October 27, 2006, 10:10 pm

There’s Somethin’ Happening Here…..


This is an interesting little gem.

I believe it was part of an ad for health insurance.

Interesting because it looks about circa 1950.

Because for what I spend on amazon.com, I could have my appendix out every ten days.

With the Grade A anesthesia!

And because this patient looks to be headed for surgery in an evening gown!

Honey, in my facility, you don’t even get to keep your underwear on!


I’ve lived through many changes in health care over the last three decades.

Seen trends come and go.

Seen fancy “miracle” drugs come and go. And come back again.

But something is happening.

The changes are coming faster.

I’m coming up on three years in my current ER.

Here are a few of the changes I’ve seen in that relatively short length of time.


Patients are more open about their health issues.

  • Patients seem more willing to let you know when they have infections like Hep C or HIV.
    • Words and intitials that used to be whispered with averted gaze are now spoken outright and without shame.
    • I like to think that patients are more comfortable because they don’t feel the stigma that was once attached to infectious disease. Maybe I’m naive. I hope not.
    • I’ve had more than one patient warn me to be extra careful when taking their blood!
  • Patients are more upfront about their sexuality and medications taken for it.
    • I used to have to ask about Viagra specifically; no nitroglycerin if Viagra is on board! I still ask, but have noticed an increased willingness to mention the presence of Viagra without being asked.
    • Again, I’d like to think this is due to increased patient education from both health-care providers and that patients feel more comfortable informing us of these medications.

More patients are using the emergency department as their source for narcotics.

  • This leads to me believe one of three scenarios:
    • 1. The patient has chronic pain and they must utilize the ER when they experience breakthrough pain or when their coping mechanisms are overwhelmed. Or…
    • 2. The patient does not have an adequate pain control regimen in place as yet and continues to experience episodes of pain requiring narcotics. This is also legitimate. Or…
    • 3. The patient is a drug-seeker. You know them. It’s a feeling in your gut. Daily visits for two weeks. Two visits in 24 hours, more than once. Overly-solicitous behavior to the nurses. (I’m good, but no, I’m not Mother Teresa, thank you anyway.) “Allergic” to every medication other than the one(s) they are asking for. There have been shifts when I have seen 6-7 of our “regulars”. Some call in ahead to see how busy we are. This is not legitimate.
  • So how do you know which is which?
    • Many times, you don’t.
    • That means everyone is treated as if their request is legitimate and they are not drug seeking.
    • But I can tell you there are more narcotics flowing out of emergency departments today than I’ve ever seen. I can also tell you that when
      • I know the patient’s name when they walk in the door,
      • when I can write their medical history from memory on the triage chart, and
      • when I am giving amounts of medication that would put me out for eternity, we have a problem, Houston.
    • Sometimes, I can’t help but feel like a drug pusher – in the literal sense. We are doing these patients a dis-service by continuing to feed their addiction. It’s a sad situation; it’s almost like they live from visit to visit. But they still come in. Because they get what they want.

There are more patients in the emergency department.

This isn’t my imagination, we’re adding more nurses like crazy to handle the load!

I’ll use my shift, the night shift, as an example:

  • The old night shift
  • Clear out the patients left over from PM shift by 0100
  • Stock the unit and order meds.
  • Catch up on all the nursing journals and research papers you have not had a chance to read. (Translation: knit, crochet, write letters, catch up on your novel, do crossword puzzles, gossip and eat, eat, eat!)
  • Put all evidence of professional journals away by 0530 so that the day shift doesn’t think you sat on your butt half the night.
  • Get ready for the daily hip fracture patient that is sure to come in between 0545 and 0630 and the daily pulmonary edema patient that will come between 0615 and 0700
The new night shift:
  • Come in at 2300, pour coffee.
  • Run your derrierre off with a nearly full department.
  • At 0200, make more coffee (you never had a chance to sip the first cup).Run your derrierre off with the new patients that have just arrived as you hit the “on” button on the coffee pot.
  • At 0400, make more coffee. Actually drink half of this cup. Go attend to the four pediatric patients from the same family who all have fevers and just walked in with all four grandparents and a fourth cousin once removed.
  • At 0600, forget any more attempts at coffee. Grab your six-inch high pile of charts and begin documenting what you did five hours previously.
  • Take the next hip fracture and pulmonary edema patients.
  • Kiss the day shift.


The paperwork has become unmanageable.

I’ve blogged on this ad nauseum.

Ostensibly, the paperwork is supposed to document good patient care.

  • In reality, it borders on preventing adequate patient care as the nurse spends more time at the chart than at the bedside.
  • You don’t get a “gold star” on your record for making sure your patients received good skin care.
  • You get a “gold star” for filling in all the blanks on the chart.

