ER visit -- part vent, should I complain? Long, as usual

Hi everyone!

We had a bit of a scare yesterday -- another one! -- and I'm about to
do some research online to figure out exactly how upset I should
really be, and whether I should make a complaint to the hospital; I
know there are some medical types reading here, and a lot of parents
who've been through the ER wringer too, so hopefully someone has some
opinions for me...

My daughter Solana is 28 months old, and she has some ongoing medical
issues. She's been diagnosed as failure to thrive, probably due to
her milk and egg allergies (she's been off both of those for 10
months, though), she was recently diagnosed with asthma, and she has
VonWillebrand's disease, which is a bleeding disorder.

Von Willebrand's is a clotting disorder, (We actually found out I have
it too) where there is, in our case, a shortage of clotting factor
VIII, as well as Von Willebrand's factor. I don't bleed spontaneously
very often, and Solana hasn't had major bleeds, but she does bruise
spontaneously, and we need to watch her very carefully to make sure
she doesn't injure her head or mucous membranes. Most of the
complications from VWD are severe nosebleeds, bleeds in the mouth from
tooth injuries, and internal bleeding resulting from trauma. It
rarely causes joint bleeding, as you may have heard of other bleeding
disorders doing.

There is a medication that works to increase Factor VIII, which then
increases VW Factor, but the hematologist feels Solana is too young to
try it, and there are issues with the testing involved -- they prefer
to wait until she's 5 years old.

So....yesterday, we went to take Sage to school for her 1st day, and
Solana saw a little friend there, and ran to hug him, he ran to hug
her, and they tipped over, Solana falling on her back and head, and
her friend falling on top of her, on concrete. I was right next to
them, but I still don't know if she lost consciousness at all. She
screamed, but not *immediately*. I was stunned, and her friend was on
top of her anyway. So, he got up, she screamed, and I went to the
door, got another mom to stand with Solana, handed Sage to her teacher
(this is all within a 10 foot area) and turned back around to Solana.
The other mom had picked her up, and she was still crying, but she
calmed down once I took her.

We went back in to make sure Sage was OK, and then went to run
errands. Her hematologist has told us that we only need to call for
head injuries or if she gets cut and we can't stop the bleeding after
20-30 minutes (i.e. scrapes and bruises of the general toddler variety
are OK). But I wasn't sure if I should call. We had only driven for
a few minutes and Solana started complaining about her head hurting,
but not where she'd fallen, which I thought was weird, she asked for
ice, and then she said she was tired and promptly went to sleep.

So, I knew I'd have to call her hematologists. I called from the car,
and they were out of the office, so I called the number they'd left,
and the nurse I spoke with said I needed to bring her to the ER at the
children's hospital, to rule out bleeding in/on her brain. We've
recently moved, so this means we would pass another hospital on the
way, but I did what she said. I made the calls I needed to to get
Sage picked up properly, and we headed to the ER. We got there at
about 1:15, 45 mintues after the fall.

I woke Solana when I parked the car, and it was hard to rouse her.
The triage nurse was not in her room, so we put in our name (and the
hematology nurse I spoke with said they'd be expecting me) and waited.
After about 15 minutes, we were called to triage, and the nurse there
was very ... I don't know ... unconcerned, I guess. She thought
Solana seemed alert, but she wasn't, and I thought since I see her
every day at this time, and she doesn't normally take a nap, I knew
better what drowsy or hard to rouse is, and I told her "She looks like
she's about to fall asleep right there!" I also asked Solana to walk
for the nurse, because she was walking weird, but the nurse said she
thought it looked OK.

I was thinking that regardless of what the nurse's opinion was, that
head trauma to child with bleeding disorder would be fairly urgent. I
was wrong. After 1 hour in the waiting room, I told the receptionist
we were going to hematology ourselves, because this was ridiculous.
She just said 'OK', and I walked outside and used my cellphone to call
the other # again. They told me to find the triage nurse and ask her
why Solana was not being seen yet. So, I went back in, and asked to
see her, and she was horrible and mean and I almost started crying.

