The ER: Stuff You Need to Know. Part 1: Triage

I recently wrote an article describing a variety of examples of poor behavior demonstrated by patients in the Triage section of my Emergency Department. While the article was written primarily to introduce the reader to some of the actual (rather than media-generated) challenges encountered by an ER nurse in a humorous vein (which is the modus operandi for all of my writing), my article evoked a tremendous negative response with regard to the readers' personal ER experiences. A majority of responders related their unpleasant experiences when they or a loved one was treated in an ER.

The most common complaint was that an extraordinarily long time was spent simply waiting: waiting to get back to a room while others who arrived in Triage later were brought back first; after arrival in a room, waiting for the nurse to come in and perform an assessment; waiting for the MD to come in; waiting for medication; waiting for tests to be performed; waiting for test results to come back; waiting for diagnosis or treatment; waiting for transfer up to a unit bed; or waiting for discharge instructions and prescriptions. Furthermore, more deeply entrenched in these woes was a complaint common to all: not being informed about what was going on with the process. These people were simply never told what was happening at any point throughout their ER experiences. (It is perfectly understandable that a person in that situation would feel forgotten and ignored, and thus become upset.)

After considering these problems, and at the suggestion of a colleague, I have determined to do something about it. I hope that this series of articles will inform and enlighten the reader regarding the challenges and intricacies of emergency medicine. I hold the firm belief that a well- and accurately- informed public makes for a great patient, because a better-informed patient is far better equipped to actively participate in the care process and is able to more effectively advocate for oneself. I have found that patients treated in this manner nearly always described a far more positive and satisfactory experience, even if an extended wait was involved. Thus, when I teach new nurses (and students), I pound into their minds the following adage:

Keep them SAFE, Keep them WARM, Keep them COMFORTABLE, and Keep them INFORMED. When a nurse does this, it goes a very long way towards making the patient feel cared for- which is the whole point of nursing, if memory serves me correctly.

Returning to the issue at hand, I begin this series where the ER process begins: Triage.

In the civilian sector, triage was adopted by emergency departments in the early 1960s when the demand for emergency services grew beyond capacity to provide everything to everyone at the same time. The process enabled overloaded emergency departments to quickly identify and treat the "super-sick" patient from among the crowds. (Interestingly, it also proved a useful tool in identifying malingerers who were inappropriately using the ER.)

With the advent of government-subsidized medical entitlement programs, emergency departments were rapidly overwhelmed with non-emergent and non-urgent cases that slowed the entire emergency care process down. The need for, and value of, an effective triage system became immediately evident. As a result, four-tier and 5-tier triage systems were developed. With either system, patients are classified by level of acuity (how sick they appear based on objective data such as vital signs, obvious trauma, or body system affected).

Level I: LIFE-THREATENING condition requiring immediate care. Not stable. Examples: CPR or intubation in progress, acute MI, acute stroke, major trauma, acute respiratory distress, or major burn;

Level II: EMERGENT but stable. Seen ASAP (within 30 minutes); Examples: Stroke when patient was last observed without symptoms more than three hours ago, Open fracture, kidney stone, testicular torsion, possible ectopic pregnancy, "hot" (surgical) abdomen, sickle cell crisis, frankly-ill child, neonate with fever, fever (with headache, stiff neck, and rash), traumatic eye injury, acute narrow-angle glaucoma, suicidal ideation.

Level III: URGENT. Stable, no distress. Seen ASAP if no Level I or II patients ahead of them. Can wait up to one hour before being seen. Examples: Closed fractures, laceration without bleeding, Drug ingestion > 3 hours prior to visit with no signs or symptoms.

Level IV: NON-URGENT. Stable, no distress, can wait at least one hour before being seen. Examples: Typical migraine, rash (without fever), abrasion, anxiety, cough/cold.

Level V: DELAYED. Can wait four or more hours before being seen. Examples: out of medications, routine exams.

