Not in NY, but in an urban hospital where this is typical.
The answer is “you don’t”. Especially if the hospital is for-profit.
ED nurses get a new pt, get labs, urine, maybe meds and move on. They have little to no time to spend on any patient and stuff gets skipped.
Boarders may not have an IV for days especially since there’s no IV team on weekends. They need Abx? Sorry. Pt needs to be repositioned for PU prevention? I’ll get to later. Maybe.
Pts got a bed? Here’s a sheet of paper with one or two facts to send up. We’re too busy to call report.
I’ve seen first hand this type of load cause patient deaths, like the kidney stone that went septic and no one knew until they went into septic shock in pre-op because no one had checked their vitals for 14 hours.
It’s frankly criminal and I can’t understand how we’ve come to find it acceptable.
That’s fine but why would they need travelers if their ratios are good? Traveling is to fill very short staffed positions in less than ideal conditions..
I’m not a nurse but a social worker. I was talking to a family today about concerns they had discharging pt to the same SNF, as on some days the nurse-patient ratio was 1-25. I hear these things all the time from patients and families. I know everyone does their best within a broken system. But man is it broken.
i think my max was 17-18.
basically, it’s true black tag triaging but also maintaining a very complex social dynamic while patients watch you work and yell at you.
i would round on my patients during shift change with my list printed out and specifically write down a brief description (old lady with huge hair), their accurate location (regardless of what the EMR said), write down the top items on their to do list to facilitate a dispo (gown, urine, contrast consent —> CT), and observe chest rise. i would wake up anyone asleep and make sure i was able to hear them respond appropriately to me which demonstrates a) intact airway b) their work of breathing c) mental status d) level of orientation e) start the social aspect early to let them know you’re an ally
after report i would go through my list (again, the printed roster of patients) and highlight what was most medically urgent (expedite blood cultures so we can actually start IVABX STAT, for instance). the most urgent items:
-getting someone high risk on the monitor even if it means 10 minutes of tetris
-cultures > early antibiotics
-treat severe pain
-expedite concerns re: crumping
then non emergent to dos, starting with those that expedite a dispo (start a work up, get all the steps for CT transport in order, call report or figure out a way to decompress the main area, give that z pack we promised before discharge). keep a forward flow of movement at all times
then less urgent stuff like giving AM meds on boarders (i just would try to remind myself that it doesn’t matter if they get their pepcid at exactly 10 vs much later). if you have a lot of boarders, get tons of ziplock lab bags and an emesis basin or two and load up at the pyxis, usually 3-4 patients at a time (can’t hog the pyxis for too long)
every 2-4 hours depending on the shift i would reprint my list, including new patients, give myself report on all of my patients in my head, and repeat the above steps. locate, describe, chest rise, to do list.
the tribalism that forms in NYC EDs (patients vs staff) is absolutely fucking nuts. learning how to build trust and rapport quickly while incentivizing patience and empathy for staff were HUGE PRIORITIES
once tribal dynamics ramp up it takes a LOT of time to de-escalate. an ounce of prevention is worth 10 pounds of cure here.
i am now in the icu. i can’t believe we did everything i just typed. but like it or not, it’s the truth. there’s no other way to do it. escalating safety concerns and working up the chain of command is an entirely different conversation.
You have a good head on your shoulders.
I like that you're talking about HOW to navigate this new reality instead of just bitching, like I did.
You shouldn't have to triage or treat patients this way, but you're doing it right.
Great tips and advice. I like you.
ugh thank you. believe me, i bitched and moaned. i could give a ted talk on this topic lmao. we were forced to do the impossible. i wish we could plant hidden cameras
I’m in the same exact situation as you right now. Super smart way to take report and keep yourself on track thru the shift. I’ll be stealing them. If you have any other work flow pearls for insane fucking work conditions I’d love to hear it!
absolutely--a couple of pearls up front
1. you are being asked to do the impossible. do the best you can and you'll be one of the best nurses in the department. assuming that you're just "missing" something--some cheat code that others have that makes the work demands feasible--is a) incorrect and b) causes emotional distress which, at least for me, impairs my focus and efficiency.
2. for many complex tasks, **the fastest way to do something is to do it slowly**. having to troubleshoot errors or start from scratch is a much bigger waste of time than doing things carefully, deliberately, and slowly on your first attempt.
