute herself or is found on the street and you can read the ER visit about how she was angry, cussing, and covered in bruises. Mention is made of the patient's father who is described as an "asshole" and a "loser" and you wonder how young she was when he raped her for the first time. Labs include positive drug screen after drug screen for cocaine all neatly arranged in columns for comparison.

There are people out there walking around, day after day, glossy-eyed, depressed, with forgotten, mentally mis-wired crack-addled babies strewn all over the metro at various foster homes. You look them in their distractible long glossed-over eyes and wonder if they'll be lucky enough for someone to take enough pity on them to call 911 when they see them lying in a back alley with a syringe sticking out of their arm not breathing, but you're sure they'll be just another person gone dead or missing, the loss causing not but a ripple in anyone's lives.

But, you're just an ER nurse and go on with the IVs, morphine, zofran, lipase/amylase, and send her back to some guy's apartment who was "nice enough" to let her stay there. She's happy because she can sell the Vicodin pills, buy crack, and avoid withdrawals for another couple days.

Each time she comes back, she's more and more ugly and ragdollish than the last time and you know it's just a matter of time.

Half a mil

Today my blog surpassed 500,000 hits!

I'd like to give thanks to Dr.Bloody Gloves for touching that phone with blood-soaked "sterile" gloves, to all the med bloggers out there who link me despite their better judgment, and to someone special who shall remain nameless that inspired the blog nickname 'Crayzee Central'.

Thank you, thank you. [Polite applause from the crowd]

Happy Hospitalist doesn't understand emergency departments

Let's do a little ER 101 here since Happy doesn't get it.

1) We are required by the law known as EMTALA to see anyone who presents to an emergency department and provide a "medical screening exam" to determine if there is a life threatening emergency that needs stabilizing treatment. If there is, we are supposed to provide said stabilizing treatment even if the patient can't pay. "Stabilizing treatment" is not a script for chronic back pain nor is it an antibiotic for otitis media. The "medical screening exam" (MSE) is vague and is not succintly defined, but usually consists of exam and/or tests to determine what the problem is and, at the same time, rule out a more serious problem. A patient c/o low abdomen pain/cramping and urinary frequency symptoms will get a pregnancy test and a UA, and, by golly, it is a UTI, not a impending rupture of an ectopic pregnancy.

2) There is no rule saying only a physician can perform a MSE nor should there be.

3) Given EMTALA, on a daily basis, we see patients from all walks of life with everything from problems that have been going on for "months" that they wanted to have "checked out today" because "they were in the neighborhood" to acute heart attacks/cardiac arrests. Also there are minor emergencies such as simple fractures of distal extremities (not grossly deformed and not needing surgery), cuts that need to be sutured to prevent them from opening and bleeding, or the never-ending stream of work injuries such as sore backs. Simple, isolated issues in non-elderly patients or patients with low risks of "other" stuff being wrong are perfect for midlevels.

4) Back in the old days, the "minor emergency" and straight-up non-acute patients would wait a long, long time and often leave, which would mean we did not treat their problem and make money off said problem. I think 5% of our patients would leave overall prior to the advent of Fast Track. The adage of "if it's an emergency, they'll stay" pretty much held true, but these are people in the market to use an emergency department for their minor problem for whatever reason. If they aren't going to our hospital, they're going to go to another one.

5) Simple problems, even with Medicaideurs, make us money (see #8).

6) Midlevels are employees of the doctor group and make the doctor group money. $100 per hour per midlevel straight profit for the physicians is not unusual. Given that these patients would otherwise leave in many cases, that's lost money for the doctors in charge of the midlevels, not only the hospital. Scenario #1 would be a patient showing up, waiting 4 hours and leaving and no one making any money. Scenario #2 is patients showing up, getting seen and treated promptly by a midlevel making $50/hr and having the midlevel make an average of $160 per hour for the doctor group and more than that for the hospital.

