Take Me First: The Triage System

Often times, when I read a medical scene in a fiction novel it generally covers treatment of a character’s injury/illness. That can be the extent of the scene. What other factors inherent to the ED can increase conflict for the character?

One of the first people you’ll come into contact with if you go to the emergency department is the triage nurse. Triage is a process of sorting patients so the sickest are seen first. Can anyone see potential areas of conflict during the triage process?

When I screen a patient in triage, I take their complaint, a set of vital signs, medical history, allergies, and current medications. For pediatrics, we get a weight because every drug dosage is based on their weight. Most likely, the parent explains why they brought their child in. I then assign them a level based on my assessment of how emergency they need to be seen. Different emergency departments will use different scoring systems but all ED’s have them. Some are three levels. The hospital I work for uses a five level triage system.

If I “level” you a one then you’re dying and need immediate resuscitation. A level two patient might be a fracture with obvious deformity that may have to be set using sedation or an infant that needs a septic work-up. A level three patient would be those requiring a work-up for their issue— like abdominal pain. A level four patient is generally a simple laceration repair or concern for fracture but not an obvious deformity. If I assign you a level five, then you could likely be seen by your doctor the next day without suffering any ill effects. This would cover things like getting a test for strep throat or having a doctor look at a rash. You can see as the “acuity” goes down (level one is the highest acuity), so do the number of tests and procedures. ED nurses are very good at anticipating what tests and procedures the doctor will likely preform.

If bed space is not an issue, patients are generally taken in order of arrival. People in the waiting room are excellent at keeping track of what order they’re in and they expect this to be maintained. However, when bed space becomes limited, then I want the doctor to see the patients who have the highest acuity first.

However, when you begin to pull people out of order, this is when tension begins to rise in the waiting room. At first, it may be subtle. I call a patient back and the ones that signed in before that one give me what I affectionately call the “evil eye”. The longer the wait, the more restless people/children become. Sometimes, sicker patients do have to wait. As a nurse, this is not an ideal situation but I also can’t place more than one patient/family in a room.

Often times, it is presumed that a patient that arrives by ambulance will automatically get a room in the department. However, if beds are tight and the patient’s acuity is low, I have triaged them to the waiting room. How happy do you think that patient is? I know this may come as a shock, but some people who call an ambulance are not having a medical emergency.

In the comments section, write a triage scenario that has high conflict in no more than five sentences. Can you do it?

***Contest reposted from February 9, 2011.***

Traumatic Brain Injuries: Initial Treatment

Last post, I have a primer on traumatic brain injuries (TBI) that you can find here. Today, I thought I’d give an overview of the treatment guidelines.

Remember, the basis of treating TBI is manipulation of the three components within the skull: the brain, the blood, or the cerebrospinal fluid (CSF). Additionally, sometimes a portion of the skull is removed.

1. Manipulating Brain Tissue.

Removing brain tissue is an option and may be done to tissue that has died. Recovery of the patient is dramatically influenced by what part of the brain was removed.

Another management strategy is to put the brain at rest by placing the patient in a medically induced coma. Medication is used to heavily sedate the patient. Typically, the patient is on continuous EEG monitoring to ensure a minimal amount of brain activity is present. The purpose of the coma is to reduce the metabolic demands of the brain in hopes of keeping swelling down and allowing the brain time to heal.

Additionally a diuretic, either hypertonic saline or Mannitol, can be given to draw water out of swollen brain cells.

2. Manipulating Blood Flow.

This can entail a couple of areas. Remove blood that has collected in the brain. Sometimes when the brain is injured, blood vessels within the brain are ripped open. Two types of bleeding can occur between the brain and the skull: a subdural or epidural hematoma. A subdural hematoma occurs from veins. An epidural hematoma occurs from an artery. Depending on the size of the hematoma, a neurosurgeon may choose to operate and remove it. Sometimes bleeding occurs within brain tissue. This type of bleeding can be small and more diffuse. Although a risk for the patient it may not be an option to surgically remove it.

Another way to change blood flow is to manipulate the size of the blood vessels inside the patient’s head. This can be done by increasing the rate of the patient’s breathing on the ventilator thereby decreasing their blood level of carbon dioxide. When this level is lower, the blood vessels inside the patient’s brain shrink in diameter. This therapy is controversial and if done, only a mild drop in carbon dioxide levels is the goal.