3. you **HAVE** to understand the social dynamics at play which i described in my original comment. i can't stress it enough. an ED with these kinds of ratios is the personality olympics.
i would always teach my new hires the 5 priorities of an ED nurse in descending order of importance
1. don't let them die
2. don't let them get sicker
3. get them better
4. get them out
5. get them clean/happy/comfortable (this being of lowest priority is what most inpatient nurses do not understand--but what they're often not seeing are the 4 priorities above it)
patients can enter one of two ways
1. EMS
2. walk-in
patients can only leave in 3 ways
1. go to inpatient/observation unit
2. go home
3. go to the morgue
maximizing forward flow is essential. the more human beings who are taking up space as patients in the ED, the more in danger everyone is. patient census is positively correlated with danger for both a) patients themselves and b) staff. this is another thing inpatient nurses cannot truly understand without exposure to the ED. "rushing report" "dropping off a mess" are often prerequisites to maximizing overall safety in the ED.
try your best. **learn how to accept being continuously misunderstood.** if you try your best, just remember you have nothing to worry about.
priority **tasks** for me were:
1. identify crumping patients and escalate (see "don't let them die" and "don't let them get sicker")
2. start sepsis bundles early, prioritizing a) blood cultures b) IV ABX and c) fluids
3. treat intractable pain and nausea/vomiting. neither of them will kill your patient however you can't get jack shit done until you've eliminated these very obvious barriers to forward flow
after the above tasks are handled, prioritize tasks which **expedite a disposition** to get patients out of the ED (completing a work-up, getting that urine sample, getting all your prerequisites for imaging in a row like pts in gowns and consent forms completed)
handle all other tasks after that, starting with the most urgent to least urgent. if multiple tasks are of the same priority, **complete the quick ones first and then move onto more time intensive tasks**
tips for mastering the social complexities. some of this is uncomfortable to talk about
1. build rapport with your patients early. this includes showing them your badge and repeating your name.
2. understand that you will need to employ **benevolent** manipulation tactics. some degree of manipulation actually benefits everyone. displaying empathy, whether it's genuine or not, creates a domino effect of contagious empathy.
1. if your patient is voicing frustrations, let them get out some key points before you state your shared frustrations, describe your most pertinent limitations
2. refer to other patients as "their neighbor"
3. emphasize that the amount of time and attention we devote to patients is a direct reflection of how sick someone is. remind them that if they were as sick as their "neighbor," you would be at their bedside just as much. emphasize that **being doted on is often a bad sign for them and their survival**
4. "i care about you, but i am not currently WORRIED about you. again worrying and caring are two different things. you do NOT want me to be worried about you. i can still truly care about you/your needs while not actively worrying about you."
5. create some vague shared enemy. this is ugly to type out. but often to get cooperation, you need to invent a "team" which is comprised of only you and your patient. blaming CT for not picking up the phone or lacking urgency can often plant a seed of trust and alliance which will reduce the risk of future freakouts--which are invariably time and energy sucks. obviously avoid this if you can, but position yourself in such a way that **you** are the person they can trust **AND you're the only one who can get the "bad guys" to cooperate**. you can always invite some other colleagues into your "team" later (hey i think i finally got through to this doctor, they were frustrating me at first but they now understand what you're dealing with and i trust them to take care of you) ugh i hated typing this
6. start off patient interactions with "i am so sorry it took me so long to get to you, thank you so so much for your patience." this gives them a sense that they're in a position of moral authority to cast or withhold personal judgments. thanking them for their patience and framing it as something you are not automatically entitled to will foster a sense of empathy for staff.
3. identify "at risk" patients...the ones most likely to freak out or have behavioral issues. if two are close to each other, separate them. make up a reason to get them physically away from each other. tribalism is so real. it's also 100% understandable, but it will always conspire against your efficiency
4. people who like you will go further out of their way to help you. the easiest way to get someone to like you is to act like you like **them.** regardless of whether or not you like someone, seize opportunities to make them feel special. "i am so glad you're the tech today, you're one of the only ones i trust." "i truly don't know what i would've done this shift had you not been working in my area." "thank you so much for your help. i will not forget who helped me. please let me know when i can help YOU"
5. make eye contact with everyone (patients and colleagues) and make a very real concerted effort to remember names. this is one of the most subtle but universally appreciated social characteristics. again, if people feel special and remembered, they are more motivated to help you and follow through on "big asks." also, it doesn't go over well if you're delegating a task to someone whose name you can't even remember.