7) There is nothing wrong, in my opinion, with charging a "provider fee" which is the same for a midlevel as it is for a doctor. The difference in education really doesn't change the treatment and exam for a simple muscle strain or a laceration repair. Some ERs have PAs or NPs doing a lot more than minor care stuff, but as long as the patient event is equivalent, the reimbursement should be. Remember, the doc is RIGHT THERE should there be any questions.

8) We're in a charity care crisis (our hospital is shelling out $50 million of unreimbursed care this year alone) and it's straight-up stupid to use one's resources unwisely. I happen to think burdening a ER doc who is trained to treat emergencies with clinic care stuff is an unwise use of resources, unless your patient volumes are low enough where you don't need any extra help.

9) Midlevels are a part of a team effort in the ER and should not be excluded when there is a definite need for their level of expertise. Just like they aren't doctors, Happy's not a midlevel so isn't privy to what they do and do not know as well. It's important to get to know any midlevels in your department to be able to properly decide what they can and can't do. Each one is a little different, but all are good at the basics.

Maybe this basic ER 101 understanding will help Happy to learn that midlevels are vital members of our team and not just people trying to play doctor. You diss midlevels, you can come down to the ER and see clinic patients; after all, that's more your specialty than it is the ER docs'. I'm guessing you wouldn't like our payer mix in the Fast Track though.

12-lead interpretation

Me: What in God's name is this? [Shows doc a weird EKG]

Doc: Hm, I'll go with "ain't right".

Where do you find an interpreter for this guy?

I recently had a patient who had a blood alcohol level of 0.34, a history of CVA and mental retardation without a single tooth in his head. I think that there are few situations in which someone's speech would be MORE slurred that this. Couldn't understand a word he said, and I thought about calling up someone working at the homeless shelter for phone translation because a bunch of markedly drunk, toothless methheads would approximate this guy, but settled with "unable to obtain history of present illness due to patient condition."

Crass-Pollination poll of the day

It's been awhile since I had a poll. Do you agree with the following candid statement made in my ER?

You should be embarrassed

To me, if you're working in an ER as a physician and you can't:

• Intubate
• Put in central lines
• Do a straightforward LP on a skinny 20-year-old
• Put in a chest tube
• Relieve a tension pneumothorax
  

...you should be embarrassed as Hell. Except in very extenuating circumstances: Intubation should NOT require anesthesia (or the paramedic who brought the patient in after they arrive in our department). Central lines should NOT have to be done by an intensivist on a crashing, septic patient because you haven't done one in "years". Interventional radiology is not the home of basic lumbar punctures. Chest tubes are not only the domain of pulmonology.

Whether you were trained as a pediatrician in the 70s or a surgeon in the 80s and have been grandfathered in to emergency medicine or not, you're still the doctor in an emergency setting and you should know how to do these very basic things. It's a procedure. It's just repetition, and there's really no excuse. You guys are an embarrassment to our hospital. No wonder some people think an NP can do your job.

The Rape of Emergency Medicine* is still alive and well today.

*=This is a semi-fictional book written by the founder of the emergency physician's organization AAEM, and talks about the origins of emergency medicine as a bunch of "generic" physicians (urologists, internists, opthamologists, etc) who picked up hours in emergency departments back in the 70s and 80s. Reminds me of work, sadly. In your ER, you probably have former generic physicians on staff, and you all know who these docs are. If you're super bored in triage on nights, it's an eye-opening read, and it's free.

Deep thought

It is cheaper to see the ER doctor and have a full head-to-toe workup for whatever ache or pain you have than it is to buy a soda in the ER lobby when you're on Medicaid.

Ominous psychiatric sign

When you're walking by a psych room and hear the word "corpse" mentioned by a patient for any reason, you know the patient is getting admitted.

Yet another thing I'll never see again

I saw a guy alert for awhile during a witnessed v-fib arrest with very effective CPR. His eyes were open, blinking normally, looking around.

He's awake, stop chest compressions!

What the Hell? Um. Ventricular fibrillation?

SHOCK ADVISED. EVERYONE CLEAR.

Zap!

Then he never regained consciousness.