Lastly, the blood pressure can be manipulated. A certain blood pressure or blood flow to the brain must be maintained in order to keep the brain alive. This is called the cerebral perfusion pressure (CPP) and is calculated by using the patient’s blood pressure and their intracranial pressure (ICP). Reducing the blood pressure is an option but you must maintain the cerebral perfusion pressure as well. This can be a challenging balancing act.

3. Manipulating Cerebrospinal Fluid (CSF)

A drain is placed to remove excess cerebrospinal fluid.

4. Removing a Portion of the Skull.

This is a viable option for management of brain swelling. A portion of the skull is removed (hemicraniectomy) to allow the brain room to swell. The portion of the skull that is removed is preserved by freezing so that is can be reattached at a later point once the swelling has eased.

Have you had a character in your novel with a traumatic brain injury? If so, what type and why did you choose it?

***Reposted from January 19, 2011.***

When Does a Person Require Blood Transfusion?

Sometimes, it’s hard to know when writing a scene when to pull the big guns out. If you have a character that is bleeding a lot (by whatever mechanism) when should you think about giving them blood? Or, better yet, when will the lack of blood begin to hamper their ability to function.

Fairly consistent among resources, hemorrhagic shock (shock related specifically to blood loss) is a life-threatening condition that results when you lose more than 20% or 1/5th of your blood supply. Patients will feel lightheaded, dizzy. Their respiratory rate and heart rate will be elevated. Their blood pressure might be low. They’ll look pale, pasty. Their skin might feel cool, clammy, dough-like.

But exactly how much blood does that translate to? I actually found this nifty little calculator that will give you a person’s estimated blood volume based on their age, sex, and weight. For instance, a man weighing 100 kg has an estimated blood volume of 7,500 ml. So losing 20% of his blood volume would be 1,500 ml of blood or approximately 3 pints of blood. A pint of whole blood (what you would donate) is approx 500 ml. A woman of the same weight has only 6,500 ml of circulating blood. An infant weighing 10 kg has only 800 ml of blood. You can see how that 20% translates much differently depending on the characters age, sex and weight.

Author Question: Transfusing Blood Post EMP Blast

Alyssa Asks:

An EMP took out all electricity 2 years ago— meaning no electricity, refrigeration, or other modern medical machines. The city has been isolated since then. Ruling gangs have raided the hospitals, but our gang of survivors managed to snag a number of essential hospital supplies including a field transfusion kit.

Patient is 6 years old. She has lost a large amount of blood from a scalp wound. They don’t know how much blood since it’s dark and they weren’t there when it happened, but she’s sheet-white, cold and clammy skin, blue lips and fingernails, shallow breath, quick pulse but low blood pressure. No access to Saline. Looks like blood is the only option.

Our nurse, she tells the others about the risks, even though the donor and recipient have the same blood type. Antibodies causing a reaction, infection, too much blood, etc. But it’s a dire situation.

Could they run an IV from the donor into a blood bag using gravity? Bags suspended in cold water to keep it cold and inject anticoagulant into the bag port once the blood starts filling it?

They’d only use one unit. Once they fill the bag, they’d use another blood tube to run it into an IV attached to our young recipient. Again, they’d use gravity, but the girl would be on a table and the blood bag suspended above her, maybe hanging on a hanger on a back of the door. Would this work?

Jordyn Says:

Thanks, Alyssa, for sending me your question. It is fairly complicated so I’m going to give a little background.

First of all, kids do not get the same amount of blood as an adult. We transfuse kids based on their weight. Your average 6 y/o weighs about 22 kg. Kids get 10ml/kg for their transfusion volume so this child needs approximately 220 ml of blood. We also don’t routinely transfuse whole blood. What we give is packed red blood cells— exactly as the name sounds. One unit of whole blood is split up into many different parts (packed red blood cells, platelets, and plasma).

What you’re talking about is giving whole blood which will lessen the amount of packed red blood cells your patient is getting. I’d stick with transfusing about 200 ml of whole blood as a marker to start. One unit of blood can hold up to 525 ml so your patient would need roughly half of one bag. It will be hard for your character to measure that in this situation so the nurse will have to go off improvement of her patient’s vital signs. These would include improved color, warmer skin, decreased heart rate and increasing blood pressure.

Bags that collect blood already have a component inside to keep the blood from clotting so I don’t think I’d even worry about an anticoagulant. I don’t even know that you’d really need to worry about cooling the blood. Collection takes somewhere between 10-30 minutes depending on the size of the vein accessed. Usually for blood collection the antecubital vein is used (the one at the crook of your elbow).