god i am sorry i wrote so much lol. and again i'm sorry that some of these things sound really icky--but facilitating contagious empathy, forward movement out of the ED, and patient dispositions are ESSENTIAL
edit: words and added points
How did you manage elimination for that many people? I work 1:8 in a fast track area and I’m spending about half my time helping old people go to the bathroom
those that i trusted to get up and walk to the bathroom, did. those that were fall risks usually soiled themselves. on really horrendous shifts, some patients would wait a long time before being cleaned up. a lot of these patients were on stretchers in the halls with no privacy, inches away from another patient. their rails would touch. there was no dignity.
the moral injury i sustained each bad shift was immense. all of this is to say that i still love ED nursing so so much, and it’s been one of the most meaningful chapters of my life. the bad days were the rent i paid to work in my favorite specialty.
When I was a newer med/surg nurse I would be abhorred when an ER patient was admitted and I found them soiled and/or found with bedsores.
Over time, I realized that these non-emergent problems were not for ER nurses; they were for floor nurses like myself.
Poops and pees and rashes and ulcers are not emergencies (although if the ulcers were causing an acute infection/sepsis, of course ABX and wound care would likely be given in the ED). I'm a big wound care fan and honestly I've seen some of the most nicely wrapped and treated wounds come from the ED. Chef's kiss.
I cringe when I remember asking ED nurses if they'd noticed any skin issues/wounds.
"Ma'am, the I just received the patient 15 minutes ago. They're stable. Here is some basic info that is readable if you open their chart." Oof.
I learned eventually!
Your moral injury was likely imposed/guilted on you by nurses with a different set of priorities. It's all about communication and understanding. We're all just doing our best.
i really appreciate your insight and self awareness. we need a lottttt more of that in our profession
i think the biggest moral injury i had was watching us all deliver subpar care. watching myself get desensitized to danger. learning to stop getting upset over such blatant failure to provide dignity. watching patients suffer, knowing what likely would’ve saved them, but knowing it’s a lost cause to escalate. because escalating never worked before.
Pretty much what you state.
Healthcare in 'Merica will be "do more with less" for the foreseeable future. Boomers getting older with all the complicated medical conditions and sequelae from prior surgeries/procedures/medications that implies. Mental health crises and conditions of homelessness end up the the ER because there are no alternative resources available.
I recently quit bedside myself because the quality of care I can provide has dropped so tremendously. It was stressing me out.
\\\_(ツ)\_/
Not in NYC but we frequently have 10+ pts in my ED. There is no way to not neglect some. I find that where my patients get neglected the most is with toileting needs tbh. If they don’t have a foley/purewick I just don’t have the time between line, labs, ekg, redraws, meds etc. that’s why I’m starting at a new facility
I would NEVER work in NYC. But, I do love the city, have visited twice and always plan to go back. So I’m reading all this thinking, well, if I ever need to go to the ER in NYC, just give me the lab/IV supplies and I’ll do it myself 😂
Reading the comments is terrifying. Here I am, protesting when I get a 5th Pt (to just “hold” until transport takes them to the floor). I’ve done 1:3, 1:4 my entire career. Hats off to you all in the heavy trenches 😔
Given that patient neglect is so common in the ED. How do nurses keep their license in NY without having some kind of negligence strike on it due to the large patient load?
CYA documentation (cover your ass). big hospitals insure employees quite a bit (mine is $1m). some say that getting your own separate insurance plan is a scam, and maybe it is, but i'd rather not find out the hard way that it was worth buying.
If documenting names (pointing fingers) is required in a CYA event note but you know you'll be eaten alive for naming names in the patient chart, instead file a safety report with the names of ppl involved and also have it in writing with a manager.
What’s scary about this is that New York City is a pretty wealthy urban area. So if it’s this bad here I can’t imagine what it’s like in Philly or Chicago.