The reason I got so upset was that in the hour I'd been there, I'd
talked to the other parents, and I knew what the kids were there for.
I know it's likely that every parent thinks their child deserves the
first and best treatment, but ... you all know what Solana was there
for. The other kids that had gone in before us were kids that had left
school mostly (ages 5-7 or 8ish), with *clearly minor* injuries
(Clearly being the main issue, in my opinion. I couldn't *see* how
badly Solana was hurt). I swear. They sent a girl in ahead of Solana
who had bitten her tongue at school, and it wasn't even bleeding
anymore, and the 'wound' was no longer visible. I looked! I just
kept thinking -- my daughter's brain may be bleeding, and this person
has no actual problem! The parents weren't even going back with the
kids when they got called because they wanted to watch their soap
operas! (Perhaps I should mention here -- I don't know if this is PC
or not, but -- that this hospital is in a major urban area, and does
get a lot of people who use the ER because they have no PCPs or
Pediatrician.)

Furious. I was so mad. So the nurse tells me she's only been letting
in kids who are having severe asthma problems, and that I should be
lucky my daughter's breathing, because these kids weren't, and that
there wasn't even room in the hallway for Solana because of all the
respiratory distress. First of all, I know she was lying. I talked
to the parents. Second, Solana was in with honest to goodness
respiratory distress last month, and I sure didn't see anything like
that happening yesterday -- no running, no shouting, etc...

Third, when we got in there, there were open rooms, the hallways were
clear (not that I think they should fill the hallways, but it is
another lie -- I've been there when the hallways are full, and I know
what it looks like. I've been there enough to know that it's gotta be
one day a year maybe that the hallways are full during the day. It
happens [at this hospital at least] between midnight and three or four
AM, and very rarely in the peds side).

Finally, I saw on the wall chart, that no one there when we were
called back had been classified a 'triage 1'. Solana was a 1 when she
had trouble breathing. Yesterday, this nurse classified Solana a
'2.5', which really offended me. [Not only because I was led to
believe this was a real emergency, but because the '.5' just seems
plain rude. Maybe I'm wrong, but I don't know. She was in worse shape
yesterday than last head injury, and that was a 2] Believe me, I do
not bring my kids to the ER for no good reason. We have a whole
contingent of very good Dr.s who will see us the day of a problem if
it's anything they think they can handle in the office. I only go if
I'm told I really need to.

And I did tell the nurse that I found it very suspicious that the
hematology nurse (who conferred with a hematologist before telling me
to go in) thought this was something we needed checked out ASAP, but
once in the ER, it's no big deal. And the nurse on the phone didn't
even know Solana was walking funny!

Anyway, after about half an hour more (3:15), we saw a resident. She
said if it weren't for the Von Willebrand's, she'd send us home, but
she had to talk to several other Dr.s, etc.... Another Doc came in at
about 3:40, and said that she still thought Solana had an 'unsteady
gait', and since she was still complaining of pain, we needed to get a
catscan. Which is what I was expecting the whole time. They didn't
take us to catscan until after 4, then they forgot to send transport
to bring us back. I took her back to the ER on my own, and while we
were waiting, Solana's regular hematology nurse came in, because they
got back from their seminar (teaching the Amish about blood disorders)
and he saw her name on the list of people who'd called in. He's
wonderful, and we had a nice long talk.

He seemed as exasperated at the wait as I did, but he was noncommital
about saying 'you were treated badly' or anything like that, which I
understand. He said that the pain being in a spot when she hadn't
fallen was a bad sign, as was the falling asleep, and the continued
trouble walking. He said they're going to try and move up the trial
of the medicine, maybe she'll get to try it this year, since she is
prone to falling on her head (with a height and weight basically at
the bottom of the charts, and a head off the top of the charts, it's
no surprise), and he doesn't want us to be spending half our time in
the ER. Yeah! He left to go check on a patient who was admitted with
a bleed earlier.

Sometime after 5 they got around to reading her catscan, and it was
negative. They checked us out at 6. I was just happy to go at that
time. I kind of wish I would've just left, before being checked out,
but I don't want to screw up our insurance, and I don't know if that
would be a problem (just leaving).

Does anyone else think it's exceptionally slow to wait three and a
half hours after a head injury with symptoms (sleeping, uneven gait,
pain moving around her head) in a child with a bleeding disorder to
get a catscan? I'm still angry (obviously), but I don't know how
angry to get, if I complain. That nurse definitely lied, I know that
for sure. Maybe, even though the hematology department called ahead,
the nurse wasn't aware of the full extent of the clotting issue?
Should I have documents prepared to take with me in the future? If
you do think it was a long time, what would you do next time? (Last
head injury we waited about the same amount of time, but she had no
symptoms, so I wasn't near tears, really) . Does anyone know, if she
had been bleeding inside her head, would that amount of waiting made
things worse -- or is there anything that could have been done in that
time to lessen an injury if there was one? Or is it like some things
where if it's going to happen it's going to happen, and there's no
stopping it? In which case, why do they send us for catscans?!?