While the blood is being collected from the donor (yes, by gravity— the bag lower than the donor), the nurse can start an IV in her patient. You would need a set of IV tubing to puncture the blood bag, prime the tubing with the blood, and then give it to your patient. No air in the line, please. Hanging the unit by any means possible is fine as long as it is higher than the recipient.

Usually, blood is given with a filter in the line so if they had stolen a blood transfusion field kit then hopefully this would be part of it.

Your other option is to do old style person to person transfusion of which you can see a photo here and not mess with collecting the blood at all.

Hope this helps and good luck with your story!

Signs Versus Symptoms

Sometimes as a nurse, I wish I could live in a Star Trek episode and pull out my tricorder, grabbing my assessment with a quick hover of the device over my patient. Those crafty gadgets could tell you everything about your patient. Unfortunately, we aren’t blessed with these yet so it’s good academia to know the difference between a sign and a symptom when writing a medical scene.

Any guesses as to what the difference is?

A symptom is something subjective felt by the patient and told to the nurse or physician. It is not measurable. For instance, a person coming in with abdominal pain might say: “I feel like I’m going to throw-up. It feels like someone is stabbing me in the gut with a knife!” All of these things the patient describes are symptoms. We can’t measure them and we only know they’re present because the patient tells us so.

A sign in the medical sense is something we can measure or directly observe. Let’s take the same patient from above. He has relayed to the medical staff that he is having some pain. Some signs of pain are sweating (diaphoresis), increased heart rate (tachycardia), and increased blood pressure (hypertension). Some patients might writhe around in pain. These we can observe and measure.

Now to throw a wrench into my definition. At times, we try to measure symptoms like pain. This is why we have pain scales. A patient states they’re having pain. The nurse replies: “Sir, on a scale of 0-10, zero being no pain and ten being the worst pain you’ve ever had in your entire life, how bad is your pain?” We attempt to measure but it is still the patient’s subjective experience.

Here’s a very common ER set-up that can increase conflict between the patient and the medical staff.

A patient presents to the ED with complaint of a headache. There are several patients to be triaged and the person takes a seat in the waiting room. He strikes up conversation with another family. After that, he puts his ear buds in and is texting on his phone. I can see that this patient has signed in and what his complaint is on my computer screen. I decide, based on his complaint and his behavior in the waiting room, he’s okay to wait for me to triage the other patients.

In triage, he continues to complain of a headache. He is warm and dry. Sits comfortably. Heart rate and blood pressure are normal. I ask him to rate his pain. “It’s 15/10. This is the worst headache of my entire life!”

See the conflict? Do you believe this patient is in pain? If yes, why? If no, why?

***Content reposted from January 26, 2011.***

Author Question: Treatment of the Burn Patient

Jennie Asks:

What happens when someone gets burned? What do the EMT’s do on the scene? The story line involves the explosion of a crosswired electrical box.  Two individuals are burned.

First, the man who threw the switch is thrown onto the floor and sparks are showering down on him and his clothes.  He is pinned beneath a shelf that he knocked over.  The second man takes his jacket and tries to put out the flames while others pull the shelf off the man on the floor.  The second man’s arm and hand are burned trying to put out the fire, and keep the sparks from falling on the man on the floor.

I have the paramedics taking the first man to the hospital. I describe very little about his condition. However, the hero is attended by the heroine who is an EMT. His burns are secondary. Would he have to go to the hospital?  Get a tetanus shot if he needs one?

Jordyn Says:

The first distinction to make is that there are several different types of Emergency Medical Service (EMS) providers and their level of responsibility to this patient will be different. An emergency medical technician (EMT) generally provides basic first aid, CPR, can administer oxygen and can assist the patient in giving some of their own medications (like an asthma inhaler or nitroglycerin tablets.) A paramedic does more advanced medical procedures and gives drugs. The level of your provider will need to be clear in the medical care they can provide.

For EMT’s, in general, burn care is as follows:

1. Remove clothing from the burn that is non-adherent.

2. Remove any constricting items. For instance, if the burn is on the ring finger, you would try and take the ring off.

3. Cover burn with a cool, wet, clean dressing. This will help control pain.

If you have a paramedic responding— it is possible that an IV could be started and the patient could get an IV narcotic for pain (something like morphine or fentanyl.)