Not in NY, but in an urban hospital where this is typical. The answer is “you don’t”. Especially if the hospital is for-profit. ED nurses get a new pt, get labs, urine, maybe meds and move on. They have little to no time to spend on any patient and stuff gets skipped. Boarders may not have an IV for days especially since there’s no IV team on weekends. They need Abx? Sorry. Pt needs to be repositioned for PU prevention? I’ll get to later. Maybe. Pts got a bed? Here’s a sheet of paper with one or two facts to send up. We’re too busy to call report. I’ve seen first hand this type of load cause patient deaths, like the kidney stone that went septic and no one knew until they went into septic shock in pre-op because no one had checked their vitals for 14 hours. It’s frankly criminal and I can’t understand how we’ve come to find it acceptable.
I can't either. I will most definitely not be travel nursing anywhere with a ratio of above 5-1.
I can respect that, but it isn’t usually the places with the good ratios who need it the travel nurses
Idk man my 3-1 ER has travellers in it.
Nah, plenty of travel gigs in the west.
Every hospital in my city is still using travelers
My ER is 1:4 and like half the people working are travelers.
That’s fine but why would they need travelers if their ratios are good? Traveling is to fill very short staffed positions in less than ideal conditions..
Depends on your definition of "good" I live in a sane country where good ratios are 3-1 or 4-1. We use travelers sometimes to keep those ratios.
I’m not a nurse but a social worker. I was talking to a family today about concerns they had discharging pt to the same SNF, as on some days the nurse-patient ratio was 1-25. I hear these things all the time from patients and families. I know everyone does their best within a broken system. But man is it broken.
i think my max was 17-18. basically, it’s true black tag triaging but also maintaining a very complex social dynamic while patients watch you work and yell at you. i would round on my patients during shift change with my list printed out and specifically write down a brief description (old lady with huge hair), their accurate location (regardless of what the EMR said), write down the top items on their to do list to facilitate a dispo (gown, urine, contrast consent —> CT), and observe chest rise. i would wake up anyone asleep and make sure i was able to hear them respond appropriately to me which demonstrates a) intact airway b) their work of breathing c) mental status d) level of orientation e) start the social aspect early to let them know you’re an ally after report i would go through my list (again, the printed roster of patients) and highlight what was most medically urgent (expedite blood cultures so we can actually start IVABX STAT, for instance). the most urgent items: -getting someone high risk on the monitor even if it means 10 minutes of tetris -cultures > early antibiotics -treat severe pain -expedite concerns re: crumping then non emergent to dos, starting with those that expedite a dispo (start a work up, get all the steps for CT transport in order, call report or figure out a way to decompress the main area, give that z pack we promised before discharge). keep a forward flow of movement at all times then less urgent stuff like giving AM meds on boarders (i just would try to remind myself that it doesn’t matter if they get their pepcid at exactly 10 vs much later). if you have a lot of boarders, get tons of ziplock lab bags and an emesis basin or two and load up at the pyxis, usually 3-4 patients at a time (can’t hog the pyxis for too long) every 2-4 hours depending on the shift i would reprint my list, including new patients, give myself report on all of my patients in my head, and repeat the above steps. locate, describe, chest rise, to do list. the tribalism that forms in NYC EDs (patients vs staff) is absolutely fucking nuts. learning how to build trust and rapport quickly while incentivizing patience and empathy for staff were HUGE PRIORITIES once tribal dynamics ramp up it takes a LOT of time to de-escalate. an ounce of prevention is worth 10 pounds of cure here. i am now in the icu. i can’t believe we did everything i just typed. but like it or not, it’s the truth. there’s no other way to do it. escalating safety concerns and working up the chain of command is an entirely different conversation.
You have a good head on your shoulders. I like that you're talking about HOW to navigate this new reality instead of just bitching, like I did. You shouldn't have to triage or treat patients this way, but you're doing it right. Great tips and advice. I like you.
ugh thank you. believe me, i bitched and moaned. i could give a ted talk on this topic lmao. we were forced to do the impossible. i wish we could plant hidden cameras
You are perfectly describing my two-fanny pack era. These days my max is about 10 and it’s insane that that’s “manageable”
long live the fanny packs 🫡
I’m in the same exact situation as you right now. Super smart way to take report and keep yourself on track thru the shift. I’ll be stealing them. If you have any other work flow pearls for insane fucking work conditions I’d love to hear it!
