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Life in Emergistan

‘Pull Till Full’ Pits Nurses against Physicians

Leap, Edwin, MD

doi: 10.1097/01.EEM.0000547690.28595.21
Life in Emergistan

Dr. Leappractices emergency medicine in rural South Carolina, is a member of the board of directors for the South Carolina College of Emergency Physicians and an op-ed columnist for the Greenville News. He is also the author of four books, Life in Emergistan, available, and Working Knights, Cats Don't Hike, and The Practice Test, all available, and of a blog, Follow him on Twitter @edwinleap, and read his past columns at



I bring you grave tidings from the land of Emergistan. As the self-appointed and lifelong prime minister of our little country, I feel compelled to share the news that we are all being threatened. By what, you ask? What dark force gathers at the border of our hallowed homeland and threatens the stability and sanity of us all?

Well, lots of things, but I have only this space with which to describe the existential threats to our well-being. The dark force I'm describing goes by the name “pultilfull.” An evil ogre if there ever was one.

Of course, its real name is “pull till full.” It goes like this: No matter how busy the doctor is, every room in the ED needs to be full if there's a patient waiting. This ideology is in place across the land in departments large and small.

The theory is, of course, that patients are all in imminent peril and only when they are in the ED proper, across from our food- and water-free work stations, are they truly safe. The waiting room, so we are told, is nothing short of a death trap, and the faster we move our charges to the actual ED, the less likely we'll have to carry their stiff corpses directly from the waiting area to the morgue.

When the physician (possibly on single coverage) has eight patients in a small ED, four of whom have chest pain, one who is septic, one sick infant, one with stroke symptoms, and one suicidal—the other beds simply have to be filled and not necessarily with more chest pain, mind you.

Whatever comes in—ankle sprain, asymptomatic hypertension, pediatric chest pain after being hit in the chest—it has to have a room. I don't mean those with abnormal vital signs or risk factors but the patients with a UTI or cough. They just need to have a room to be safe.

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Generating Distraction

I've tried to explain my position to nursing administration, and the answer is, “Dr. Leap, they're safer here than they are in the waiting room.” To which I asked, “Then why do we have a waiting room? Let's just expand the ED or line the halls with chairs.”

“Well, we can't do that; you know that.”

So we continue to “pull till full.” What happens is that the liability then somehow shifts. I, or another physician, PA, or NP has to be constantly aware of what's going on. It also means we feel a greater sense of urgency to see the next patient, to keep things moving, to massage our numbers.

When every room is full, however, it's a distraction from providing good care to the ones who are here. It also means more people standing in doorways, tapping their feet, asking, “How much longer?” or saying, “Can I have a blanket or a cup of ice?” It means more people wondering why the doctor is just “goofing off on his computer.” Distractions are dangerous, and I think “pull till full” creates unneeded distractions.

But whether you think this is a good idea (and I respect you if you do), here's where the whole theory breaks down, fellow Emergistanis. If I'm the only doc with three nurses, we pull till full. “You'll be fine,” they tell me.

If the nursing staff feels stretched or if they're a nurse or tech short, however, then patients wait. In the perilous, gator-filled swamp of a waiting room. “They're fine.” If the night physician only has a PA for another hour and wants to knock the numbers down, but the nurses feel overwhelmed, then nobody is coming back, even if there are rooms, even if the chart says, “chest pain.”

To review, one overwhelmed doctor, four nurses who are not: Get over it.

Two doctors, three overwhelmed nurses: ED comes to a standstill.

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Doctors Against Nurses

Look, I get it. Nurses follow orders from up on high. This is really a national issue of administration and ridiculous customer satisfaction standards mixed with genuine concerns for patient safety. But it's a rule applied unfairly. It puts nurses in the driver's seat of the ED tempo, with physicians having next to no input.

It makes nurses do anything to avoid being yelled at by the people with clipboards running the numbers. If that means every room is full all the time, then that's the way it goes. Unless, of course, that doesn't work for the nursing staff.

I miss the days when we weren't played against each other. When we were all really a team. Those were the days when the physician could say (of a patient he knew well), “That patient doesn't come back until everyone else is cleared out.” And it was OK. I miss being in charge. I was responsible for their safety then as I am now. But judgment wasn't a four-letter-word.

I understand that the waiting room can be dangerous. Bring the chest pains back! Bring back the old abdominal pains and dehydrated children and those who are at risk! Sometimes triage actually works, and the waiting room is for waiting. And the waiting room allows us to work more effectively in a way that is safe and sane for everyone involved.

Long live Emergistan! Semper a decem.

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