Chief Complaint

I suppose I should clarify what I do at Kadlec. I am a nursing student, not a nurse. I suppose I am a nurse-in-training, but I do not interact with the patients. In all reality, I do, jokingly, once the doctor has done so and it is apporpriate for me to do it as well. Let's say that I have not left a patient's room with the doctor telling me to knock it off. Yeah, I am surprised too. I am a scribe. Not the quiver-n-bow type scribe, but a medical scribe. I make paper. Well, electronic paper. I chart while the physician examines the patient. I track lab results and diagnostic tests for the doctor and prompt him or her to read them, interpret them and I will transcribe these verbal findings onto the chart.

Now, as mundane as that might sound, I love doing it. I love seeing the interaction that the docs have with patients. I love seeing their minds work and asking questions about the process. It is a trememndous learning experience, just as I thought it would be when I first applied. All the doctors are amazing clinicians and I know that when I am done with school I will owe them a debt of gratitude for both teaching me and tolerating me. However, I have seen some really, REALLY stupid things roll into the emergency room. Things that do not require emergent care and things that are referred from doc-in-the-box type clinics for further evaluation. The list of things that should not come into the emergency room is in my head, which, as we all know, can be a very insane place to hang.

A "chief complaint" is the complaint that the patient complains the most about. For example, often times a patient has so many complaints in triage that the nurse has to narrow it down to one. Often times, even that one is bullshit. However, since people come into the emergency room, the deserve proper, adequate care to relive this complaint. The list of interesting chief complaints is somewhat comical since what their diagnosis ends up being often has nothing directly to do with their chief complaint. For the uneducated, however, here is a list of things that do not require EMERGENT CARE...since that is what is done at the EMERGENCY ROOM.

1. Bug Bites - not brown recluse bites or black widow bites, or numerous wasp stings, but just 5-6 mosquito bites, none of which are infected. Simple treatment would include over the counter Benadryl (antihistamine to relieve itching) or Calamine lotion (topical ointment to relieve itching), both of which were not administered prior to arrival. When asked why they came to the emergency room, the parents of this 9-year old indicated that their child was itching these "huge bites," the biggest of which was about the size of a grain of rice. Diagnosis : bug bites, multiple. Prescription: OTC (over the counter) Benadryl. That will be $400 please.

2. Nausea - no vomiting, no diarrhea, just a stomach ache. When asked to grade the pain on a scale of 0-10, with 10 being someone smashing your legs with a sledgehammer, the patient graded it a 9, remote control in hand switching it to the NBA playoffs, feet crossed over each other, bed reclined, ala home recliner comfort. No abdominal tenderness to palpation, no fever, no real illness. I think this guy was tired of dealing with wife and kids while the game was on. A CT scan later to rule out any acute injury, $1000 or so, and off he went. Be sure to drink lots of fluids.

3. "My pee smells really bad..." - Sounds like it could be a urinary tract infection? Sounds serious enough, right? I mean we have all been taught that stinky anything is indicative of an infection, right? If that were the case I have had an ass infection my whole life. While being questioned about recent food, drink or antibiotic use, patient indicated that he had ingested some asparagus prior to arrival. End of exam. Diagnosis - normal exam. Prescription - car keys.

4. Abdominal pain/pelvic pain - I cannot fathom menstrual cramp pain, at least directly. However, every 28 days I do get an indirect idea of how these feel. Ouch. I get it. But when asked if these cramps are different from previous menstrual cramps, the patient indicated these are the same. No abnormal or excessive bleeding. WHY ARE YOU HERE? "I am out of Motrin." Wow....really? This will be some expensive Motrin. Next.

5. "My skin hurts." - Can you describe the type of pain you feel? "No not really." Is it like an itcing or burning pain? "yes, its like that." Is it also like a cramping pain? "yes EXACTLY like that. My skin feels very crampy." Can you tell me one spot that hurts worse that anywhere else? "Right about here (motions hands over his whole body; head to toe)." Have you taken anything for the pain? "I took some Benadryl and Motrin." Did you have any relief? "No, that made it worse." Are you allergic to any medications? "Ibuprofen and Benadryl." Did you know you were allergic to ibuprofen before you took it? "I didn't take ibuprofen, I took Motrin." That's ibuprofen...they're the same thing. "Oh...well, why is it worse?" Because you are having an allergic reaction to the medication you took. "Oh...can I get a shot of Dilaudid then?" I'm sorry, according to your care plan, I cannot administer any narcotics during your visit to the Emergency Room. "Oh ok, well I am feeling much better now. Can I just leave?" This happens quite often...more than you know.

There are many, many more I could illustrate but I don't want to bore you any further. From a student perspective, it is a great opportunity to listen to patients talk and be able to filter out the bullshit. My filter was not as keen as it was before I started. I am a tad cynical when my kids come complaining about certain ailments. When my wife took Peyton, now 8 years old, to the emergency room as a two-year old (see previous blog post from 2005), I laughed before she left, as did the docs at the ER I am sure. Diagnosis, diaper rash. Prescription: diaper rash ointment. I think that visits was about $300. Should have framed the bill. Unless they are bleeding from their numerous orifices profusely, or have dangling limbs bending in ways that God did not intend, they can wait to see a doc-in-the-box.

I don't want my kids to be someone else's blog fodder. They are for mine.