So it appears the rapid changes I’ve witnessed in the last three years are a mixed bag.

On the one hand, patients are more willing to discuss intimate aspects of their care with their health-care providers.

On the other hand, the census of my emergency department is swelling secondary to non-emergent patients utilizing our services.

A major factor are patients with chronic pain utilizing the ER for pain relief services on a continual basis. Most are legitimate. Many are not. And that is sad for two reasons.

  • Addiction sucks.
  • The abusers make it that much harder for legitimate pain patients to be viewed clearly and dispassionately.

Add the increasing amounts of paperwork, and you see a much different ER than you saw just three years ago.

I wonder what changes I’ll be writing about in 2010…..


  • Sid Schwab

    October 28, 2006 at 10:30 am

    Re: grade A anesthesia. There’s an old saw about the patient asking the anesthesiologist how much he charges and, when he hears the answers, exclaims: You charge that much just to put me asleep???? No, the answer comes. Putting you to sleep is free. We only charge for waking you back up.

  • Deacon Barry

    October 28, 2006 at 1:28 pm

    You get regular hip fractures and pulmonary oedemas at awkward times. With us it’s corneal ulcers – and we always seem to get them coming in on Friday afternoon! Why Friday? It’s as if they wait until their working week is finished before deciding to do something about that sore eye they’ve had since Tuesday…

  • Fat Doctor

    October 28, 2006 at 3:12 pm

    Kim, where on earth do you find these pics? Please tell! I won’t steal the concept (promise) but I just have to know! 🙂

  • motherjones-rn

    October 28, 2006 at 3:26 pm

    What do you mean you’re not like Mother Teresa? A nurse must have the patients of a saint to work in an ER.

    I love the sign about grade A anesthesia.


  • Rob

    October 28, 2006 at 8:50 pm

    The narcotics thing is the bane of our existence in the office as well. On a typical day I will get 10-20 phone calls regarding narcotics. You are always doing this intricate dance of wanting to meet the needs of your patients without creating addicts. As I get older I am meaner and meaner about them. When I first started out I cared more about making patients mad at me. The problem is, if I turn them away, guess where they end up. Yes, in the ER.

  • TC

    October 29, 2006 at 2:56 am

    I hear ya about the drug seekers. But are you really going to make any difference to there addiction in one ER visit? Or even several visits? It’s not a good forum to address a possible addiction problem. Something really needs to be done with the state of all mental health services, including addiction treatment, which has become virtually non-existent in my neck of the woods unless you have really good health insurance.

  • angry doc

    October 29, 2006 at 4:44 am


    I’m going to steal that picture for my own blog. 🙂

  • S. R.

    October 29, 2006 at 3:42 pm

    The drug thing happens on the medical floor too. 10/10 pain every two hours that can only be removed with the 4mg shot of Morhpine, not the Vicodin 5/500 tab. If you still have 10/10 pain every two hours after 7-14 days in the hospital, you should be writhing, urinating yourself, and in the ICU, not asking for sandwiches.

    It’s not that i don’t care about pain; it’s that these requests take away from other patient’s care. Addicition is narcissism, however.

  • Carol

    October 29, 2006 at 8:58 pm

    Just a laygirl’s observation… I read more and more about ER’s being swamped with pain patients, and about office doctors being stingy with narcotic rx because the gov’t is watching like the KGB, and sometimes even arresting doctors for treating intractable pain with big narcotic scripts. I wonder if there is a correlation?

  • apgaRN

    October 30, 2006 at 9:56 am

    And then come the babes… if mom has been abusing narcs (or other drugs) throughout pregnancy, baby is addicted too. The high-pitched screaming of a baby in withdrawal is enough to put me over the edge. And to keep me from feeling an ounce of sympathy for drug-seeking moms.

  • TuxBaby

    October 30, 2006 at 1:02 pm

    I can relate! We get those “frequent flyers” too. I remember about 4-5 regulars who I could probably pre-chart the initial info, and stash the charts under the triage desk for the next visit… (of course I didn’t actually DO that)! I also know of some of the drug seekers being not-so-thrilled with the ER doc for giving them Stadol or Talwin and sending them on their way- and without the great high they had hoped to get. We’ve even had some call in to see what ER doc was on shift- because some were more free (more naive?) than others.

    As for the paperwork…. you get gold stars for yours?!?? I never got any stars for my stacks-of-charts! **pout**


  • Sometimes desperate ER patient

    December 3, 2006 at 8:26 pm

    I make sure that I NEVER ask for any narcotics in the ER, and yet they all treat me like a potential drug seeker. Why? I would rather have pain than to have to put up with the yuckky side effects of pain pills.

  • Virginia

    January 27, 2007 at 12:19 pm

    Thank you for the great web site – a true resource, and one many people clearly enjoy

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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