May 28, 2007, 6:47 pm

Two Be or Not Two Be


This nurse needs a vacation.


She is experiencing one of the rarer symptoms of burn-out.

The free-floating Coke bottle visual hallucination.

As long as she doesn’t reach for it, her co-workers will be none the wiser.

The minute her hand rises up to grab the non-existant beverage…well…it may be too late.

So, if you see your co-worker staring longingly into space, parch lipped and glassy eyed, intervene!

Go get them a Coke!

Better yet, a Pepsi! (I can’t stand Coke…)


It is present in every emergency department.

You don’t see it coming…

…until it is too late.

You’ll want to cry.

You’ll feel like screaming.

It can drive you over the edge on a busy shift.

You can’t control it.

You can’t stop it.

Yes, my friends it is…..

The Two-Fer!


What exactly is a “two-fer”?

The term is slang meaning “two for the doc”. It occurs when someone presents to the emergency room for treatment and someone in the group accompanying the patient decides that they, too, need emergency services.

Right then.


A two-fer can present in various forms:

  • The Upfront Two-fer

These patients usually walk in together but sign in as separate patients on the triage sheet. Often, they were in the same vehicle that was rear-ended at five miles-per-hour ninety minutes prior to arrival. Neither of them have any symptoms, but they feel they needed to be checked out because they were in a car accident, after all. Sometimes, a parent will present two children for treatment at the same time because they both have a fever or cough. Pretty straightforward – what you see is what you get.

  • The You-Have-GOT-to-Be-Kidding Two-Fer

A few examples will explain this form of the two-fer better than a dry description.

Example: a young female presents with abdominal pain and discharge, bringing along her friend for support. Sometime during the visit, the friend, like, thinks she might, like, have discharge too and like, wants to sign in.

Example: the patient presents with something simple like an ankle sprain. Their bring a posse of friends for support. Sometime during the visit, a friend tells the nurse they have itchy toes and wonders what it could possibly be. Wait…a….minute! They are in the emergency department and there is a doctor there, right? They go to triage to sign in. A seven-hundred dollar case of athlete’s foot.

Not all two-fers are actually comprised of only two patients. This brings us to our third category.

  • The Multiple Two-Fer

A two-fer can also come in as a multiple of two. You might have two. Or four. Or six. For some reason it is never an odd number.

It’s the family of six who have that bumper bump and demand that all of them be signed in and seen, even though five of them have no symptoms and the kids are playing and laughing on the floor.

It’s the mother of six who brings all of the children into the emergency department because they all have been coughing for over a week. She wants all of them signed in.

Now, there are some legitimate two-fers out there. The spouse of a patient who develops chest pain. A visitor who develops an allergic reaction while sitting in the ER. These are truly cases of being in the right place at the right time.

But the others? We have to see them all. Even if there are no symptoms, we are required to see every single one of the bumper bumps. Every single one of the kids with upper respiratory infections. Every athlete’s foot and “oh, gee, I may have an STD, too!” person who decides to take advantage of the fact that they happen to be near a doctor.

I once spent an hour triaging six children (from the age of six and down) from one family for something they should have seen a pediatrician for (and yes, they did have one!).

There are really no answers, just observations.

It’s just another form of the system abuse we all see everyday.

But…what is actually broken here? The program or the participants?

That sounds like a good topic for another post.


  • Type-B Premed

    May 28, 2007 at 8:37 pm

    Ah yes, the two-fer. We actually get semi-regular three-fers as well.
    It’s particularly frustrating when all of the children are the same sex, very close in age, with names made from random groupings of the alphabet.

  • Max E Nurse

    May 29, 2007 at 2:47 am

    Kim you have forgetten something…
    The BOGOF + twofer.
    The buy one get one free, (AKA BOGOF) is a patient that comes in with a cough, then mentions the pain in their elbow. and “while I am here could you see my husbands toe nails!”
    I HAVE 12 Fricking minutes & am already running late. Book another appointment….


  • TC

    May 29, 2007 at 3:17 am

    Oh God! I remember the whole families coming in to be checked out for running noses and such. Oh, it sucks to be on triage at those times. LOL about the discharge-that, like, so happens. Or the $700 pregnancy check. I don’t understand why, when a home pregnancy test costs $10 why women still come to the ER to see if they’re pregnant. Eeek.

  • laura

    May 29, 2007 at 7:32 am

    as i walk past the ed on my way to the nicu i often wonder why the good people living in my neck of the woods must bring the entire family, a few close friends and the neighbors down the street with them when they check in? you’d think you were at the local mall or something.

  • JC Jones

    May 29, 2007 at 11:02 am

    Oh, God. I remember those days. When you start screaming at medical students, it’s really time to get out. I did, & I can assure you, there really is life after ER, as addictive as it is…jc

  • Nursing A Headache

    May 29, 2007 at 11:06 am

    Or the people who BRING IN THEIR LUNCH when they come! I am constantly amazed by them — they bring in the whole family and bags of fast food and settle down in front of the TV. It’s like a picnic.

    But, Kim, as far as your question goes, the answer is a two-fer — both the program and participants are broken. We can’t turn away anyone from an ED because what if it really turns out to be emergent and we get sued? We don’t educate our ED users enough on going to Urgent Care or their own doc because it’s easier to bitch.

    Picture this: an ED and an urgent care (both open 24/7) next to each other in a hospital. One entrance, nurses triaging patients as them come in, directing them to the appropriate venue, or telling them to go home and call their own doc in the morning. If they don’t have a doc, set them up with a clinic… Think is can’t work? It does now in San Jose at the county hospital and it’s saving them time, money and two-fer frustration!

  • Dean Moyer

    May 29, 2007 at 3:36 pm

    I agree with “Nursing a Headache” above:

    “Picture this: an ED and an urgent care (both open 24/7) next to each other in a hospital. One entrance, nurses triaging patients as them come in, directing them to the appropriate venue, or telling them to go home and call their own doc in the morning. If they don’t have a doc, set them up with a clinic… Think is can’t work? It does now in San Jose at the county hospital and it’s saving them time, money and two-fer frustration!”

    From a patient’s point of view, most of us would actually welcome the guidance… not to mention the chance to save on the bill. Improving efficiency would help everyone all around.

    Great blog, btw. I’ve added you to my blogroll.

  • KC Saul

    May 29, 2007 at 5:40 pm

    Believe it or not, we patients would kind of like an alternative when the situation is urgent but not life-threatening. In our area there is a pediatrician’s office that is *only* open at night and on holidays. They can give stitches and even deal with broken bones. As between the ER and them, I’d take my kids to the pediatrics place for anything other than a life-threatening emergency.

    I’d love a similar place for grown-ups. I’d go there with a broken bone/sprained ankle before I’d clutter up an ER. In fact, I’d go there for a probable kidney stone first. If I need lithotripsy I’m not going to get it in the ED anyway.

  • John Rutherford,D.V.M.

    June 17, 2007 at 12:53 pm

    I am a Veterinary ER doc. The twofer happens all the time, usually the owner is more concerned with the dog’s chronic dermatitis than the projectile vomiting that has gone on for 5 days.The other scenario is they want an opinion about the other cat at home who has a chronic problem diagnosed by the family veterinarian, they can’t remember the name of the problem but know they give him a small blue pill every day.

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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