Another thing that will never happen again

I talked Dr. Big Work-Up out of ordering a completely unnecessary test which was likely ordered to delay the patient's disposition long enough so the patient could be signed out to the oncoming doc. I mean, you order a huge work-up, sit on the patient for a couple hours and then when everything comes back negative, order just one more thing that's not even related to the chief complaint? We all know what you're doing. No more tests. Make a decision.

Probably the best behind-the-scenes nursing maneuver I've done all week.

Something that never will happen again

I called lab to see why a troponin hadn't been resulted 45 minutes after it had been drawn, something I've been doing like qpatient lately.

Me: Yo, lab, you got the troponin on patient # 545432594059305940594059405904-b [because you can't use a Social Security number anymore duhr]? It's not in the computer yet.

Lab tech: Hm. Lemme look. Can I have that patient ID number again?

Me: Sure. [Takes deep breath] 545432594059305940594059405904-b. [Nearly passes out]

Lab tech: Oh, I see what happened here. Nobody ran that. Looks like we must have forgotten. I'll throw it on the machine, should be resulted in 7 minutes or so.
---
Yes, folks, the first time ever that the lab didn't make up a crusty-old excuse as to why the test wasn't done. A little honesty goes a long way to not pissing me off.

Linguistic pet peeve

Other than ERP's British-English spelling tendencies, my new official linguistic pet peeve is....

people over age 5 who use the term "worser".

My headache's getting worser.

My throat pain has been getting worser all day!

My stomachache has been getting worser all week.

Um, your command of the English language is making my tolerance of stupidity worser. That crap makes me cringe each and every time.

Since your complaint doesn't resemble an emergency, even given a highly-liberal definition of said term, and you know you'll be waiting in the lobby forever for someone to have mercy on you enough to give you a room, how about, ya know, picking up a book and reading it? Just about any book will do. If you read a little every day, by the time you're 30, you may even achieve a rudimentary understanding of the English language.

Monitored room

Medic: The patient has been making suicidal statements to family and friends. He admits to drinking to excess on the weekends and smoking HCTZ daily.

Me: [Giggles] Wow, he may need a monitored room then. What was his BP?

Bundle branch block disappearing act

So somedood comes in by ambulance with a story suspicious for acute coronary syndrome. Chest pain, sweating, nausea, and near-syncope occurring at rest without any other obvious cause. My nursing spidey sense was tingling and whatnot. Usually when that happens for a chest paineur, they try to pull shit on me, like bradying down, or throwing a little ST-elevation into the mix after a few minutes. Dood was nervous that he was having a heart attack at home, so he slammed four, count 'em four, regular-strength aspirins. We give one, but whatever, four is better than zero, I guess.

The monitor showed a right bundle branch block.

I know lots of people bitch and moan about EMRs, how they're expensive and really really hard to learn what with all the typing and clicking and stuff, but I fired up the EMR and found a routine clinic EKG from a few months ago which also showed a right bundle branch block, so, meh, yawny yawny.

Anyway, dood's chest pain goes away with nitro and a tich of morphine and whoosh, off to xray. When dood comes back, we see normal sinus rhythm with no bundle branch block on the monitor.

The doctor is like, "EKG changes! Excellent! Obvious admit!"

The patient stayed in normal sinus for the duration of the ER visit, pinked up, and was a new man. My question for all you smart people is: The Hell? Educate the nurse.

Condescending co-worker

I hate you, Condescending Nurse. Not only are you layzee as shit, you're horrible and mean and need to go away. Eight hours with you is far too much.

Update 12/10/08: CN apologized to me. Sorta. There was a bald-faced lie mixed in with her apology, but it was still an apology which is better than persistent hostility.

The new ER nurse reality check

Experienced nurse to new trainee: "Just to warn you, this job will beat you down. You'll be tired, you'll not want to come some days, you'll question if you're really cut out for this, SOBs and drug seekers may even make you spiral into a depression that you can't explain. It's okay, I'm your preceptor, I'll help you through it."