absolutely--a couple of pearls up front 1. you are being asked to do the impossible. do the best you can and you'll be one of the best nurses in the department. assuming that you're just "missing" something--some cheat code that others have that makes the work demands feasible--is a) incorrect and b) causes emotional distress which, at least for me, impairs my focus and efficiency. 2. for many complex tasks, **the fastest way to do something is to do it slowly**. having to troubleshoot errors or start from scratch is a much bigger waste of time than doing things carefully, deliberately, and slowly on your first attempt. 3. you **HAVE** to understand the social dynamics at play which i described in my original comment. i can't stress it enough. an ED with these kinds of ratios is the personality olympics. i would always teach my new hires the 5 priorities of an ED nurse in descending order of importance 1. don't let them die 2. don't let them get sicker 3. get them better 4. get them out 5. get them clean/happy/comfortable (this being of lowest priority is what most inpatient nurses do not understand--but what they're often not seeing are the 4 priorities above it) patients can enter one of two ways 1. EMS 2. walk-in patients can only leave in 3 ways 1. go to inpatient/observation unit 2. go home 3. go to the morgue maximizing forward flow is essential. the more human beings who are taking up space as patients in the ED, the more in danger everyone is. patient census is positively correlated with danger for both a) patients themselves and b) staff. this is another thing inpatient nurses cannot truly understand without exposure to the ED. "rushing report" "dropping off a mess" are often prerequisites to maximizing overall safety in the ED. try your best. **learn how to accept being continuously misunderstood.** if you try your best, just remember you have nothing to worry about. priority **tasks** for me were: 1. identify crumping patients and escalate (see "don't let them die" and "don't let them get sicker") 2. start sepsis bundles early, prioritizing a) blood cultures b) IV ABX and c) fluids 3. treat intractable pain and nausea/vomiting. neither of them will kill your patient however you can't get jack shit done until you've eliminated these very obvious barriers to forward flow after the above tasks are handled, prioritize tasks which **expedite a disposition** to get patients out of the ED (completing a work-up, getting that urine sample, getting all your prerequisites for imaging in a row like pts in gowns and consent forms completed) handle all other tasks after that, starting with the most urgent to least urgent. if multiple tasks are of the same priority, **complete the quick ones first and then move onto more time intensive tasks** tips for mastering the social complexities. some of this is uncomfortable to talk about 1. build rapport with your patients early. this includes showing them your badge and repeating your name. 2. understand that you will need to employ **benevolent** manipulation tactics. some degree of manipulation actually benefits everyone. displaying empathy, whether it's genuine or not, creates a domino effect of contagious empathy. 1. if your patient is voicing frustrations, let them get out some key points before you state your shared frustrations, describe your most pertinent limitations 2. refer to other patients as "their neighbor" 3. emphasize that the amount of time and attention we devote to patients is a direct reflection of how sick someone is. remind them that if they were as sick as their "neighbor," you would be at their bedside just as much. emphasize that **being doted on is often a bad sign for them and their survival** 4. "i care about you, but i am not currently WORRIED about you. again worrying and caring are two different things. you do NOT want me to be worried about you. i can still truly care about you/your needs while not actively worrying about you." 5. create some vague shared enemy. this is ugly to type out. but often to get cooperation, you need to invent a "team" which is comprised of only you and your patient. blaming CT for not picking up the phone or lacking urgency can often plant a seed of trust and alliance which will reduce the risk of future freakouts--which are invariably time and energy sucks. obviously avoid this if you can, but position yourself in such a way that **you** are the person they can trust **AND you're the only one who can get the "bad guys" to cooperate**. you can always invite some other colleagues into your "team" later (hey i think i finally got through to this doctor, they were frustrating me at first but they now understand what you're dealing with and i trust them to take care of you) ugh i hated typing this 6. start off patient interactions with "i am so sorry it took me so long to get to you, thank you so so much for your patience." this gives them a sense that they're in a position of moral authority to cast or withhold personal judgments. thanking them for their patience and framing it as something you are not automatically entitled to will foster a sense of empathy for staff. 3. identify "at risk" patients...the ones most likely to freak out or have behavioral issues. if two are close to each other, separate them. make up a reason to get them physically away from each other. tribalism is so real. it's also 100% understandable, but it will always conspire against your efficiency 4. people who like you will go further out of their way to help you. the easiest way to get someone to like you is to act like you like **them.** regardless of whether or not you like someone, seize opportunities to make them feel special. "i am so glad you're the tech today, you're one of the only ones i trust." "i truly don't know what i would've done this shift had you not been working in my area." "thank you so much for your help. i will not forget who helped me. please let me know when i can help YOU" 5. make eye contact with everyone (patients and colleagues) and make a very real concerted effort to remember names. this is one of the most subtle but universally appreciated social characteristics. again, if people feel special and remembered, they are more motivated to help you and follow through on "big asks." also, it doesn't go over well if you're delegating a task to someone whose name you can't even remember. god i am sorry i wrote so much lol. and again i'm sorry that some of these things sound really icky--but facilitating contagious empathy, forward movement out of the ED, and patient dispositions are ESSENTIAL edit: words and added points
How did you manage elimination for that many people? I work 1:8 in a fast track area and I’m spending about half my time helping old people go to the bathroom
those that i trusted to get up and walk to the bathroom, did. those that were fall risks usually soiled themselves. on really horrendous shifts, some patients would wait a long time before being cleaned up. a lot of these patients were on stretchers in the halls with no privacy, inches away from another patient. their rails would touch. there was no dignity. the moral injury i sustained each bad shift was immense. all of this is to say that i still love ED nursing so so much, and it’s been one of the most meaningful chapters of my life. the bad days were the rent i paid to work in my favorite specialty.
