“Why do y’all give in?” Molly asked one of the Academy doctors about a drug seeker. “He goes to a different hospital every day of the week. I would bet my last dime he sells the pills.”

The doctor shrugged. “I sometimes find it easier to give drug seekers what they want than deal with them raising hell.”

Molly knew of one drug seeker who had gone to an ER every day that Molly had worked for the past six years. “I want to know how he still has Medicaid,” Molly said. “That’s a minimum of $600 to $800 per visit. Conservatively, that’s $1.3 million to support a drug dealer and addict. I worry about what will happen to healthcare costs if we can’t get our act together.” When he became her patient, she used a larger needle than necessary on purpose to draw his blood; it was the only time she had ever practiced punitive medicine. Less than an hour after he left Citycenter, he showed up at another ER to get more drugs.

The ER abusers who most infuriated Molly were the homeless people who claimed they had a problem—chest pain, abdominal pain—so that the ER, as required, started a full workup. Then they would ask for a sandwich. “Some will even admit that the only reason they came in was for a sandwich,” Molly said. “Are you effing kidding me? You think taxpayers should pay six hundred dollars so y’all can get a sandwich?!”

Another abuse of the system routinely occurred on weekends at Citycenter, which wasn’t far from a jail. Come morning, people incarcerated for drunk driving or drunk and disorderly conduct looked for any excuse to leave their cell. Police escorted a 22-year-old college student from jail to the ER because he had slept in his contact lenses and claimed he needed eye drops. “To avoid doing paperwork, sometimes the police ask patients if they want to go to jail for being drunk and disorderly in public or to the hospital. Of course they choose the hospital!” Molly said.

ERs were packed with nonemergencies. One patient came into the ER complaining of acne. Another man showed up because his barber told him he was going bald. And then there were the patients who visited the ER simply because it fit best with their schedules. Several patients checked in because their doctor couldn’t see them until the afternoon. One of Molly’s Academy patients had an outpatient prescription for an ultrasound, but said, “The line was too long, so I came here.” Instead of paying $200 for the exam, the patient’s insurance company would now pay the minimum of $600 for an ER visit plus approximately $500 for an “emergency” ultrasound.

Molly decided to emulate another triage nurse, who greeted patients by asking, “And what’s your emergency today?” While the phrasing wouldn’t embarrass patients enough to leave, perhaps it would discourage them from coming to the ER the next time they had a nonemergency complaint.

JULIETTE

  PINES MEMORIAL, May

Juliette was working triage with Erin when a thin man in his late fifties came in. He had pulmonary problems and his doctor sent him to the ER because of an irregular EKG. His vitals were fine. “Do you have any chest pain?” Juliette asked him.

“No.”

“Any cardiac history?”

“No.”

“Shortness of breath?”

“No.”

Erin took the man to the adjacent lab room while Juliette began triaging the next patient. “Are you doing okay?” Juliette heard Erin say.

“I’m okay,” the patient said.

“Do you feel weak?” Erin asked as she began to place the IV.

“No,” the man said. “But . . . I think I need to lay my head back.”

“Juliette!” Erin shouted. “You need to come in here!”

Juliette rushed to the room. The man looked unconscious. “Do you have a pulse?” Juliette asked.

Erin already had her hand on his neck. “No, I don’t have a pulse.”

Juliette quickly checked the man’s neck. She couldn’t find a pulse, either. He was barely breathing. “Agonal respirations,” Juliette said. “I’m starting CPR.” Juliette pushed the Code Blue button behind the chair and began doing chest compressions. Erin began airway management with the ambu bag.

They wheeled the chair toward patient rooms while continuing CPR. “We need a bed!” Juliette announced as they dashed through the double doors.

Juliette had performed solo CPR twice (as opposed to working a code with a hospital team). Once, she and her daughter were going out to dinner when a businessman collapsed on the sidewalk. Juliette did chest compressions until, finally, he came to.

That time, Juliette had been scared because she was outside of the hospital setting, without equipment and staff that could support her. She had not been afraid recently when a 50-year-old woman came into the ER for bradycardia, a slow heart rate. Juliette had asked a new tech to put in an IV, but when she returned to the patient’s room, she discovered that the tech instead had gone to triage. Juliette was hooking the woman up to the cardiac monitor when the patient took her hand and said breathily, “I just want to say good-bye.”

“What are you talking about?” Juliette said. The words sounded strange.

“I’m just going to say good-bye,” the woman repeated. Her eyes went vapid. The monitor showed the woman’s heart rate plummeting to zero. There was no time to press a code button. There was no IV to utilize.

Juliette didn’t even think. She did the precordial thump, a method of resuscitating a patient in cardiac arrest: She raised her forearm to her nose and brought it down hard on the woman’s chest. The woman opened her eyes and burst into tears. She seemed to know exactly what had happened. “Thank you,” she whispered, grasping Juliette’s hand. “Thank you.”

When Juliette yelled at the tech, he blamed the new zoning rules, another Westnorth policy. “They set up our priorities so we’re supposed to help with triaging,” he complained.

“If I ask you to put a line in somebody who has a heart rate below forty, you need to put the line in,” Juliette said.

Shortly after the tech placed the IV, the woman’s heart rate rose. Later, Juliette learned that the woman received a pacemaker.

Juliette wasn’t going to lose this cardiac patient, either. Her arms ached but she continued the compressions. About a minute later, his eyes flickered. He looked around in a daze. “What happened?” he asked. Juliette savored the adrenaline rush.

Erin turned to her. “He was totally gone! His eyes were rolled back, he was shaking all over before he went still!” Agonal convulsions sometimes preceded clinical death.

Carla, a nurse in the clique, walked by. “Way to save a life!” she told Juliette, who smiled.

Once the man was in a room, the cardiologist came downstairs to evaluate him. “It turns out he also passed out at the pulmonologist’s office when he got some bad news, so it might have just been a vasovagal reaction,” the doctor told Juliette. A vasovagal reaction is a nervous system reflex that causes a sudden drop in heart rate, resulting in less blood pressure to the brain and leading some patients to lose consciousness. The doctor nevertheless admitted the man to the hospital’s cardiac unit.

When asked later what it felt like to save a life, Juliette said, “It’s amazing. That’s what we’re supposed to be doing but it doesn’t happen every day. Most days are about cleaning up poop or addressing abdominal pain or nasty family members.”

At the start of her shift the next morning, Juliette looked over the charts for Mr. Morse, a 77-year-old who had come in overnight. She noticed that the night shift had made a mistake. The man had blood in his urine and low blood pressure, but the nurses hadn’t done a three-way bladder irrigation. These irrigations weren’t pretty, but they usually worked. If a man had a large clot in his bladder, treatment involved inserting a catheter into his penis to flush out the clot.

Juliette caught the night nurse before she left.