Readers Guide to Triage

Triage is the part of the ER visit with which the general public seems to have the most difficulty.

When in triage, I usually greet patients by asking, "What can we do for you today?". I think it is so much more friendly than saying "Why are you here" (just sounds too confrontational), or "What brings you here today" (because the average asshole will say, my car, my mother-in-law, or a taxi. It is unfunny and unproductive and makes the patient look like an idiot, frankly).

By asking "What can we do for you", it is opportunity for me to collect information and to create a dialog about why the patient is in the ER, and and gives the patient an opportunity to state their expectations. We are in the business (and business it surely is, make no mistake about that) of helping people, but it does require a little bit of effort on the patient's part.

What is not helpful are the following responses:

1. "I don't know, you tell me"

2. "My doctor told me to come in" (also the school nurse, trainer, day care provider, home care nurse, my neighbor who is a nurse's aide. Oh, and my mother is also a big one)

3. "Kill me" (also I want to die, or simply lying on the floor moaning while texting all of your friends)

4. "I'm sick".

Each of these answers will earn at minimum a withering glance, such as the one Nurse Jackie is offering. I don' t even respond anymore, except to possibly say "Is there anything you'd like to add to that?"

Other less than helpful responses include:

5. "Well, it all started with _______ in 1998.....".
Please, just keep it to a single compalint if possible. Sore throat. Migraine. Shortness of breath. Chest pain. Cold symptoms. Vomiting. Very simply, I don't need to know every aspect of your medical history. And, you will just wind up repeating it to the doctor, who also really doesn't need to know you had a colonoscopy or a mammogram in the last 5 years. Sheesh. Plus being long winded in triage only delays your care.

6. "You have my records"
I might, but why should I look them up? It takes time away from other patients. If you don't have the ability (are short of breath, mentally debilitated, or require resuscitation) I might look them up. But, if you don't care to provide me with the information or it is too much of a chore, consider that may also be for me.

Things triage nurses never say, but are always thinking. If thought bubbles were visible, we would all be screwed:

7. It's not nearly as bad as you think. (Actually, I do say this quite often for things like lacerations especially for frightened kids. Especially if I'm pretty sure they won't need sutures)

8. You aren't as sick as you think you are. (Mostly for the Man-Cold; a blog in and of itself)

9. Did you call your doctor about this chronic/long time/insignificant issue?

10. If you already have percocet and oxycontin at home, what more did you think we could do for you?

11. You aren't really wheezing if you are consciously making the noise yourself in the back of your throat.

12. You are not unconscious if you are merely lying with your eyes closed

13. You have got to be on crack if you think I believe that you weigh only 250 pounds/smoke 3 cigarettes per day/have no money in your Coach bag next to your Iphone to buy an inhaler .

14. Did you think to try ice/Tylenol/ibuprofen?

15. You injured this a week ago, have been playing sports and going to school, it's not swollen and a bone isn't sticking out, but it's just "not better". Are you an idiot?

16. You have had an antibiotic for 24 hours and you are not all better. Are you an idiot?

17. You don't know any of your medications; don't you think that you should? (For this I usually offer a handy little plastic sleeve and a medication list card; people love giveaways)

Also: if I offer you a wheelchair it is because I am concerned about liability, not necessarily that you shouldn't be walking on it since clearly you have been walking around on it for days.

Today's Last Patient of the Night.....

was a 20 month old brought by mother for "vomiting".



Me: When did the vomiting start?

Mom: A half hour ago. He was with my ex. I think he might have gotten into some medicine.

Me: What makes you say that?

Mom: Well it was blue and green and had chunks in it. Nyquil is blue.

Me: Did you speak to the Dad to see if it was possible, or that he had been given any blue foods?

Mom: What?! There are no naturally occuring blue foods!

Me: Rainbow Goldfish? Skittles? May not be natural, but they come in green and blue.

Mom: Oh. I didn't think of that.



Note: the child had eaten a lot rainbow colored Goldfish crackers when mom checked.

Little Mr. Man...

...was 94 years old, pleasantly demented and was a "surprise" roll up via ambulance from a local nursing home. "Oh, didn't they call you?" (Do they EVER?).

