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— Chet Varns takes a lot of guff from people he doesn't know and likely won't see again. A volunteer at the sign-in desk at Palomar Hospital's emergency room in Escondido, Varns passes new patients a clipboard and tries to keep everyone in the ER waiting room happy. No matter how irate they get, he smiles and shows patience, but it doesn't always work. "They get angry with everybody, including themselves; they can get belligerent. It's mostly patients who have to wait for a long time because there's not enough room to accommodate them in the back."

Varns and volunteers like him are the first people patients see when they enter an emergency room. "I try to triage patients and have them fill out a form so the triage nurse can decide their severity of illness and process them through the paperwork. I've been here when there isn't seating room in the waiting room and all the beds in back were full. If someone wants to cause a big problem, I just call one of the medical staff." Varns has been volunteering for six months, since his retirement from the Air Force Medical Corps.

The wait in emergency rooms can last for hours, even after getting a bed. About one percent of that time will be spent with a doctor. Most of the care given in the ER comes from volunteers and nurses.

Randy Ball is the charge nurse for Palomar's ER and has been for 12 years. She makes sure that the patient load is equitable for the doctors and nurses. "I handle all the problems. I'm, basically, the captain of the ship."

Ball understands what Varns faces when the ER starts to get crowded. "We see people based on acuity. Every patient is seen by a registered nurse at triage. Based on complaint, the way the patient looks, their vital signs, and their history, that nurse assigns a classification. Our classifications go from urgent to emergent to immediate. If you come in with a splinter in your finger, you're not going to be seen very soon, especially if we're busy, because your injury isn't life-threatening. But if you come in clutching your chest, looking pasty-white, telling me you have an impending feeling of doom, you're going to come right back. And an ambulance patient takes precedent over anyone. So if an ambulance rolls in, that bumps others back." Ball points to a big board with slots holding file folders. "The charts come in from triage color-coded. Blue means that it's very, very minor, and they can sit out there if need be. Green means a little sicker, yellow means a little sicker than green, and red means they have to come back immediately or as soon as possible -- chest pain, someone's amputated a body part -- that kind of thing. They come to me to decide where the patient should go. Let's say I have a yellow chart here with a patient with abdominal pain. If I have an ambulance come in, even though this patient is supposed to be the next one back, that ambulance takes precedent."

Ball's assessment of the changes in the ER seems to mirror the changes at other hospitals. "It used to be that our busiest times were weekends and during the week after 5:00, but that's no longer true. We're busy all the time, whether it's patients from the waiting room or ambulances coming in from the community. There's no downtime anymore. Weekends are usually a little bit heavier because people tend to partake of risk-taking behaviors. Doctors' offices are closed, so we tend to see more people who are sick. They either don't want to take the time during the week to go to their doctor, or they decide to come in here on the weekend. Usually, after 3:00 in the afternoon, we really get slammed. It can last all night. Sometimes, when I come on at 7:00 in the morning, we're still busy."

The patients at Palomar don't always come in with the same complaints one would find at urban emergency rooms. "We have a large catchment area -- over 100 square miles for our trauma. We get a lot of people from the desert, motorcycle riders from Palomar Mountain, that kind of thing. Usually, the all-terrain vehicles, the motorcycles, they tend to do...I'm not really sure what it is they do out there! Ride the sand dunes, that kind of thing. Then, on the weekends, we usually get at least two motorcycle accidents off of Palomar Mountain. We're real close to Barona Racetrack, so we get patients from there -- motocross races. We just got a patient from out there Monday. I guess they're filming a Disney movie out there, and he had a motorcycle crash and came in to us. And we get your routine shootings and stabbings, car accidents, that kind of stuff.

"It just seems like on sunny weekends, people like to ride their motorcycles on Palomar Mountain, and those things are like rocket ships! They're faster than a motorcycle needs to go, and they crash with regularity. Since the helmet laws went into effect, head injuries aren't as prevalent as they used to be. They tend to have more orthopedic injuries -- more broken arms, broken legs, broken pelvises. I read somewhere that the organ-donation rate has gone down since the helmet laws went into effect, because you don't have as many fatalities. You also get the chest and abdominal trauma from the motorcycles."

Another sign of the changing times is the nursing shortage. "It's the same as everywhere else -- not enough qualified nurses. When someone leaves our department, there's not the experienced nurses out there to hire and come in. That's countywide -- I should say nationwide."

Like most ER workers, the unusual has become routine for Ball. "It never ceases to amaze me, the things that can happen to the human body. We see a lot of motor-vehicle accident injuries, since we're right on the I-15 corridor. I've talked with the CHP officers when they come in, and it's such a straight shot. Once you get past Escondido there's nothing between here and Temecula to slow you down. I think they drive faster on 15."

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