The patient is classified according to objective findings (abnormal vital signs, obvious distress, etc.) The experienced and astute triage nurse also develops a "sick sense" (being able to quickly visually assess a patient for a genuine life-threatening illness, as opposed to the fakers who pretend to have seizures or who feign unconsciousness as they come through the door).

It is absolutely essential that the reader understand this system because it governs the entire flow of the emergency medical process. The patient is not merely classified randomly and arbitrarily by the triage nurse. It also provides the inarguable reason why one person may arrive first but be seen later than another person who comes in after them. While one person my have a migraine and be completely and undeniably miserable, if another person arrives with signs and symptoms of a higher-acuity condition, that person is going in first, and no amount of complaining is going to change this fact. Furthermore, screaming, crying, or otherwise acting out will never qualify a patient to receive a higher acuity "just to shut them up." It just upsets everyone else who has to endure the childish, selfish and obnoxious behavior.)

Triage is one of the trickiest, most challenging functions for the ER nurse. Symptoms of a potentially life-threatening condition can be subtle, and can even be discovered "accidentally" when a patient is complaining of a problem that would itself provide for a lower acuity assignment. In my career, I have had at least six patients who complained of abdominal pain without vomiting or diarrhea (which at face value, merits an acuity of II to IV, depending on vital signs). But every single one of those six made a seemingly-offhand remark, or described their pain in a particular way, that caused my "suspicion index" to send up massive red flares. In each case, acting merely on my suspicion through the simple act of looking at and feeling both legs revealed one being colder and paler than the other- and that the patient's pain was not gastrointestinal at all, but that he or she was suffering from a dissecting abdominal aortic aneurism, which merits an acuity level of I with an exclamation point. (Only one of those patients died, and that was because his aorta completely tore within moments of sitting down in my triage booth. When the aorta blows out, there is nothing anyone can do; death occurs in ten seconds or less- there often isn't even enough time for the patient to say more than a startled, "Oh!" before the lights go out forever (It happened once). He just said, "I can't breathe," and he was gone. But had I been less experienced, I might have missed all six.)

The effective and safe triage nurse demonstrates experience, awareness, astuteness, coolness under pressure, and razor-sharp critical thinking skills. Where I work, no nurse with less than two full years as a full-time ER nurse is allowed to go anywhere near triage- even if only to give the triage nurse a 30-minute break. It is no place for the neophyte or any nurse who is still in the process of gaining confidence of his or her abilities. As illustrated above, people live and die on the quality of the triage nurse's assessment. When a waiting room is packed and more people are coming in, and just when three rooms are opening up the charge nurse informs triage that three medics have arrived with Level I patients, the triage nurse has no choice but to hold the line.

I have had many nights like that in Triage. In some ways, it is more difficult than working in a Level I thrash. Instead of one patient, I have thirty or forty with variable levels of acuity. This, again, is where experience and calm is an absolute requirement. Nobody likes to be stared at; and the awkwardness is amplified when every one of the people staring at the triage nurse is not feeling well and has been waiting for hours. How does one cope with this potentially-volatile situation? The question introduces two more equally-vital traits of the triage nurse: empathy and compassion.

In my experience, it really does not take much effort to help even a miserably uncomfortable person endure a long wait. It is amazing how calming to a room full of patients it is to simply circulate around the waiting room periodically, offer a blanket or pillow, and say "I know you've waited a long time. Has anything changed? We are working as fast as we can. We haven't forgotten about you. As long as you are out here, you are my patient and I will look out for you."

When people see you actively following up on them and looking after them, they feel cared for. All it requires is one minute of time to infuse calm into a crowded, highly-charged waiting room. Granted, there are times when it may not help (a demented patient with "sundowner's syndrome," a belligerent drunk or drug user, for example). But otherwise, I have never, in all my experience, known this approach to have failed me in calming down a room full of upset patients.

In fact, the triage nurse is required to re-assess everybody waiting on a regular basis. Making rounds is a quick and efficient means of doing that.