I just wanted to say 'if the shit is getting you down, start a blog and never, ever tell anyone about it ever even if you're the 3rd most popular nursing blogger in the country.' ;-)

Here's a new one I haven't heard

A chronic paineur who likely has some real chronic pain but uses this to obtain more narcs than is necessary asked the doc for an Oxycontin refill for a few days since they were "stolen" [again] but said that her 40mg Oxycontins weren't covered by insurance, so he'd need to write it for two 20 mg tabs for each 40 mg dose needed because that was covered, but the 40mg tab was not.

Um, really? You think anyone not born yesterday is going to buy that?

Choices

It's important to give an anxious or difficult patient choices, however trivial.

Emergent chief complaint of the night

CC: Excessive masturbation and rectal pain from "self-stimulation"

Ghetto ambulance chaser

Some chick with a couple of school-aged kids in tow storms into the lobby and demands to be brought back to the room of her relative. Um, sorry, no one by that name in the computer.

This is not an unusual occurrence because sometimes the relatives beat the ambulance to the hospital or else the ambulance is there and the patient is not yet in the computer. Most people understand the rationale of why we wait until the people are in the computer before we let relatives back. In short, we can't verify that you belong in our department and, if the person isn't in a room yet, where are you going to go? Just walk around aimlessly?

Instead, we get, "This girl being a bitch, she not lettin' us back. This bitch think she somethin' special!"

Ma'am, people refrain from using cuss words in a hospital lobby, and especially in front of your children.

Whatever.

So, instead of waiting for her relative to be put in the computer, she [unbeknownst to me] positions herself in front of the security-coded ambulance doors that let medics into the emergency department and tries to follow a random set of medics pushing a random stretcher into the emergency department because "that bitch not letting us back". The medics successfully stopped her.

I go over there and ask her to come back into the lobby and to please remove her kids from the ambulance garage. They'd just walked in there and decided to snoop around the ambulances like it's National Night Out and the local medic service was there doing ambulance tours or something.

"Shut up bitch!" one of the 12-year-old looking kids says to me when I tell them to get out of the ambulance bay please and thank you.

"Young man, no matter how she is talking to us, that is no excuse for YOU to speak to a nurse that way. Now get out of there before an ambulance runs you over."

Meanwhile, I'm like what the fuck and call security and tell them some chick and some little boy are cussing us out and trying to follow ambulances into the emergency department.

Sad.

Hospitable

There was one shift where a notoriously a-holish hospitalist was on, being his usual personality-disordered a-hole self: Trying to block admissions, criticizing, being condescending, questioning all of the ER doc's conclusions, etc. At some point during this particularly busy shift, Dr. WTF, who I've decided is back on his game, started [with excellent deadpan, I might add] asking for the secretary to page the Hospitable-ist Service every time he had to put in a consult for Dr. A-Hole. Funny shit.

Tears

"What the heck is wrong with these people? This is the emergency department not the nurse's office at an elementary school! Sniffly nose? COME ON!"

---Medical student, 4th week in our ER, after reading a particularly non-urgent patient's triage note

Your first crush. Your first kiss. The first time you fall in love. These are all well and good, but the first time you realize people are total system-abusing losers who need to get a life, find a job and quit coming to the ER for the most trivial complaints is the most special moment of a young health care student's life. Brings a tear to my eye every time I witness it firsthand.

Emergent chief complaint of the night

CC: I woke up and was out of bottled water so I had a glass of tap water and it tasted like urine.

Okay, so what is the the medical problem you want to be seen for?

"I want to be tested to see if I just drank urine because that's nas-tay."

Sure we'll order up the oft-run "trace urine" buccal swab and then tell you to rinse your mouth out with mouthwash if it comes back positive.

Ghetto

The other day, we had a flood on one floor from a burst pipe, a leaky roof on another causing a mini-flood, and a fire in the lab all going at the same time. This situation actually cheered me up. Only at my hospital. High fives all around.