Thanks for reading, and any opinions/advice,

Tina.
(and the still sleepy, kind of grumpy but OK Solana, and Sage, who
loved school and almost didn't notice that I'd just tossed her in
there and run back out)

snip
Does anyone else think it's exceptionally slow to wait three and a
half hours after a head injury with symptoms (sleeping, uneven gait,
pain moving around her head) in a child with a bleeding disorder to
get a catscan? I'm still angry (obviously), but I don't know how
angry to get, if I complain. That nurse definitely lied, I know that
for sure. Maybe, even though the hematology department called ahead,
the nurse wasn't aware of the full extent of the clotting issue?
Should I have documents prepared to take with me in the future? If
you do think it was a long time, what would you do next time? (Last
head injury we waited about the same amount of time, but she had no
symptoms, so I wasn't near tears, really) . Does anyone know, if she
had been bleeding inside her head, would that amount of waiting made
things worse -- or is there anything that could have been done in that
time to lessen an injury if there was one? Or is it like some things
where if it's going to happen it's going to happen, and there's no
stopping it? In which case, why do they send us for catscans?!?

Thanks for reading, and any opinions/advice,

Tina.

Okay... Yes... It's a long time to wait for a head injury with obvious
symptoms!
The wait time, if there had been bleeding on the brain could have killed
her! (I dealt with this when my dad was injured.) They sent you for a
catscan to make sure. With bleeding on the brain, it depends on the
severity. Unfortunately, there's no way to tell until a scan is done.

(and the still sleepy, kind of grumpy but OK Solana, and Sage, who
loved school and almost didn't notice that I'd just tossed her in
there and run back out)

"Tina" wrote in message
om...
Does anyone else think it's exceptionally slow to wait three and a
half hours after a head injury with symptoms (sleeping, uneven gait,
pain moving around her head) in a child with a bleeding disorder to
get a catscan? I'm still angry (obviously), but I don't know how
angry to get, if I complain. That nurse definitely lied, I know that
for sure. Maybe, even though the hematology department called ahead,
the nurse wasn't aware of the full extent of the clotting issue?
Should I have documents prepared to take with me in the future? If
you do think it was a long time, what would you do next time? (Last
head injury we waited about the same amount of time, but she had no
symptoms, so I wasn't near tears, really) . Does anyone know, if she
had been bleeding inside her head, would that amount of waiting made
things worse -- or is there anything that could have been done in that
time to lessen an injury if there was one? Or is it like some things
where if it's going to happen it's going to happen, and there's no
stopping it? In which case, why do they send us for catscans?!?

I don't know the answer to all your questions, but from a layperson's POV, I
do think your DD's case sounds quite serious. Maybe the nurse didn't know
what VW is. Though they have medical training, they aren't MD's and they do
err quite a bit with the diagnostics. Some MD's I know personally complain
about the emergency cases they get in urgent care or in their office that
should obviously have been sent to the ER next door. These are patients who
are triaged by a nurse. I remember once, I was very ill and my lungs
started to feel like they were collapsing right as I was talking to the
nurse. She told me I was just anxious. Of course I was anxious, I wasn't
getting air, though not to the point of passing out or turning blue, but
it's alarming just the same. Never happened before or since. Anyway, they
don't always know what they are talking about. When you have your doubts,
make a fuss. At least have the nurse's opinion of the severity your child's
problem assessed by the MD on duty. Then, if he concurs, you have at least
a second opinion and would feel more at ease with the wait.

Tina wrote in message
Does anyone else think it's exceptionally slow to wait three and a
half hours after a head injury with symptoms (sleeping, uneven gait,
pain moving around her head) in a child with a bleeding disorder to
get a catscan? I'm still angry (obviously), but I don't know how
angry to get, if I complain. That nurse definitely lied, I know that
for sure. Maybe, even though the hematology department called ahead,
the nurse wasn't aware of the full extent of the clotting issue?
Should I have documents prepared to take with me in the future? If
you do think it was a long time, what would you do next time? (Last
head injury we waited about the same amount of time, but she had no
symptoms, so I wasn't near tears, really) . Does anyone know, if she
had been bleeding inside her head, would that amount of waiting made
things worse -- or is there anything that could have been done in that
time to lessen an injury if there was one? Or is it like some things
where if it's going to happen it's going to happen, and there's no
stopping it? In which case, why do they send us for catscans?!?

