Life used to be so simple in the ER.

If a patient needed to stay in the hospital, you obtained a room number from Admitting.

You then would take a final set of vital signs to verify that the patient was indeed stable for transport, bring your nursing notes up to date and double check the lab work to make sure that no one missed the potassium level of 9 or the hemoglobin of 1.

A call to the receiving nurse was then placed to give “report”, a verbal narrative of the history of the present illness and emergency department course, adding significant historical medical information as necessary: allergies, previous surgeries, etc.

After receiving a litany of 15 reasons why the receiving nurse can’t take the patient right then, a negotiation ensues. A time for transport is agreed upon and the patient goes up with his chart.

Oh, how I long for the good old days.

Approximately one year ago, some agency (JACHO?) decides that things must change for the good of the patient! Here is what now must be done before the patient goes up:

• Report must be faxed.

• This entails writing the entire report. So, everything that you have just spent hours writing on the nursing notes must be summarized and rewritten on the fax report form. Even I, with my passion for charting, think this is asinine. It is also mandatory.

• It takes longer to fill out the fax report than it does to verbally report.

• The only advantage is the nurse can’t give you 15 reasons for not taking the patient any longer.

• In my facility, the policy is the patient comes up 30 minutes after the fax. Oh, and we call to confirm that the fax is on the way. In the beginning they mysteriously weren’t received.

• Okay, in the interest of fairness, sometimes faxes are sent to the wrong floor or a bed number is changed after report has been faxed.

• And the floor/unit nurses get a 30 minute “heads-up” after the fax and before the patient arrives so they can prioritize prior to getting the patient. Which I know I would greatly appreciate if I worked up on the floors.

• We tried faxing the nursing notes instead for a brief period, thinking that would cover all the bases, but how shall I put this, not all nurses are thorough “charters” and/or it was difficult to read through to get the pertinent information.

• We need to practice “medication reconciliation”.

• This means that, when a patient is going to be admitted, an exact list of what medications the patient is taking, including vitamins and herbal supplements must be listed, along with the dosage, frequency and the last time the patient took the medicine. Allergies and adverse reactions are also noted for a second time (first on the nursing notes).

• The goal is a noble one: to make sure the patient is discharged with the medications “matching” the ones they came in taking, with or without changes.

• This is all done on a new form that acts as a physician’s order sheet for meds (ie they can check to order the drug as written or to not order it.

• Guess who gets to get all this information ready for admission – yep, the ER nurse. They say the family can fill out the form and sometimes the patients come in with beautiful computerized lists that bring tears of joy to my eyes. But usually the family is anxious about doing that so it falls to the nurse to complete.

• Oh, and by the way, those beautiful computerized lists? We can’t copy them. They must be re-copied, by hand, on the form.

• Signature recognition

• On a separate form, in addition to signing your name twice on the nursing notes, you must print your name, sign your name, and designate your work station.

• Apparently illegible handwriting is making signature reading a lost art.

• To my blessed delight, my facility no longer requires this form. But for many months this was also mandatory.

So, in one year, three new pieces of paperwork were added to the already hectic activity that accompanies a patient admission. Two of which require the nurse to sit, undisturbed, for a minimum of 20 minutes to complete in addition to all the regular paperwork. We have no recourse but to do as we are told.

I wish someone would tell these agencies off.

Where is Simon Cowell when you need him?

I hate spleens. I really do. I mean, I’m glad I still have mine, and I fully intend to keep it. But spleens aren’t very forgiving and sometimes they are downright sneaky.

Young girl, early teens, unrestrained front seat passenger of a car driven approximately 25 mph head first into a wall. Old car, long ago, no airbags to deploy.

Patient is ambulatory on scene without c/o neck, back or head pain. Slight pain to lower left ribs but nothing more. Mother arrives on scene and signs patient out AMA, stating she will transport patient to the ER. And she does.

My ER. My non-trauma center ER. As triage nurse for the day, I began taking the history. Slight pain on palpation when left lower ribs are softly touched. Pain increasing slightly with inspiration. Lungs clear. Denies SOB. I’m thinking pulmonary contusion, maybe rib fracture. The mechanism of injury was not great, but the patient was walking and looking good on scene and when he got to the triage station. Then, suddenly the patient begins to look rather, uh, sick. Icky. Pale. Nauseated. Shocky. Bad.

This is not good.

Mom gets sent out to registration and patient comes with me, in a wheelchair for obvious reasons but now she can’t stand up straight anyway. I grab the ER doc on the way in. He examines the patient only to discover within about one-half second that it is not the ribs, it’s left upper abdominal pain and we are goin’ to the OR. Mom returns within minutes and gets the scoop. Two large bore IVs with a bolus (BP falling)while the OR gets ready and off we go.

Ruptured spleen.

I hate it when they do that.