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.

My Spinning Head

My head is spinning. Seriously spinning.

Let me see. A combined twelve years of elementary school and high school. Four years of college. Four years of medical school. One year of internship. And three years of residency. Oh yeah, don't forget about the thirteen years of "life" I've had since all of this formal schooling and training has finished.

Yet, for all of this experience and hard work, I felt abandoned. Confused. Wayward. Standing in the middle of a store aisle. I ended up looking to my left, ready to plead for a stranger's help. I looked to my right, hopeful that some angelic vision enveloped in a bright, shining aura would proclaim the answer to my question. And I looked ahead of me, acutely aware of all of my options.

Which cough and cold medicine should I buy?

You might laugh but, seriously, how does the common person do this? Here I am, with all of this medical knowledge and ER experience in my back pocket, and even I can't make a decision to what I should buy in this endless cough and cold medicine aisle.

It started out simple enough. Traveling down the fourteen hours to Hilton Head these past few days, staying in a hotel room halfway through the trip, lots of car time with some lingering kid-coughs, closed continuous car circulating air, and, before I could blink, my wife has a runny nose, sinus congestion, and headache. And is feeling rundown. And is achy everywhere. And has a sore throat. And a fever, "well, maybe I don't have a fever but I feel warm." I'm sure it was brewing before we left but, unfortunately, presented itself at the start of our vacation.

The thing is, my wife never gets sick. Seriously. She takes her vitamins, she exercises, she eats her vegetables, and not from a can, mind you (that would be me and my love-affair with young, tender peas). She consistently partakes in all the things that I only do on a sporadic basis. But, here we are, on vacation, and she's the one whose ass is dragging. I would take one for the team, in a heartbeat, if I could spare her this misery. But, I have to admit, for once, it's nice to not be the adult in the house getting the kids' spill-off illnesses.

She's not a complainer (of the two of us, that would be me), so when she asked me if there were any medications she could take to feel better, I knew she was not feeling well.

We went out as a family to WalMart to buy her some medication for her symptoms. The irony of it--driving fourteen hours to go to a store that exists five minutes from our home--was not lost on me. But to our credit, we did try the local grocery store first.

I walked into the store, very clear about what kind of medicines she needed to get back on track. How hard could this be, really? She and the kids grabbed a cart to fill-up on our needed supplies for a week of condo-living. I searched out the pharmacy section. "I'll meet up with you in a few minutes," I had said. On hindsight, a stupid statement.

I found the cough and cold medication aisle quickly. I started picking up the boxes to read the active ingredients. Cough suppressant? Cough expectorant? Nasal decongestant? Antihistamine? After sorting through all of those options, then, I had to decide if I wanted acetaminophen (Tylenol) or ibuprofen (Motrin or Advil). Okay Jim, I comforted myself, just take your time and start over.

I decided a different approach--let's go with the proclamations on the front of the box. Cold Multi-Symptom (regular or severe), Sinus Congestion, Headache and Sinus, Cough and Headache, Sore Throat and Cough, Sore Throat, Cough, and Sinus...you get the picture. If nothing else, I appreciated the selling of every single variable you could squeeze out of the common cold.

So picture it, you are at the store shopping and you see a guy scratching his head, rubbing his chin, pacing back and forth, picking up a box off the shelf just to replace it back in seconds, and that would be me. With all of my infinite medical wisdom.

I finally sorted through all of these options before realizing, "Wait, she'll need both a daytime and a nighttime medication." I sure didn't want my wife to get tired in the daytime during our time at Hilton Head, right? Possibly risk sleepwalking through our vacation? So, guess what? She'd need the nighttime version, too. Unfortunately, though, the daytime formula I had decided on didn't have an alternate nighttime version (it's usually just an addition of some form of antihistamine). So what did I do? Well, of course, I started over.

The minutes dragged, the active ingredients blurred, and the box-front symptoms united to form one big blob of an illness. Finally, after much frustration, I picked out what I thought was the best option for my wife's illness.

"Daddy," I heard my youngest call, just as I was wrapping up my choice. Looking down the aisle, I saw my smiling family approach me. "What took you so long?"

I held up the boxes I chose for my wife to see. I must have looked like the village idiot, extreme pride radiating from my pathetic face, eagerly anticipating my wife's approval of the two $2.68 boxes of miracles. Please, please, I remember thinking, tell me how good I did.

What she asked next was like fingernails on my brain's chalkboard. "What about the liquid, Jim? How's that?" I think I stomped my feet, my mind screaming "No, no, no" while my voice remained silent. "Or," she continued, walking down the aisle, scanning the options, "maybe I'll just do gel-caps." She looked at several boxes quickly, scanning each's front and back in just short of ten seconds. "Yeah," she said, "I think these will do." She had found a combo-box of both daytime and nighttime medication with, evidently, just the right active ingredients to treat her symptoms.

I think I'll just place this whole experience in the "knows too much," category, thank you very much. I might just be giving myself too much credit, though, on that one.

Now, if you don't mind, I have to go take a couple Tylenol for my headache. Or maybe Motrin. Oops, I mean Aleve...

As usual, big thanks for reading. Next post follows on Wednesday, March 17. Hope everyone is well...see you then...