Thanks for reading, and any opinions/advice,

Tina.

This is horrible an inexcusable. I'm a critical care nurse, and I'm seeing
red right now. Your child should have been first priority. Yes, a delay
could have certainly been detrimental had there been bleeding in her head.
I would document EVERYTHING while it's fresh in your head regarding times
and what you said to the triage nurse. I would also call the nurse manager
in the ER *today*, and if that gets you no where, go directly to the vice
president of nursing in the hospital. The fact that the hematologist was
rightly concerned is your backup. He of course would be noncomittal on the
length of time it took for you to be seen, but maybe he is doing something
about it quietly.

I do want to say that while there may have been minor issues with the kids
in the waiting room, you don't know what kinds of emergencies were brought
in by ambulance. Those always get first priority and people in the waiting
room never even see those patients. However, your daughter still should have
received prompt care.

laurie
mommy to Jessica, 2.5 years
and Christopher, 5 months

*This email address is now valid*
(and the still sleepy, kind of grumpy but OK Solana, and Sage, who
loved school and almost didn't notice that I'd just tossed her in
there and run back out)

toypup wrote in message .. .

"Tina" wrote in message
. com...
Does anyone else think it's exceptionally slow to wait three and a
half hours after a head injury with symptoms (sleeping, uneven gait,
pain moving around her head) in a child with a bleeding disorder to
get a catscan? I'm still angry (obviously), but I don't know how
angry to get, if I complain. That nurse definitely lied, I know that
for sure. Maybe, even though the hematology department called ahead,
the nurse wasn't aware of the full extent of the clotting issue?
Should I have documents prepared to take with me in the future? If
you do think it was a long time, what would you do next time? (Last
head injury we waited about the same amount of time, but she had no
symptoms, so I wasn't near tears, really) . Does anyone know, if she
had been bleeding inside her head, would that amount of waiting made
things worse -- or is there anything that could have been done in that
time to lessen an injury if there was one? Or is it like some things
where if it's going to happen it's going to happen, and there's no
stopping it? In which case, why do they send us for catscans?!?

I don't know the answer to all your questions, but from a layperson's POV,
I
do think your DD's case sounds quite serious. Maybe the nurse didn't know
what VW is. Though they have medical training, they aren't MD's and they
do
err quite a bit with the diagnostics.

Knowing that VW is a clotting disease should be enough. That coupled with
the fact that the child was sleepy, complaining of head pain, and the mom
said she wasn't acting right are all major red flags. This nurses "triaging"
abilities are deplorable.

laurie
mommy to Jessica, 2.5 years
and Christopher, 5 months

*This email address is now valid*

Some MD's I know personally complain
about the emergency cases they get in urgent care or in their office that
should obviously have been sent to the ER next door. These are patients
who
are triaged by a nurse. I remember once, I was very ill and my lungs
started to feel like they were collapsing right as I was talking to the
nurse. She told me I was just anxious. Of course I was anxious, I wasn't
getting air, though not to the point of passing out or turning blue, but
it's alarming just the same. Never happened before or since. Anyway, they
don't always know what they are talking about. When you have your doubts,
make a fuss. At least have the nurse's opinion of the severity your
child's
problem assessed by the MD on duty. Then, if he concurs, you have at least
a second opinion and would feel more at ease with the wait.

Yeah, I'd complain, and in writing to .

I'm kind of dumbfounded at the way the ER treated you. My middle kid
has no medical conditions that make high risk like your child. He's a
pretty healthy kid. When he was in Grade 1 he got wonked twice on the
head in the school yard and got a concussion - and I should mention,
he never lost consciousness, but he did throw up and was dizzy, drowsy
and very pale (he looked really awful). We took him to Sick Kids
hospital here in Toronto, where there usually is really long wait in
the ER (if what's wrong is not immediately life threatening, you can
be there for a loooooong time, even with broken bones). Because it was
a head injury and poor Con was looking so green-grey, they took him in
immediately - we jumped the queue, they examined him immediately and
sent us off for a scan right away.