I cannot speak for the practices of every nurse, hospital, or emergency department. Many factors not mentioned here can create a positive or negative experience for the patient. But I strongly encourage you, the reader, to advocate for yourself or your loved one. This is not Cuba; our medical system is still driven by a free-market economy. That means if enough patients get upset, they can tell their friends not to go to that hospital, and so on. People will start avoiding that hospital. The hospital is a business. No patients means no revenue. State agencies will begin to wonder what is going on at that hospital. The hospital will either change, lose accreditation, go bankrupt, or lapse into backwater obscurity.

Here is what you can do: If there is a problem, speak up! If more than an hour has passed since you have been informed or have seen your nurse, speak up! If you have not been seen, gone to a diagnostic test, received results, been treated for the diagnosis, or received your discharge instruction more than an hour after being informed of the step, speak up! And if you feel that you are not being informed about any part of the care process, speak up!

You, the patient, do not exist for us; We, the Emergency Department, exist for you. If we work together as a team, we both will be the more satisfied and enriched for it.

Having just had emergency surgery and just being released from the hospital after 4 days and having been in emergency 3 times in 4 days, and been misdiagnosed in each instance, I have a question.

You, the patient, do not exist for us; We, the Emergency Department, exist for you.

Who pays/hires whom to perform a service?

Oh and as person that suffered with migraines for 15 years, I can tell you, there IS distress.

Interesting stuff! It ties in with my wife’s ER experience last year. While carrying our daughter around, she stepped on a toy and slid down to the floor, breaking a metatarsal bone in the process. By the time we realized that this wasn’t something that just “keep an icepack on it and keep it elevated” could fix, all the local doc-in-the-box clinics were closed. The nearest ER we knew of was crosstown; and this is no underfunded two-bit hospital, it’s Duke University’s flagship teaching hospital. (Say what you will about living in Nifongville, it’s blue as hell around here, but darned if we aren’t surrounded by some of the best healthcare in the country, all within an hour’s drive.)

So leaving me at home to take care of our 18-month-old, she limped out to the car and drove off to the Duke ER. She got there at 10:30. She didn’t get home until 5:30 am. She sat in the waiting room before getting triaged, then they stuck her in a cubicle for two hours with nobody coming back to look at her, not even a pain pill for her throbbing foot. A doctor came in, poked around it for a couple minutes, then left. Another 90 minute wait before a second doctor came in, poked around it for a couple minutes, then solemnly told her that yes, she’d broken her foot. Thank you, Doctor Obvious!

She was in tears by the time she got home, and not just from the pain or the total lack of sleep. She’d gotten treated like an inconvenience, not a patient. A broken foot is not life-threatening and doesn’t require immediate emergency care, even on a slow summer Tuesday night in Durham, NC. But it wouldn’t have killed them to actually show some compassion and bedside manner, would it?

Postscript: She went back for a followup two days later with an orthopedist. He checked it, said “yep, you broke thus-and-such metatarsal, stay off it for a while.” “Well,” she said, “I’ve got a toddler, how long do I need to stay off it and what do I need to do to heal faster?” “I’ll let you be the boss of that,” he replied, and left.

}:-)4

You know I saw this before and I just couldn’t bring myself to respond. I am so aggravated with nurses and triage nurses playing God. Nurses don’t assess patients anymore they just chart. I had a nurse chart pedal pulses, bowel sounds, heart sounds, lungs sounds, pupil sizes -— and the nurse had never done a thing for me except send the aid in to check my vital signs. They gave me an IV push med and never even wiped the port with alcohol swab. They(the triage nurse) told me my pain wasn’t real. She made me get out of the ambulance and EMT stetcher and sat up in a chair and wait in the waiting room when I was collapsing from fluid volume loss. Now they have the audacity to send me a bill. You can have my RN licenses I don’t want it any longer.

