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.***

Are ED Patients Selfish?

When I first read it, I didn’t think it was a joke but actual research. When I read further and figured it was a humor based website– I was a little disappointed. 

Why? Because the article validated what I feel like at work many days. Parents of patients have a limited view of the total department and its needs or demands on my time. They simply want their problem fixed as immediately as possible.
The problem is, the reality of the ER will never meet those expectations of . . . really anyone. 
How often have you had to wait for a doctor’s appointment? That is, an actual scheduled time to meet with your physician. Rarely, am I seen within 30 minutes by the actual doctor. First, the office schedules you before your “real” time for paperwork, etc and also for the hope that you’ll show up on time for the actual appointment time even if you’re running late.
Did that make sense? 
My point is . . . why has it become the expectation that emergency care means you’ll be seen expeditiously? I’ll be the first to say that we’ve not helped ourselves as emergency care providers in this arena. I actually think posting wait times (like a restaurant) feeds into this idea that you’ll be seen upon arrival. 
Our goal is to save the sickest people first. That means we may not see you in order. That means we may not get to you in the hour you’ve allotted for your emergency care to take place. 
In my experience, most patients want to be seen by the provider within fifteen minutes of arrival and discharged home in sixty minutes. 
Once, when I worked in a dedicated urgent care, we had a sick infant come in who needed to be intubated. When explaining to families why there was a delay, someone actually said, “That doesn’t mean we should wait. That family should have gone to the ER.”
That may be true but now they’re here . . . with us . . . and we have to manage their illness. 
I’m not sure what the answer is. How do we make your ER visit more enjoyable? More timely yet still cost effective? Isn’t that the crux of the problem? You’re coming with a problem to be solved and a time frame in mind.
Just what if we can’t fix either? Is it our fault?

Curious to know what you think. 

Sorting though Disaster: Triage and 9/11

As a tribute to the upcoming ten year anniversary of 9/11, I thought it would be nice to have our resident ER doc write about triage.
Where were you on 9/11? Please, leave a comment today.
Most people over the age of twenty probably have some memory burned into their mind of the fire consuming the World Trade Towers and their ultimate collapse and destruction.
I had just flown in from Chicago the night before. I remember waking up to the incessant ringing of our phone. Tired from the previous night, I was adamant about letting the machine pick it up. It became clear after about five minutes of solid ringing that perhaps it was an emergency. I answered and a good friend of mine was on the other end blubbering, crying—nonsensical. I remember fragments of her words—“planes crashed” , “New York”, “Thank God you’re back!”–“Just turn on your TV!”
I think I sat on the couch watching the tragedy unfold for the next three days.
A good friend of mine was working as a nurse at the time of the attacks. She’d just gotten off the night shift and was getting settled into sleep when the events broke. Immediately, she hustled back out of her apartment to go back to the hospital.
Upon her arrival, they were setting up for multiple victims, beginning to formulate a plan of how they would triage the patients.
Here’s triage from the ED doctor’s perspective: Dr. Edwards.
Some extraordinarily difficult decisions have to be made when you’re dealing with a mass casualty situation. Unless you have unlimited resources to treat everyone, victims will have to be triaged.  Triage comes from the French verb trier–meaning to sort–and classically we think of three triage categories: 1) those victims so gravely injured they will not survive regardless of what you do; 2) those who can probably be saved if the right things are done quickly; and 3) those with lesser injuries who may be in distress but who can obviously wait (i.e., the walking wounded). 
 Battlefields have always been the crucible of innovations in trauma care, and indeed the modern concept of triage dates to the Napoleonic Wars of the late eighteenth and early nineteenth centuries.  The individual credited with inventing it (as well as field hospitals and fast-moving ambulances manned by trained individuals) was Dominique Jean Larrey, the French emperor’s surgeon-in-chief. 
 Partly in response to 9/11, disaster medicine is now an actual specialty unto itself, with post-graduate fellowships and board exams.  Because of this, triage grows into more of a science each year as we evolve ever more sophisticated rating scales based upon injuries and vital signs to help providers make those fateful decisions about whom they will race to save.  
 The person assigned to triage duty must be trained to rapidly differentiate hopeless cases from those who might be saved, Typically, that individual will attach a color-coded tag alerting the rest of the team to the patient’s category, and will also perform immediate life-saving maneuvers including the control of external bleeding, needle decompression of pneumothoraces (collapsed lungs), the insertion of mechanical airways, the initiation of field IV fluid resuscitation.  But more often primary triage involves deciding who must be transported to the hospital first. 
 When a mass casualty event occurs, hospitals switch into “disaster mode.”  Carefully worked out plans involving the assignment of crisis team roles and the mobilization of additional staff–all practiced in regular drills, lest we become complacent–are activated.  Hallways and lounges become triage and treatment areas.  Larrey would have been impressed.

Frank Edwards was born and raised in Western New York.  After serving as an Army helicopter pilot in Vietnam, he studied English and Chemistry at UNC Chapel Hill, then received an M.D. from the University of Rochester.  Along the way he earned an MFA in Writing at Warren Wilson College.  He continues to write, teach and practice emergency medicine. More information can be found at http://www.frankjedwards.com/.