In the case of your child, who has a known medical problem that makes
this kind of injury particularly dangerous AND a specialist called
ahead, whoever did the triage when you came in should be fired. Just
plain inexcusable.

Mary G.

In article ,
(Mary Gordon) wrote:

Yeah, I'd complain, and in writing to .

I'm kind of dumbfounded at the way the ER treated you. My middle kid
has no medical conditions that make high risk like your child. He's a
pretty healthy kid. When he was in Grade 1 he got wonked twice on the
head in the school yard and got a concussion - and I should mention,
he never lost consciousness, but he did throw up and was dizzy, drowsy
and very pale (he looked really awful). We took him to Sick Kids
hospital here in Toronto, where there usually is really long wait in
the ER (if what's wrong is not immediately life threatening, you can
be there for a loooooong time, even with broken bones). Because it was
a head injury and poor Con was looking so green-grey, they took him in
immediately - we jumped the queue, they examined him immediately and
sent us off for a scan right away.

In the case of your child, who has a known medical problem that makes
this kind of injury particularly dangerous AND a specialist called
ahead, whoever did the triage when you came in should be fired. Just
plain inexcusable.

Mary G.



you might also want to refer to this condition as 'hemophilia' next time
-- VW is a mild form of this illness and people might respond more
quickly to something they recognize

"Tina" wrote in message
om...
Does anyone else think it's exceptionally slow to wait three and a
half hours after a head injury with symptoms (sleeping, uneven gait,
pain moving around her head) in a child with a bleeding disorder to
get a catscan? I'm still angry (obviously), but I don't know how
angry to get, if I complain. That nurse definitely lied, I know that
for sure.

I agree with everyone that 3.5 hours seems like far too long to have to wait
to be seen after an incident like this, particularly if the child has a
known clotting disorder. OTOH, I have to say that my experience suggests
it's not at all uncommon and might even be normal.

When Julian cut his finger open with a pair of scissors on a Sunday, we too
him to the ER. It was very busy, and we eventually ended up going to an
urgent care center because the wait was 6+ hours. However, it was an hour
(and maybe 1.5 hours) before we were even triaged. And during that hour, we
met a couple with a son a little over than Solana who'd had a garden tool
fall on his head at a local home improvement warehouse. He had a significant
laceration on the top of his head and had been exhibiting other potential
symptoms of concussion/brain-bleed like Solana (sleepiness, nausea). They
had been there at 3 hours by the time we met them and they had still not
been seen by the doctor when we left, so they must have waited a good 4
hours before they were seen!

Similarly, when we went to the ER after Julian broke his arm, we waited a
good 6 hours and during that time, I met a woman whose son was exhibiting
symptoms of meningitis and he had not been seen in over 2 hours!

The problem, as I understand it, is that the ER's are *way* understaffed.
Even if they have rooms available, they don't have enough doctors and nurses
to care for people occupying them. So they really have to do their best to
figure out which cases are truly critical and which can wait a little longer
without being life-threatening. Another think you have to remember is that
you don't know whether any truly serious and life-threatening cases came in
via ambulance. (That's the way I arrived at the ER, and I bypassed the
triage nurses altogether so people waiting in the waiting room didn't even
know I was there.)

All of that said, I think the nurse in your case made a mistake when
triaging Solana and classified the seriousness of her case incorrectly. I
think it would probably be a good idea to carry with you some sort of
information from her hematologist explaining her clotting disorder and that
any time she has an injury which might be associated with bleeding, she
needs to be treated as considerably more "critical" than the average child
with a similar injury. I also think when you feel you're getting the
brush-off, it never hurts to say something like, "I understand that you are
very busy, but I feel my child's condition is more critical than you are
suggesting. I am willing to wait, but I want it understood that if my child
suffers harm because you did not take my concerns seriously, I *will* bring
a lawsuit for medical malpractice." I hate it that I believe I have to
threaten lawsuits to get action, but it *does* tend to get attention!
--
Be well, Barbara
(Julian [6], Aurora [4], and Vernon's [18mo] mom)
See us at http://photos.yahoo.com/guavaln

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In article [email protected],
"Circe" wrote:

"Tina" wrote in message
om...
Does anyone else think it's exceptionally slow to wait three and a
half hours after a head injury with symptoms (sleeping, uneven gait,
pain moving around her head) in a child with a bleeding disorder to
get a catscan? I'm still angry (obviously), but I don't know how
angry to get, if I complain. That nurse definitely lied, I know that
for sure.

