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One of the rules of working in the E/D is that you don't pick charts. When you're in a position to take a hit (and sometimes when you really aren't, but you have to anyhow) you walk up to the rack and grab the first chart there. You sign your name in all the places that require your signature and then lastly, you read the triage note which explains why the patient is there. This holds true universally, unless the patient is in dire straits indeed - and if that's the case, you won't need to look at the chart at all because one of the nurses will be giving you a look that says, "Now, smartass."
There is a reason for this rule, and it is a good one:
You've been there eight hours, and you know that you have four to go before you stop grabbing new charts. After that you have another hour or so of catch-up; finishing paperwork left over from your shift, getting folks tucked away for sign-out or discharge. You don't sign out simple unpleasant tasks to your colleagues just because your shift is over - it ain't cool.
So there you are, kinda tired. You need to take a leak. You're hungry, 'cause you haven't had a chance to eat all day. Your coffee is cold or someone tossed it, or you just looked in the kitchen and discovered that someone filched the cheesesteak you've been looking forward to for the past three hours. You're jonesing for a smoke.
You look at the chart rack and see "Vag. bleed" when you've had three today already. Or you see "Dizzy. passed out?" Perhaps it's, "Fell, cut head" and you just got done sewing up a child who screamed in your ear for thirty minutes non-stop. You don't want to see this patient, so you go to the next one down the list - it looks like something that could be really fun or interesting. The next guy along does the same thing.
Guess what happens? Yep - Mrs. Wilkins comes storming out of room 27 saying, "Goddammit, we've been in here for three hours, and little Ernie just puked again, and he's burning up with fever, and when are we going to see a goddamned doctor?"
So you don't pick charts. The triage nurses know what the hell they're doing when they put things in the order they do. If someone's really acutely sick, they'll go to the head of the line. If not, you take 'em in the order you get 'em. Period.
The folks I've been working with are really very good about it. I haven't seen anyone picking charts yet, and I suspect I won't. Though I must confess that when the surgery intern and I went to the rack simultaneously and grabbed charts, I whined. Whining is categorically uncool, but I did it anyway.
"Aw hell. I just spent fifty minutes on a messy leg laceration, and I don't wanna do another one. Crap."
He looked down at his chart, then up at me. "Wanna swap? This is a vaginal bleed."
I thought about it for all of two seconds and said, "Okay."
I justified it to myself by thinking, "well, no one waited any longer because of it," but I feel vaguely guilty about it still.
It turned out to be easier on me than on him though - my patient was twenty weeks pregnant by dates with no prenatal care whatsoever. This was her eighth pregnancy, and she had one child. The other six pregnancies were ended by miscarriages. A quick call to the OB/Gyn intern got me, "send her up to labor and delivery now." Instant turf to OB.
"Wait - why am I going up to labor and delivery? Am I having another miscarriage?" There was panic in her voice, pain and fear all over her features. The four year-old with her was saying, "Is mommy going to be okay? I want mommy to be okay!"
"Yes sweetie, your mommy is going to be okay. Ma'am - I don't know, but you could very well be. That's why I want the OB/Gyn doctors to see you. They specialize in this sort of thing. They're experts."
So there I was, one away and two cooking, waiting for labs to come back so I could decide what to do with them. Back to the chart rack. There was nothing in it but a triage-sheet. You get a triage sheet (as opposed to an entire chart) for someone really sick. You grab it and trot on in to see the patient right away. I was, however, on the south side of the E/D, and they're not supposed to triage super-sick people there. "Quel bizarre," I thought. I picked up the sheet and my heart sank.
"14 y.o. f, raped," it said, "never sexually active before this."
Karma. I had whined, and then swapped a chart - call it a soft pick. Murphy, the Lord of Chaos, grinned wickedly and balanced the equation.
I went into the family room where the two women from the rape crisis team were going to take down her story. I needed to hear it for my own documentation, and I didn't want to put her through relating the ordeal a second time. "Please feel free to chime in with any questions during the interview," one of them said.
When their interview was concluded, I asked the two women if I could photo-copy their notes. One looked somewhat startled, then smiled and said, "sure." The other looked at me like I was rancid dogmeat -- with maggots. I would really like to know what was going through her mind - why she so clearly felt nothing but contempt and loathing for me. Does she dislike doctors in general? Men? The color of my hair? My earrings?
The nurse who was helping me was wonderful. Actually, it's really the other way around: I was helping her. She did the vast majority of the evidence collection and counseling, and all of the hand-holding. After the interview with the rape-crisis people, she took the victim back to the room and told me, "I'm going to be about forty-five minutes. I'll call you into the room when I'm ready for you."
The exam itself was an ordeal - not for me, but for my patient. She was scared out of her mind - and when it comes down to it, I can't blame her at all. She cried the whole way through it.
After the physical exam was over I asked, "the pain you had while I was examining you - was it on the outside or where the speculum was?"
"No."
"Was it inside?"
"Yes."
"Was it where the speculum was, or was it deeper?"
"It was deep. Deep inside."
She had no pain whatsoever when I moved her cervix with my fingers - or rather no change in her overall discomfort. Thus it's incredibly unlikely that there was any infection or intra-pelvic process going on.
I do not doubt for a moment that her pain was real though. I fear that she may suffer with that pain for years, or the rest of her life, even though there is no physical cause for it.
After that, it was just paperwork. Reams and reams of forms. The nurse came out of the room. "What next?"
I thought for a moment. "We need to get baseline tests for HIV, hepatitis and syphilis. Umm . . . Oh hell, I almost forgot. We need to offer her `morning after' pills. We need to make sure that she follows up with our Gyn clinic. Am I forgetting anything? Did I do okay?"
"You did fine."
She is fourteen years old. She had asked a friend for help while she was being raped. The friend literally stopped, turned her back, and walked away. Her world has just crashed catastrophically
I can't understand it.
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