The Signature

D I V E R S I T Y I N E M E R G E N C Y C A R E

Author: Sheri Cook, RN, CEN, Tallahassee, Fla

Section Editor: Renee Semonin-Holleran, RN, PhD, CEN,CCRN, CFRN, CTRN, FAEN

Sheri Cook is Emergency Services Educator, Bixler Emergency Center,Tallahassee Memorial Hospital, Tallahassee, Fla.

For correspondence, write: Sheri Cook, RN, CEN, Bixler EmergencyCenter, Tallahassee Memorial Hospital, 1300 Miccosukee Rd,Tallahassee, FL 31317; E-mail: sheri.cook@tmh.org.

J Emerg Nurs 2007;33:372-4.

Available online 4 June 2007.

0099-1767/$32.00

Copyright n 2007 by the Emergency Nurses Association.

doi: 10.1016/j.jen.2007.03.011

372

hen addressing the concept of diversity, we

W need to remember marginalized patients,

who commonly are seen in the emergency

department. The following story emphasizes the impor-

tance of truly ‘‘caring’’ for our patients. (Note: The episode

I am about to relate was written 2 years ago when I was a

staff nurse in a busy regional emergency center, where we

cared for more than 70,000 patients per year.)

I am a nurse with more than 25 years of experience

under my belt (yes, you can cut me in half and count the

rings). At this time I was working two 12-hour shifts every

Saturday and Sunday. Because I did not work full time in

the emergency center, I was almost always happy to be

there—fresh and not world weary, or so I thought until

this particular Sunday.

On this day, on the acute side of our department,

having 3 rooms and a hall bed assigned, I had the luxury of

having only 2 beds occupied. As usual, patients remaining

from Saturday night included persons with ethyl alcohol–

facilitated injuries. My mission was to:

1. wait until they sobered up enough to be safely discharged;

2. serve them breakfast, particularly food that might make

their movement out of the department smoother;

3. get them a taxi if they did not have family or friends

who could provide transportation; and

4. get a set of vital signs, including a neurological check,

to ensure that someone did not miss a subdural bleed,

and check blood sugar or other potential problem elec-

trolyte imbalances.

After report, I was off to door number 1. The patient

in this room had an insect bite that had progressed into

an invasive cellulitis. Intravenous antibiotics were hanging

JOURNAL OF EMERGENCY NURSING 33:4 August 2007

D I V E R S I T Y I N E M E R G E N C Y C A R E / C o o k

and he was too inebriated to put together a sentence, let

alone a history. He had a pulse and his intravenous line

was not infiltrated. He was positioned on his side in case

of vomiting. His pupils were equal and reactive to light.

I believe he is oriented to person and place, so my work

is done in this room; it is up to his liver to complete the

work of bringing down his blood alcohol to a level that

will enable us to communicate.

I go on to see patient number 2, a man who fell

down and sustained a head laceration. It is his third

admission to our emergency center in 48 hours, and this

time the wound required sutures. Each incident involved

ethyl alcohol and Social Services and the patient not getting

any further than the closest liquor store. He is upset,

and upon entering the room, I am now included in his

verbal assault. I gather from his complaints that a baseball

cap is missing. He was bending over to pick up the change

that had fallen out of his pocket when he had been supine.

He is homeless; all his belongings are contained in a small

duff le that is missing a handle because it had been cut off

by some aggressive paramedic. Now the grumbling starts

about the broken strap. He carries the usual assortment of

drifter assets: papers; tobacco products; clothing odds and

ends (I note he does not have an entire change of clothes,

and none appear or smell clean); and last but not least,

a sausage of some kind—summer? Kielbasa? It was

uncooked, and there was no refrigeration unit in sight. I

choke back my anger as his latest tirade includes com-

mentary about my work ethic and my mother. Holding my

hand up, I indicate that I will be right back (he probably

thought I was scooting out of the room to grab security to

force him back out on the street). Instead, I go to the closet

where we keep extras of this and that. The search for a cap

for this big irate man is fruitless. However, I am able to

procure an almost new jacket, new shirt, slightly used

backpack, and various toiletries. I return to the room with

these items, and as I escort him to the shower, the yelling

stops—it is not a thank you, but it will do. If we have

admission number 4 for him later in the day, at least he

will be cleaner and, I hope, a little less angry.

I am feeling noble because I rose above personal insults

about my mom and myself and treated the least of us with

respect. I am causing myself arm pain from patting my

own back. It is now time for church to be letting out and

August 2007 33:4

the Sunday morning rush is starting. (I used to think that

God ‘‘got you’’ if you did not go to church on Sunday, but

my own observations [evidence based, of course] did not

bear this out. You are as likely to succumb to a syncopal

spell or myocardial infarction at home as in the church.

The Lord does work in mysterious ways; my personal belief

is that He has a sense of humor.)