Gunner....one of the more vivid of the many memories I have of my long tenure in a big city ER was of an incident that went like this....

A patient had been wheeled directly into the trauma room by the city ambulance service having OD'd.They worked on her for a while but she expired.Before our ER's redesign all ambulance patients were wheeled in *right* past patients (and relatives) in the waiting room.Not long after the OD's arrival a woman went up to the front desk demanding to be seen right away....all the while acknowledging that she had nothing more than an ankle sprain. At this point the front desk secretary,who was brand new to Emergency medicine,told this woman "did you see that patient who was just brought in a while ago? Well,she ***died**.And she stressed the word "died".Not only the patient but everyone else in the waiting room heard this interaction.I must say that the secretary's response quieted the patient right down but I remember saying to myself at the time "oh,God...no! Please tell me that you didn't just say that".

Ah,the fun we had! (Well,not always)

I agree with everything you say.
It really does make it better to have someone stop by and say a few words once in a while, at least, while you're waiting for, literally, hours.

I, personally, would like to see ERs go back to treating emergencies and turn away the petty.

I realize that not everything that seems petty IS petty, as seen by your examples above, but some ARE petty and should not be taking up the ERs time and resources.

I suppose we should tell him.

It’s when one or more of your thingies twists around on the strings they dangle down from.

Those strings are a duct (viaduct? Vy not a chicken?) and an artery and a vein.

Twisting them together is like pinching a garden hose, it cuts off the flow, strangling the blood supply to “Them”

“They” will croak without a fresh supply of oxygenated blood.

“They” will let you know they are NOT HAPPY with this prospect.

our medical system is still driven by a free-market economy

This is simply not true, especially with respect to emergency room care. The system is increasingly dominated by nonpaying patients (and that includes those with Medicare/Medicaid who have not and will not pay into the system anywhere near what they will take out of it, even if their medical needs turn out to be only average), including outright fakers seeking free narcotics and people with self-inflicted ailments for which they patently refuse to follow to medical advice to treat or mitigate. The quantity and quality of service available is what can be produced with the funds provided by the 50% or so of paying patients, and the available service is then divided evenly among the 100% of patients who show up -- often actually going disproportionately to the nonpayers, since they tend to have more serious medical problems and injuries due to irresponsible lifestyle choices.

The people who pay for the system, who are pretty much the same ones who only come to the ER with legitimate emergencies and who either don't self-inflict ailments or who follow medical advice to treat self-inflicted ailments after they've arisen, end up getting treated just the same as the fakers and my-health-is-somebody-else's-responsibility crowd. What really aggravates me is that there doesn't seem to be any sense of outrage about this among medical professionals. The career gang-banger/crack dealer/crack addict with a history of faking seizures or extreme pain in ERs in attempts to get narcotics, shouldn't go to the front of the line even if he DOES have a dissecting aortic aneurysm that night -- he should have been arrested, convicted, and tattooed/microchipped after his previous ER misdeeds, to identify him as holding "Serve Last in ER" status. The hardworking, honest, heavily-taxed father with the very mild stroke symptoms should be popped ahead of him.

Netizen, thank you for sharing your experiences. I hope what follows helps. What I meant by my final statement is that the whole reason that the ER exists is to serve its community, not to shave the community serve it. I was not implying that you were somehow unimportant. If I could have been clearer with that statement, I apologize. The public pays us to apply our best efforts and skill to every patient of every level of acuity. If you feel that your ER has failed you, I encourage you to contact your hospital's administration and share your experience with them. As I said: I cannot speak for every nurse, hospital or department.

There are standards that we as professionals must meet. If we do not meet those standards, then we have failed our patients and our community. Speak up! Enough people complaining about their experiences really can bring about improvement. I will pray for your rapid and full recovery. Having had two migraines in my entire life, I can honestly say that those were two too many. And I know from personal experience how horrifically painful a migraine can be. My own experience helps me to empathize, but of course,'empathy' is not a pain medication.

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