Wednesday, June 16, 2010

Two-fers And More

Anyone who has worked in an emergency department is well aware of the term "two-fer." It is a term that seems to be accompanied by dread and a discouraging shake of the head. Unfortunately, though, it is a reality that comes with our jobs. And as much as we'd like to run from a two-fer, we have all learned that it is better to just suck-it-up and deal with the situation.

Two-fer. See, just thinking about it, I can feel my heart rate picking up.

So, as the name implies, we are not dealing with a single patient. Nope. A two-fer typically means that there are at least two patients from one family that wish to be seen. For example, a mother with some URI symptoms may decide to be seen by a physician as long as she is checking-in her sick toddler, he with a fever and some ear tugging. Maybe it's the elderly couple who have both decided that their diarrhea is from eating out at a local buffet house. "I knew I shouldn't have eaten the rice, Edgar. It didn't look right." Maybe, even, it's twin pelvic exams for the college roommates who do everything together.

Surprisingly, though, I think patient number two does not typically plan on being seen but, instead, makes the split-decision to be treated once they arrive at the ER. And why not, really? They are already here. If their family or friend is going to be treated, they may as well get "checked-out, too."

If it were only two patients, maybe it still wouldn't be such a big deal. But guess what? Yep, you guessed it. Sometimes there is a "three-fer" signed in. Sometimes, even, a "four-fer" and a "five-fer." A general rule is that the more people that sign in from the same family, the less sick they really are. And because of that, they usually get sent to our express track. Don't you think, for one minute even, that I don't appreciate immensely that provider taking one for the team.

A few years back, one of my favorite physician assistants, a compassionate free-spirit named Patty (imagine Carole King dancing wildly at Woodstock), was assigned to my supervision. And it was during this shift that Patty set a new record. In my book, anyway.

Guess how many she saw from one family? Five? Nope. Six? Nope. Drum roll, please...Patty saw seven patients from the same family. Is "seven-fer" the right term here? I don't honestly know.

Can you even imagine walking into one treatment room and finding seven patients, though, waiting to be seen? I can't, although Patty seemed to take it all with a grain of salt. "I may as well just buckle-up and get this family taken care of, Jim," she replied when I called her to ask if she needed any help. And tell her that I thought she was a god. "They all seem to have the sniffles," she added, "I'll be okay."

It turns out that two adult-cousins, mothers in their twenties, each brought in two of their kids to be seen for cough and cold symptoms of a day's duration. While checking in their kids, the two adults decided that they, too, wanted to be "checked out." Heck yeah, why not? So let's count. One mommy plus two kids equals three. Plus, one mommy and two more kids. Three plus three equals six. Not seven.

Oh, but while this family was in triage, one of the young mother's decided to run back home and get her third child, an infant, who "was just starting to get a runny nose, too." So, while she was away, the other mother took charge of four unruly, poorly-behaved kids. We could hear them, three halls over in our acute ER, causing a ruckus. Wouldn't you think that if they were sick enough to come to the ER, they would be somewhat fatigued or a little wiped-out?

This, my friend, is how Patty ended up with seven patients in one room. While mom number two was away, mom number one was placed in one treatment room with the four waiting kids. The door was shut after a few minutes, by nursing, because of their disrupting behavior, until Patty went in to perform her exam. Pardon me, I mean exams.

Happily, Patty reported that there was no significant concerns or illnesses in the room. An ear infection here. A strep throat there. Otherwise, normal cough and cold symptoms presumed to be viral.

"Patty," I had to ask, "is this a record for you?"

She didn't even flinch. "Hell, yeah, Jim," she said, chuckling, "and I hope I never have to top it."

I was eager to see how she approached so many patients. Maybe she saw one or two patients at a time and then stepped out to fill out the medical charts. That's how I would do it, I think. To avoid all that confusion.

"Nope," Patty said, shaking her head and pulling out a ratty 8 1/2" x 11" paper, "all of my notes are right here." As the mothers had talked, she had taken notes on each patient and then immediately performed their exam. "If I had stepped out of that room, even one time," she added, "I don't think I would have ever gone back in." When she was done, she stepped out of the room and formally filled out each patient chart, their discharge instructions, and their prescriptions, if needed.

Time spent? One hour. Which, when you think about it, is a good average. Seven patients an hour. Us ER docs typically average two to three patients an hour, although our patients may be a bit sicker. Nonetheless, Patty kicked ass. And I told her so.

"Yeah, well thanks, I guess," Patty said, wondering if I was teasing her or being serious. Maybe a bit of both, actually.

News of Patty's heroics travelled fast through our ER and, for the next week, she was looked at with nothing less that pure adoration. Honestly, I think she soaked all the glory and attention right-up. Who wouldn't. Some even nicknamed her "Seven."

As much as a team player that I am, though, I was very glad that it was Patty who stepped up to the plate to see this family. And not me. I think Patty single-handedly saved me from becoming a befuddled bobble-head.

Suddenly, a two-fer doesn't sound all that bad anymore...

As always, big thanks for reading. I hope everyone is having a great week. See you Friday, June 18.


Heather said...


Hysterical! I so needed that this morning.

Although, you know, Jack's kinda sniffly, and J has a slight fever, and I'm not feeling so hot... ;)

Kate said...