If the character is burned by the electrical current, this poses a whole new set of problems. I get the feeling he is burned by the electricity because you mention that he has been thrown back. Electrical burns typically have an entrance and an exit wound like the hand and foot. The electricity enters one part but has to exit somewhere.

The other problem with electrical burns is that your heart pumps based on an electrical conduction system. An electrical burn can injure the electrical conduction system of the heart and we will look very closely at whether or not the heart sustained injury. This could be evaluated initially by a 12-Lead ECG and lab work that measures muscle breakdown specific to the heart. The issue with electrical burns is that the damage is often unseen because the electricity will injure you internally but we can’t see it externally except and the entrance and exit sites.

The other thought was the extent of your patient’s burns and this would make a difference in their medical care. Burns are generally calculated based on the percentage of skin that is affected. You can find examples of these tables by clicking this link. Adults and kids are calculated differently.

Burns <15% body surface area (BSA) would get cool, moist compresses. However, burns > 15% would get dry, sterile dressings. The reason for this is that burn patients have lost their skin integrity. Your skin helps your body maintain its temperature. Some consider it the largest organ in the body. When you burn >15% and apply cool, wet dressings, this can pull enough heat away from the patient to cause them to become hypothermic. We actually have to help burn patients maintain their body temperature by cranking up the heat in the room or using other warming techniques.

Your patient will have to go to the hospital. Initial ED treatment would be IV placement, fluid resuscitation (there is a formula we use for this and is dependent on the burn percentage), pain medication (like morphine), and likely consulting with a burn center to help determine his course of treatment. Tetanus shot would be updated if he hasn’t had one in the last five years.

Did you know that paramedic protocols are relatively easy to find online? For instance, this link shows all of the Denver Metro Prehospital Protocols. Referencing these will be one of the best sources for researching what type of prehospital care your character would receive for their given ailment.

***This content originally posted December 10, 2010.***

Button Batteries: Preventable Cause of Pediatric Death

There is nothing that will raise the ire of a pediatric nurse more than a preventable pediatric death. So, in an effort to educate the public, today I’m focusing on a very real danger in your home that could kill your child if ingested and that is the button battery.

battery-106353_1920Button batteries are those disc shaped, silver batteries that are found in hearing aids, watches, weight scales, and often toys. I would be surprised if you didn’t have these in your home.

Typically they are swallowed by younger children (age 1-3) who may or may not tell you what has happened. We can tell the difference between a button battery and a coin by a characteristic halo appearance of a button battery on x-ray. If you look at the underside of the battery, you’ll see this gap that will show on film.

If the battery becomes lodged in the upper esophagus, it leaks a highly caustic alkaline solution, even if the battery is spent, that begins to erode through tissue. This process happens quickly. I’ve seen these burns develop in just two hours. These burns can lead to scarring and long term complications— that can be a minor complication.

There is also a deadly complication. Even after the battery is removed, this alkaline solution can remain in place, eroding and burning away tissue. Typically, the cause of death in a button battery ingestion is hemorrhage because this solution eventually erodes through a major blood vessel. Even if the patient is in a hospital when the bleeding starts it is very difficult to repair.

For prevention:

1. Button batteries need to be treated as highly toxic objects. They should be kept out of the reach of children (even locked up) like other dangerous objects in your home.

2. Toys that have button batteries need to have screws that lock them in place. Toys should be checked frequently to be sure this compartment stays locked. Best case is not to have these types of toys in your house at all with younger kids.

3. Be aware of items in other environments that have button batteries. Button batteries are used in hearing aids. So be careful at grandma and grandpa’s house and have a discussion with any caregiver about the dangers of having these unsecured.

4. Give age appropriate education to other children in the home about how dangerous button batteries are. Tell older children to tell you immediately if they see a younger sibling with anything in their mouth that they’re not supposed to have. Have them show you toys when they break to see if the battery has become loose. If it’s not there— find it.

5. If swallowed, proceed immediately to the closest emergency department. I mean, really drive there now. You don’t need to call 911 but you do need to go. Do not delay being seen. Button battery ingestions are a true emergency. Your child should immediately receive and x-ray to determine the location of the battery. Treatment depends on its location.

6. If discharged home after a button battery ingestion, any bleeding needs to be treated as an emergency as well. If bleeding is significant then you should call 911 and be transported. Even minor (or spot) bleeding from the mouth needs to be evaluated emergently.

For additional cases and information you can read here and here.

As one of my physician co-workers said, “Respect the button battery.”

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