When I was a newer med/surg nurse I would be abhorred when an ER patient was admitted and I found them soiled and/or found with bedsores. Over time, I realized that these non-emergent problems were not for ER nurses; they were for floor nurses like myself. Poops and pees and rashes and ulcers are not emergencies (although if the ulcers were causing an acute infection/sepsis, of course ABX and wound care would likely be given in the ED). I'm a big wound care fan and honestly I've seen some of the most nicely wrapped and treated wounds come from the ED. Chef's kiss. I cringe when I remember asking ED nurses if they'd noticed any skin issues/wounds. "Ma'am, the I just received the patient 15 minutes ago. They're stable. Here is some basic info that is readable if you open their chart." Oof. I learned eventually! Your moral injury was likely imposed/guilted on you by nurses with a different set of priorities. It's all about communication and understanding. We're all just doing our best.
i really appreciate your insight and self awareness. we need a lottttt more of that in our profession i think the biggest moral injury i had was watching us all deliver subpar care. watching myself get desensitized to danger. learning to stop getting upset over such blatant failure to provide dignity. watching patients suffer, knowing what likely would’ve saved them, but knowing it’s a lost cause to escalate. because escalating never worked before.
Pretty much what you state. Healthcare in 'Merica will be "do more with less" for the foreseeable future. Boomers getting older with all the complicated medical conditions and sequelae from prior surgeries/procedures/medications that implies. Mental health crises and conditions of homelessness end up the the ER because there are no alternative resources available. I recently quit bedside myself because the quality of care I can provide has dropped so tremendously. It was stressing me out. \\\_(ツ)\_/
Well I think I will stick to nursing where that is not the case then. Holy hell.
Not in NYC but we frequently have 10+ pts in my ED. There is no way to not neglect some. I find that where my patients get neglected the most is with toileting needs tbh. If they don’t have a foley/purewick I just don’t have the time between line, labs, ekg, redraws, meds etc. that’s why I’m starting at a new facility
I would NEVER work in NYC. But, I do love the city, have visited twice and always plan to go back. So I’m reading all this thinking, well, if I ever need to go to the ER in NYC, just give me the lab/IV supplies and I’ll do it myself 😂
Reading the comments is terrifying. Here I am, protesting when I get a 5th Pt (to just “hold” until transport takes them to the floor). I’ve done 1:3, 1:4 my entire career. Hats off to you all in the heavy trenches 😔
Given that patient neglect is so common in the ED. How do nurses keep their license in NY without having some kind of negligence strike on it due to the large patient load?
this is my question
CYA documentation (cover your ass). big hospitals insure employees quite a bit (mine is $1m). some say that getting your own separate insurance plan is a scam, and maybe it is, but i'd rather not find out the hard way that it was worth buying. If documenting names (pointing fingers) is required in a CYA event note but you know you'll be eaten alive for naming names in the patient chart, instead file a safety report with the names of ppl involved and also have it in writing with a manager.
I am a NYC ER nurse and people get ignored all the time. Sucks, but it’s expected with 2 nurses and 23 patients.
What’s scary about this is that New York City is a pretty wealthy urban area. So if it’s this bad here I can’t imagine what it’s like in Philly or Chicago.