My arm is around you but I cannot protect you.
I posted this photograph on instagram several weeks ago after an especially difficult shift. You see, my seven-year-old son wants to be a doctor when he grows up. A prospect that should fill me with joy instead leaves me worried. I cannot wish for him a job where we struggle with torrential verbal abuse by parents of our paediatric patients. Of course, I realise discussing these challenges might be controversial. Aren’t doctors meant to have a high pain threshold, the primary reason for our existence being to serve the public?
Perhaps it is rude to start off on an accusatory foot. Maybe I’ll turn this on its head and address issues that irk parents. Here are three common complaints regarding waiting time that we encounter daily in the children’s emergency department. I’ll explain as best as I can. Please note that this is a personal blog. It does not represent the views held by either the ministry of health or my hospital. Nonetheless I hope you’ll hear me out; often it is difficult to get a word in edgewise.
Why was my queue number skipped?
What Is Triage?
Most emergency medical services practise a system of triage. To triage is to sort. This way, patients who are most ill or injured get help first. In my department, the nurses have a triage point set up near the entrance, right after you take a queue number. Of course, if your child is ill or injured, you won’t have to wait long at all, before the doctors attend to him. This might mean that your child sees a doctor before those who had taken earlier queue numbers. Conversely, if your child is (fortunately) less ill, say, with an uncomplicated fever, then your waiting time might be (unfortunately) longer. https://www.straitstimes.com/singapore/ae-units-flooded-with-non-emergency-cases
What If Things Change After Initial Triage?
As a result of the triage system, queue numbers aren’t called in sequence. However, in the time you were waiting to be attended to, if your child deteriorates, approach us. We may rapidly triage your child again. Triage is a dynamic process and circumstances can change over time. If indeed your child now requires urgent attention, rest assured: Help will be rendered appropriately.
How does the nurse know if my child’s condition is serious?
Nurses train to make a rapid assessment. How serious a child’s condition is, is based on several factors.
The triage nurses look at objective numbers. They have charts for heart rate, blood pressure, oxygen levels and temperature. They also take into account the appearance of the child and his complaint. For instance, a young child whose heart rate is too fast for his age, is pale and bleeding from a large wound, will be prioritised over an older child who is lively and complains of runny nose.
To save time for less urgent cases waiting for a doctor, nurses may initiate investigations like blood tests and x-rays. They can even start treatment, like fever medication, so that precious time is not wasted. By the time your child is seen by a doctor, some of the results may be out, expediting the consultation.
Why can’t someone tell me what my waiting time is?
What’s The Nurse Doing?
Other than triage, our nurses do plenty of work like serve medication and simple blood tests. For safety, the nurses need to verify the patient’s identity and drug allergies before serving the correct dose of the correct medication. They also need to verify the identity of the patient at several points before taking blood, labeling the samples and dispatching them to the laboratory. These safety measures taken time and require concentration; they shouldn’t be rushed. In fact, nurses do many other duties but I’m sure you get the idea. No nurse’s assigned duty is to be yelled at about the waiting time.
What’s The Doctor Doing?
Doctors may also be attending to ill patients or performing a procedure on an injured patient. We may simply be discussing management plans with patients waiting to be discharged. Often we are asked to juggle many tasks simultaneously. When this is impossible as all tasks take time, we must choose what is urgent and important. More importantly, these matters require our undivided attention. Once again, doctors shouldn’t break away from their tasks just to discuss waiting time.
Nobody Knows For Sure What Your Waiting Time Is
When you understand what goes on behind the scenes, you might see why it is difficult for the nurse or doctor to pull away just to explain what the waiting time is. In fact, it might even be dangerous to do so. Yet, a long line of parents queue up next to the nurses serving medication, or interrupt other patients’ consultations with doctors. They just want to ask how long they have to wait. Unfortunately, that answer is difficult to predict, because the existing patients being managed by the doctors may take a variable amount of time to be treated. At any moment, an ambulance might bring another ill child that might need to be attended to immediately.
Being a parent myself, I understand that this answer is disappointing. To every parent, their own child has the highest priority. However it is the reality of the situation and no amount of yelling can change it. If anything, yelling at us actually delays everyone’s treatment and prolongs the waiting time.
Trials & Tribulations Of Triage
I hope this post is helpful to explain the system of triage. The adage “first come, first served” does not apply. Unfortunately, I don’t have ready solutions to the perennial problem of the long waiting time. And I am truly sorry. Our resources are finite, so abstract solutions to make the hospital bigger or train more specialists don’t work.
A helpful strategy might include managing expectations. Maybe we can educate the community on when to come to the emergency department (versus when to go to the polyclinic for instance). http://www.smj.org.sg/article/understanding-decisions-leading-nonurgent-visits-paediatric-emergency-department-caregivers Common presenting complaints include Fever Pitch . Some parents have suggested having a signboard in the waiting area to estimate what the longest or average waiting time is. What do you think can be done? I would love to hear from you, but please don’t yell at my residents and nurses! [Addendum 16 June 2019: Our department now has a dynamic screen that shows the longest waiting time. Thank you for your suggestions!]