JOUR

He is homeless; all his belongings arecontained in a small duffle that ismissing a handle because it had beencut off by some aggressive paramedic.

Finally, my third patient arrives, a middle-aged woman

with abdominal pain that was severe enough to cause her

to dial 911. It seems that half of the patients I get

have abdominal difficulties—boring, boring, boring. I was

ready for something that would get the blood pumping,

a little trauma or septic shock or even an acute myo-

cardial infarction. Blast, time to get to it. When I ask her

age, she says, ‘‘Don’t you have that on your records?’’ I

respond that by providing a date of birth she will give us

better access to her records. She finally answers, saying she

is 46, and she gives me a birth date that ends in the year

1956. At this point I chuckle and repeat the question of

age, saying that I am 46 and was born in 1958. I make a

comment about new math or maybe say it is time to stop

adding years to your age when you reach a certain age.

She clams up and I decide she has no sense of humor—

the infirmed rarely do—and I finish my triage, thinking

I really must have upset her. She is answering only every

third question, making triage tedious. She cannot define

her pain, yet it was severe enough an hour ago for her to

call for ambulance. I describe her as vague, ambiguous,

distracted, and inattentive, almost like she was on drugs,

which she denies using. However, as soon as I administer

some medications for her pain, she becomes quite verbal

(nothing like a little dilaudid to make someone chatty;

have we let interrogators in on the use of administering this

medication in times of war for extracting information?). This

really could have facilitated her triage. She chants repeatedly

that she is worried about being admitted and she really needs

to get home to her sister.

NAL OF EMERGENCY NURSING 373

D I V E R S I T Y I N E M E R G E N C Y C A R E / C o o k

Her radiographs confirm that she is full of stool

(one of the questions she did not answer in the initial

triage). She has stool from the pyloric valve to the rectum.

At this point, with the help of the dilaudid, I attempt to

get a detailed elimination history, complete with when,

size, amount, frequency, and consistency. She looks at me

like I have grown a third eye, wanting to know about her

poop. Finally I give up, thinking, ‘‘You can take your

toileting habits and history to the grave.’’ I proceed with

the discharge instructions. I label her in my mind as an

odd duck. Little did I know that this label was about

to change, and the label of myself, which in the last hour

had been ‘‘noble,’’ is about to become ‘‘horse patute.’’

374

I am feeling noble because I rose abovepersonal insults to my mom and myselfand treated the least of us with respect.

The discharge instructions included all that was

legally mandatory and a jug of Go Lytely Bowel Prep. I

carefully gave her instructions about mixing the bowel prep

and included the standard wisecracks about ‘‘You will go,

you will go a lot and often, you will go forcefully and

mightily, but you will not go lightly.’’ I hand her the

discharge forms to sign, and she does not even offer a smile

for my Go Lytely humor. Now I wait as she forages in her

purse and pulls out her change clutch. From this she

extracts a frayed and extremely worn Social Security card.

She then very carefully and incorrectly copies her name

onto the discharge forms.

I realize how wrong I have been about her, ignoring

all the signs. I am shaken down to my very cynical core.

How could I have missed the mark so far? All of the signs

were there. I hang my head in shame, and my soul weeps.

She probably could not do math and did not understand

my attempts at bedside humor. She was afraid and wanted

her sister; she did not want to be in this environment

without some help navigating it, and I was of no help or

service. She probably perceived that I was making fun

of her.

I rapidly work toward service and dignity recovery.

I explain the discharge instructions as I would to a 6-year-

old child—that the stuff in the jug, you mix like Kool-

J

aid. Fill it with water to the line. It is going to make you

poop—a lot—but you have a lot in there and that is why

you have a stomachache. She finally smiles at me and

shakes her head yes!

OUR

I realize how wrong I have been abouther, ignoring all the signs.

This patient probably had an intelligence quotient

of around or below 70. She did not know a lot of things,

but she was smart enough to know how to hide her deficits

by not responding and through indifference. I was busy

thinking and sorting labels—maybe she was drinking,

using drugs, or was noncompliant and aloof. I misjudged

this lady to the point that it could have affected her

care, had she been more ill. I could have been more open,

patient, and kinder; instead, my preconceived notions pro-

duced a caustic professional indifference.

It is difficult for nurses in any emergency department

to stay fresh and look at each person with an unjaundiced

eye. We must not lose our ability to care and be com-

passionate. It is so easy to look at each patient as a diagnosis

or a set of circumstances and to prejudge. I challenge my

cynical self to do a better job and not be so sarcastic and

prejudging, and I challenge you to do the same. This

challenge can be difficult with the abuses seen in our

departments, especially the lack of resources and staff. You

can affect every patient for the remainder of his or her day

or rest of his or her life. In emergency nursing we are

charged to make a difference in each life we touch; let that

be a light of hope, integrity, and compassion.

NAL OF EMERGENCY NURSING 33:4 August 2007