I found the smallest IV needle I could, a 24 gauge, and got my bag of normal saline ready to go as soon as I got the needle in the vein. The parents' worries about their two-year-old were most likely misplaced. He had a runny nose and a low-grade temperature, but to me his lungs sounded clear and his breathing wasn't forced. No telltale cough. In all likelihood, he didn't belong in an emergency room.
But how would his parents -- hard-working migrant laborers who spoke little English -- know all this? For them, the Yuma, AZ, Emergency Room was an all-night clinic. Better safe than sorry. Like a majority of the nighttime admissions to the ER, their paperwork read "self pay" in the box labeled "guarantor." Because this visit, and many others like it this night, would be billed in excess of what this family made in a month, the likelihood of their even receiving a hospital bill was less than zero.
I got a tech in to help. A brawny guy who spoke Spanish, he spread his torso over the tot completely immobilizing him. I pulled out the hidden needle, tried to blocked out the screams from the child, and prayed to God that I got a vein on the first try. It worked, thanks to the iron grip of my tech on the child and on his emotions.
The printed results came back negative, and a doctor eventually visited the family with his preprinted discharge and an Rx for Cipromycin, the antibiotic du jour for the winter of 2006. Not that I blame the doctor; malpractice insurance premiums for ER physicians are high, and by the standards of the law, he had performed due diligence.
Repeat this scenario nightly, and this was my life as an ER nurse for the migratory labor season of Yuma, the "Lettuce Capital of the World." It's not unlike all ERs across the country.
Emergency rooms have morphed into 24-hour diagnostic centers. Physicians are expected not just to set broken arms and ship out stroke victims, but also to follow the trail of exotic bacteria and discover concealed cancerous tumors. In the trade, this is called "zebra hunting;" on TV, Dr. House is the classic zebra hunter.
My life as a traveling ER nurse is summed up by my notes from a night shift holding down a three-bed ICU in a rural New Mexico hospital:
Last night the ER sent me a thirties-something guy to sleep it off in the ICU. His blood alcohol was off the scale and he tested positive for marijuana. Apparently, after partying with friends, he had slinked off to lie down and later they found him passed out, breathing but non-verbal. The EMTs brought him into the ER, where he was given the reversal agent, Narcan, and a liter of fluids reinforced with vitamins (in color, fluorescent yellow and known as a "banana bag").
According to his old chart, this patient had been in the hospital before and had a history of poorly controlled diabetes. The Narcan brought him around to reality, shouting and struggling to leave the ER. He was sent to me in the ICU in four-point leathers, but not before he was taken for a chest x-ray, a CAT scan of his head, and a CAT scan of his cervical spine. These tests were sent to Australia for an interpretation by a radiologist (daytime there). This, in addition to the blood panel that included not just a toxin screen but also a complete metabolic panel and blood count.
Actually, the only relevant test for this fellow, with a history of diabetes, was to rule out a diabetic coma, which can mimic intoxication. This could have been done with a simple finger stick. With all, the bill probably amounted to $3,000 worth of testing, plus a physician fee in the neighborhood of $500, assorted ER fees in the hundreds, and a $1,500 stay in the ICU overnight. Let's round it off to $5,000.
The patient ended up fine, sleeping off the alcohol. He didn't have insurance, or the ability to pay the bill, so the hospital was stuck with it.
Well-intentioned national policy makes ERs available to all comers, preempting primary care physicians and urgent care. Constant litigation pushes up the bar, so doctors are left being better safe than sorry. The result: 24/7 mini Mayo Clinics, where expensive CAT scans and blood tests rule the day, even for two-year-olds with runny noses.
"Paging Dr. House, STAT! The ER is hemorrhaging red ink!"