Friday, September 25, 2009

Doctors v. Nurses and 100% Sensitivity

This may not be intuitive so I'll 'splain sumthin to ya. In the ER nurses do the triage... they intake patients and get an initial history and decide if they are bad sick or regular sick or bullshit sick.

Now, if you think it's hard to put one over on the IRS or your spouse you have another thing coming when you meet most triage nurses. To them no one is sick, no one... everyone is a bullshitter, and they are usually right (of course I am taking poetic license here, but not much).

I, on the other hand, think everyone is sicker than shit and I act accordingly, and I am usually wrong (poor specificity). So why do I do this, and why do all ER docs who practice more than a few months think this way? Because once a week, maybe twice, sumdood like the above dood ambles through our ER and I look for badness and, shit on a stick, I find it.

The above gentleman WAS drunk... I'm talking professional drunk, BAL 350. He fell down went boom the night before and his dad brought him in because he was slurring his speech. DUH! He's fucking plastered right? YES! He is. He had a little abrasion on his forehead. That's it. He also has an intraparenchymal bleed that may kill him. We scan, not because we can, but because we must.

In the ER the expectation of the physicians is that we miss exactly ZERO serious medical conditions (100% sensitivity). I scan and lab and poke and prod even the most obvious malingering drug seeker because the malingering drug-seekers get sick too, and they are exactly the people (along with their families) who will call the Cochrane firm at the merest whiff of a mistake on my part. They also do not, typically, pay for their care, and they abuse the EMS system to get to me because they 'don't have a ride'.

The above CT scan is a fine example of why a triage nurse can base a lot of her judgement on the obvious, but, as tempting as it is for me to do the same, I would like to keep my house and my car. Gotta go, there's a drunk gal with belly pain just arrived by EMS... I think I'll scan her.


  1. I can already read the Wows and other expletives from the medical community.
    I don't have an interpreter available 24hrs a day, so to me it means nothing. Pretty picture? It looks like The Rorschach (sp?)Ink Blot Test.
    Can you explain? Thanks!

  2. 911
    If we Triage Nurses didn't act like everyone was bullshit sick, you would be so overwhelmed with the bullshitters, that you wouldn't be able to get to those that were really sick.

  3. gregg,
    you are making my point. this is not a dig on nurses, it's a dig on the system that says i have to suspend clinical judgement entirely. you are RIGHT to call bullshit because it helps me think about the patient, and i too am RIGHT to take the triage assessment with a grain of salt every time.

    dear amy 65c,
    will add some explanation to pic tomorrow.

  4. The dark parts ... is that blood?

  5. One of my nursing instructors told us:

    "When you go in to assess a patient, you don't leave the room until you find something wrong". I quite often had a hard time finding something wrong.

    It took me a long time to figure out why this was a good idea....but I never said I was a quick thinker.

  6. The black area around the front of the skull - which is pointing up - is atrophy. Atrophy just tells you that the patient is on the elderly side of life. The white area on the left side of the skull is the intraventricular hemorrhage or bleeding on the brain. Hope that helps you a little bit..

  7. 911,
    Please never suspend your clinical judgement, no matter what the clipboards say, or the nurses...and I'm a nurse.

    I had a triage nurse kind of blow me off because my vital signs fell into "normal" parameters. I tried to tell her that my normal resting pulse was 60, not 92, and my pulse ox around 98, not 92. She was unmoved. I was short of breath.

    Turns out I had pneumonia. So glad the ER doc was thorough.

  8. "The black area around the front of the skull - which is pointing up - is atrophy."

    wow a self performed lobotomy? (Alcoholism)

  9. oh come on're not still upset about the Napoleon syndrome comment are ya? I thought we were past that..

    Atrophy is the partial or complete wasting away of a part of the body. Cerebral Atrophy can very well be a normal process in the elderly since atrophy can occur when disuse or lack of exercise of the organ is present. However, since the patient listed above is an alcoholic, I would definitely have to agree with ANON that the loss of neurons is alcohol related.

    If only lobotomies were still common practice...

  10. That's why I love being a nurse...hourly wage, ability to walk away when my shift is done and no additional malpractice insurance premiums to pay. When it comes right down to it, it's your ass in the sling, not mine, when the idiot boy who cried wolf actually gets mauled by the damn wolf. I thought he was just a service dog...go figure!

  11. Am I right in guessing that (if he has coverage) this scan will be covered by Medicare? And that the scans you do to rule out this type of thing are not covered, when there is no brain injury found?

  12. dear anon.
    right on bro.

    matt m,
    this guy's scan was covered by you. he was uninsured, a 'self pay' patient, and got everything including top-notch NSurg care... you pay, i pay, he doesn't.

  13. Dr.G Medical Examiner had just exactly a case like that. It's weird to think a chance thing like an ER schedule can have such profound effects on our lives. I get weary of the bullshitters, too. But my alcoholic Dad died inside a CT scanner--not I guess from a head injury, but that staff was very compassionate, they deserve a special place in heaven.

  14. dear anonymous,

    don't know who 'dr g medical examiner' is but intracranial hemorrhage with apparently minimal force happens with great frequency, especially in the alcohol abusing population.

    i am terribely sorry about your dad... every time i send someone to scan i have to decide whether they go on a monitor or not. if they do go on a monitor a nurse has to go with them and that puts us a nurse down in the ER. if they do not go on monitor i am nervous until they get back BECAUSE people do die there and running a code in radiology is difficult to say the least.


  15. I'm sorry, I guess I assume everybody watches Discovery Health Channel. It's Jan Garavaglia, ME of Orange County, FL. Basically takes the audience w/ her as she determines cause of death in various cases, plus some lifestyle advice in her "How Not to Die" segments.
    The effort was made in radiology, but as you say, it's difficult. However, I was GREATLY comforted by the time and kindness one ER nurse took to tell me what happened as I lived in another state. Thats the point I return to over and over. Daniel Freeman Hosp, you rocked that day.

  16. And when a pt comes to the ER, complains of flank pain, does not have a history of kidney stones, asks for narcotics...then maybe it really is his first kidney stone. (True story.)

  17. We're not all retarded...We're trained that drunk head injury is auto-scan for head/neck crap. TNCC, baby.

  18. nurse k,
    you my gal baby! where have you been?