I agree with everyone that 3.5 hours seems like far too long to have to wait
to be seen after an incident like this, particularly if the child has a
known clotting disorder. OTOH, I have to say that my experience suggests
it's not at all uncommon and might even be normal.

When Julian cut his finger open with a pair of scissors on a Sunday, we too
him to the ER. It was very busy, and we eventually ended up going to an
urgent care center because the wait was 6+ hours. However, it was an hour
(and maybe 1.5 hours) before we were even triaged. And during that hour, we
met a couple with a son a little over than Solana who'd had a garden tool
fall on his head at a local home improvement warehouse. He had a significant
laceration on the top of his head and had been exhibiting other potential
symptoms of concussion/brain-bleed like Solana (sleepiness, nausea). They
had been there at 3 hours by the time we met them and they had still not
been seen by the doctor when we left, so they must have waited a good 4
hours before they were seen!

one of the reasons for this is that people take kids with cut fingers to
the ER -- it is this great surge of trivial problems that clog things up

part of the reason is that ERs are used as primary care by those without
insurance, and pediatricians who routinely worked with patients with
minor problems e.g. broken arms, cut fingers etc in the past, now don't
work after hours and send people to ERs and part of it is the judgment
of people who think it appropriate to use an ER for a trivial problem.

"Jenn" wrote in message
...
one of the reasons for this is that people take kids with cut fingers to
the ER -- it is this great surge of trivial problems that clog things up

This was NOT a trivial cut and it makes me see red that you assume it was.
It was a SERIOUS cut. It was literally gushing blood and we were not
entirely sure at first whether he had severed the bone. He needed 6 g*ddamn
stitches and no one in the ER thought it was trivial--simply that he wasn't
in danger of dying or losing the finger if he had to wait a few hours to be
seen. (The only reason we were able to take him to the urgent care center
for the stitches was because a second pass by the triage nurse determined
that the cut didn't quite make it all the way to bone.)

Don't patronize me. I know the difference between a minor injury and a
serious one, and this was serious. It was not *life-threatening*, I agree,
but it needed attention *that* day (and it was a Sunday, so where exactly
should I have taken him other than the ER, especially since I didn't know
the urgent care center even existed until after we got to the ER?).

part of the reason is that ERs are used as primary care by those without
insurance, and pediatricians who routinely worked with patients with
minor problems e.g. broken arms,

And another one. When Julian broke his arm, I was *told* by my pediatrician
to take him to the ER because it needed to be set and she couldn't do it due
to the way the bones were broken. If he hadn't broken both the ulna and the
radius, she probably *would* have set it herself, but under the
circumstances, she didn't feel she could. (For a host of reasons, this
turned out to be a mistake, but I was taking the advice of my PHYSICIAN when
I took him to ER that time. You think perhaps the *pediatrician* can't tell
the difference between a problem she can treat and a problem she can't?)

cut fingers etc in the past, now don't
work after hours and send people to ERs and part of it is the judgment
of people who think it appropriate to use an ER for a trivial problem.

Well, I agree, there are plenty of "trivial" problems in the ER. (There was
the lady my husband ran into in the ER when I was in cardiac arrest who was
there because she'd taken too many diet pills and felt funny. Well, stop
taking too many diet pills!) Notwithstanding, there are times when the ER is
the *only* option--weekends, nights, etc.--and a condition is emergent
enough to require treatment before the regular pediatrician's office and/or
the urgent care center is open. It is not the fault of parents that the ER
is their only option in these situations, and given that the limitations for
off-hours care are well-known, it seems to be that the ERs ought to be
staffed appropriately to handle the load (though, of course, I realize that
is easier said than done given the shortage of qualified nurses and doctors
willing to do ER duty).
--
Be well, Barbara
(Julian [6], Aurora [4], and Vernon's [18mo] mom)
See us at http://photos.yahoo.com/guavaln

This week's special at the English Language Butcher Shop:
"No parking passed this sign" -- hotel parking lot sign

All opinions expressed in this post are well-reasoned and insightful.
Needless to say, they are not those of my Internet Service Provider, its
other subscribers or lackeys. Anyone who says otherwise is itchin' for a
fight. -- with apologies to Michael Feldman