After all the alert codes were called, the managers were "dispatched" on another overhead page to a room to deal with this situation which I thought was hilarious. Of course, it was decided at this meeting that THE ER would get all or the vast majority the telemetry patients if the flooded floors had to be evacuated. After all, you can't violate the floor staffing ratios and fill empty but "unstaffed" floor beds, but you can give the ER as many patients as will physically fit in the halls and we're just supposed to adapt or something. Meanwhile, of course, independent of the flooding and fires, we're on ambulance divert getting killed with people in halls on portable monitors and bilateral codes.

Newsflash: If the telemetry unit is flooded, you can't move telemetry admits up to telemetry to make room to take telemetry patients from "the flood".

Whatever. Grab a mop, call a plumber, upper management, and start cleaning. No inpatients are coming down here.

ER triage screening questions

Suck.

It is an important but under-appreciated skill for ER nurses to be able to go through the JCAHO-required ER screening questions as fast as possible, similar to someone running a farm auction, because we all know that the answers are largely irrelevant to whatever we're about to do.

Oh, so you are an otherwise healthy housewife who cut your finger on a broken glass while washing the dishes and probably need a couple stitches, eh? Let me take your vital signs, determine your pain level, characteristic and location of said pain as if it's not obvious, your last menstrual period (or "the 6th vital sign" as I call it), and the approximate time of your last tetanus shot. Lemme ask you some other stuff:

1) Are you being hit, kicked, pushed or yelled at by anyone important to you? [Then I have to click through another list of things that are "warning signs" of domestic abuse like "neglect in seeking treatment."]
2) Are you allergic to avacados, bananas, or kiwifruit? [Not kidding, actual screening question for a latex allergy]
3) Have you had an unplanned weight loss of greater than 10 pounds in the last 3 months? [Are we going to address this during a visit for a lac? Nope, but still have to ask because we do.] Do you have any trouble chewing or swallowing? Can you afford food? Have you not eaten your usual amount for more than the last four days?
4) Do you have any trouble learning such as vision loss, hearing loss, or a learning disability?
5) Have you had a productive cough for greater than 3 months? Night sweats?
6) Do you have any metal or implanted devices in your body? [A fun one to ask acutely psychotic patients]
7) Have you ever been told you have an MRSA or VRE infection? [I like the answers to this one. "Oh, I'm allergic to sulfa." "I think I have a cold." "I'm diabetic so I get lots of infections." Um, okay.]

Then I have to click through if I think the patient is a known sex offender, known to be violent or is currently threatening and likely to be violent towards staff, or, if in my opinion, the patient is showing signs of suicidality.

Then it's medical/surgical history, med rec (entering names, dosages and frequency of medications taken without using any "banned" phrases like, heaven forbid, 'QD', including herbal supplements and vitamins, I might add) , and FINALLY, a triage note summarizing everything in 2-3 sentences.

Patient arrives by car. Chief complaint is a laceration in right middle finger. Bleeding controlled, no numbness. Tetanus up-to-date.

Wow. It's like I could have written the same note without asking any of the screening questions. Go figure.

Picture a more reality-based episode of 'ER' where the happy, prototypically-perfect child with a benign-sounding sore throat suddenly codes in the lobby (every happy child with a benign complaint codes in 'ER' as we all know), except no one rushes in with great fanfare to help the child because they're screening everyone for kiwifruit allergies and the other patients think the poor lad is just sleeping and the parents are off smoking meth in the car in the parking lot. Incidentally, part II of II is entitled "The Lawsuit" and the kiwifruit-screening triage nurse is paraded in front of cameras flanked by her union rep saying "I was just following orders" and allegorical comparisons to Nuremberg are made. Or some shit.

All I'm trying to say:

Imagine if that kiwifruit time could be devoted to, oh, I dunno, retriaging people? Seeing if anyone is deteriorating? Seeing if that little old lady is sleeping in the lobby or crumping? I think turning emergency triage nurses into de facto public health and community wellness nurses is the wrong thing to do. If you're going to make us sing kumbaya with all the patients or else discipline me, my boss or my hospital, don't complain when the triage nurse doesn't catch something bad going on in the lobby.