Sometimes new people don't even know what they're up against until someone tells them differently. Wahoo!

Anonymous said...

Getting seen in an ER for the sniffles??? What a complete waste of health care resources.

rlbates said...


Have Myelin? said...

Oh my...and all I want for Christmas is a doctor that accepts Medicaid. LOL.

You are a riot! =)

911RN said...

Way to go, Patty! Commonly, have two-fers and three-fers. Never, 7, thankfully!! Probably the most I have ever had is four or five.

Dread seeing the "family" all signing in for triage. Feel sorry for the triage nurse if it is not me, silently pray they don't put the fam in "my room" and if they do- hate the discharge process the most...ends up being all the same diagnosis, for the most part.URI, cold, flu...something viral, benign.

May have one, out of the whole bunch, that truly was "sick" worthy of treatment that receives a RX for ear infection etc. Parents always ask and want to know why the other child didn't get RX- "because they don't have an ear infection" - Duh?

It's just a cold. Well, why can't brother/sister have one to prevent the ear infection- she/he started with the same thing, first, and got THE Ear Infection...other child (not being treated) will get it next!! Then must explain the A&P of the ear, colds and not everyone will end up with ear infection. We don't treat viruses with antibiotics, etc. Why are you treating THE Ear Infection... that's a virus causing it. NO, explain the difference....and it goes on and on! To the two-fer mentality family- veteran ER staff KNOW what I mean. Two-fer families tend not to be the sharpest knife in the drawer.

Child with ear infection was probably the one that drove the whole process, to begin with, to go to ER and needed to be seen. The rest just jumped on the "need to checked out" bandwagon- sigh!

Great post.

leslie said...

I thought this post was going to be about the much more difficult two-fer, two members of the same family badly injured in a car accident or assault. By comparison, this particular two-fer is almost fun.

Anna said...

Jim, you know this just reminded me when my sister was sick, my mother automatically used to take me. I think after I got sick just being at the doctors, probably picked up from there. The worst one was when I had to be home for 1 month away from school, I don't think I was that sick, but I think again my mother did it so I could keep my older sister company, and the worst, because she was sicker then me, I had to watch her eating the better treats (yes its real!), lol. Thanks for sharing and having said that, I learn something. Anna :)

EMT GFP said...

I can honestly say, the only time my family has ever done something like this was when we were in a car accident and I went in for chest pain and difficulty breathing from accident. It was only after my other and my sister realize that I was okay that they discovered they had injuries too.

Thankfully I have never pulled a "sniffles" episode nor have brought a family of patients in on the ambulance.

SeaSpray said...

Good for Patty ..I mean Seven ..Good for seven! :)

I never heard it called two-fer before ..but have experienced it and it is usually something like the sniffles or a stomach virus. Better than scabies tho!

I can understand trying to kill 2 7 birds with one stone ..but NOT at EMERGENCY department prices! Had to be MDCD patients. Usually is. I do not mean to be negative own mom had mdcd after her mdcr ..but never abused the system ..ever.

Like Leslie ..I also thought it was going to be something bad.

Too bad you can't redirect them to their pcp.

Katie said...

Well done, Patty!

The closest my glued-to-the-hip roommate and I ever got to twin pelvic exams was my offering to drive her to the ER for her kidney stones. But there would have been one patient and one note-taker but not a two-fer.

<>< Katie

Maha said...

A two for one deal is always available when you don't want one! Enjoying catching up on your blog again :)

Anonymous said...


Texas reader said...

If you use paper and don't do everything on a computer outside the room, it might be a good idea to sit in there with them and not give them their scrips and let them go until you have finished the paperwork on ALL of them. Better yet, do one exam, then the paperwork for it, then the next exam. Putting all the notes on one page got them out of there so fast they won't hesitate to do it again.

ER's Mom said...

Seven is a saint.

And if she ever gets a nine-fer, she can now become Seven-o-nine.


Anonymous said...

During my pediatric residency, I saw a "seven-fer" in the ER to rule out sexual abuse. A young boy in the home had been diagnosed with gonorrhea they day before and all seven other foster kids had to be examined and tested. What a nightmare! It took me all afternoon (probably 3 hours or more!), but in the end we actually found the perpetrator (an adolescent in the home)... so I told myself it was worthwhile!

And, as much as I would like to tell you I'm making this up, I'm not.

Smalltown RN said...

What a great story...we all need a Patty around every once in awhile.

Sorry I haven't been around lately doc...been kinda busy....hope you are having a wonderful Father's day!


Peter said...

My last brush with a two-fer involved a brand new mother-in-law and her brand new daughter-in-law. Both had been admitted for overdosing on the bubbly. They didn't stay long and could be heard throughout the corridors of the hospital laughing and burping their way to freedom.

Take Care,

Anonymous said...

I'm a vet, and I have to say I hate two-fers. They're usually two dogs from the same family who were found near the remnants of the wrapper to a bar of dark chocolate. Figure $2000 (at a specialty 24 hour hospital) a pop for inducing emesis, activated charcoal, IV fluids, telemetry, blood pressure monitoring, seizure watch, intake bloods.... I get lots of scowls and yells even though A) I'm not the one who left out the chocolate, and B) I don't set the prices.