He had an infection in his finger, more specifically a paronychia. He had been a nail biter for most of his 94 years. Mr. Man was also blind, very hard of hearing and was wearing headphones that disappeared into the front of his shirt, connected to I have no idea what....something. Perhaps a poor-man's hearing apparatus. Maybe it was just a cassette of a mother's heartbeat, the ocean, yoga music or jungle sounds.

Still, he was very cute.

Even when he wandered out of his room without clothing while Jane and I were busy wrangling a toddler who needed stitches.

Poor Ellen. She would much rather avoid any nudity or sexual references altogether, but recognized that we were both busy so she kindly threw a sheet on him lest he scandalize the old ladies in the waiting room.

This was on the heels of her latest discovery of vandalism. And on her very desk.

Ellen was tired of people walking off with her pens. So, she artfully decorated a few pens with large plastic flowers; the kind that people generally do not walk off with. Next, she placed said pens with a bunch of tiny decorative pebbles in a little glass jar which she labeled "PENS"in bright red.

Some wisenheimer clandestinely placed an "I" between the "N" and the "S". You know what that spells.

Now relabled, the "N" and the "S" are so close together you could not possibly get and "I" in there. There will be no nasty penis references on Ellen's desk at this Catholic hospital, you can bet your boots.

And nobody walks off with the pens, either.

Ellen, controlling crime, nudity, and inappropriate sexual references in the ER. What would we do without her?

The Best Defense....

The Talker got a patient complaint, and since I was working that night I was interrogated about my culpability asked what I remembered about it.

The complaint went something like this:
The doctor said he thought I was addicted or selling the drugs since I have had a few ER visits recently. He made me feel bad. He wouldn't give me any drugs and it was a waste of my time.

Oh, yeah. I remember alright.
The patient wanted Vicodin for her complaint and said her doctor had sent her over. She had just been seen in our Downtown facility the night before for a different pain related complaint, where Parvati (being relatively new) had given her the ol' IV fluid and IV med routine that we have come to expect of her for every patient with a chronic pain complaint. She has been notified that we don't routinely do this on every patient, much to her surprise. Anyway, the patient refused a CT scan and left the department before her care was completed.

The Talker got the patient's covering physician on the phone, who was well aware of this patient. He told The Talker that the patient had a long history going from ER to ER, abusing narcotics, had a pain contract, and that she wasn't to receive any prescriptions for narcotics.

The Talker spent at least 25 minutes with this patient discussing harmful behaviors but never said anything about the patient selling drugs; it is not part of his "Narcotic Avoidance" speech, so I can' only imagine where she got that.

My boss was a little bit at a loss for how to handle it.

I suggested that she just call the patient and tell her everyone involved with her care has been fired; it has at least as much truth as her complaint.

We Do This To Ourselves

So with New Cathy gone, I have had a few days of working with SIC (Second in Command). She's not too bad to work with as long as we are busy. I have figured out that I am somehow threatening to her, or that my experience makes her feel inadequate. The sum total of her ER experience lies within our small 6 room facility. That doesn't make her a bad ER nurse, she is actually a very good nurse and I have never knowingly said or done anything to make her think that I felt she was incompetent, but people can be so weird. Having worked in larger, busier ER's where nurses have more autonomy and/or standing orders, (and flow rather depends on it) I sometimes chafe at waiting to get things started when I know that they are going to be required anyway. I appreciate that we all come from different backgrounds, so maybe she is finally getting comfortable enough to let her guard down instead of always being on the attack. Anyway, we were working with Bobo, who is still, apparently on his meds and willing to have a laugh or two.

Bobo had the misfortune of having to deliver (for the first time since his residency) a baby several months ago at our treat 'n transfer station and Taco stand. Luckily, he was working with Mikki who has some OB experience and the midwife showed up to "coach" over his shoulder. Mom and baby did fine, but Sherry and Bobo were shaken up since nothing strikes fear into the hearts of ER personnel like the sight of a gravid female in active labor. At Your Cervix, I know this is your thing so hats off to you.

You can maybe understand why the 39 week pregnant female who "just wanted a labor check" (we don't do this) was not an especially welcome patient, especially since she didn't want to have to drive to the Big House downtown. You should know that, especially anxiety provoking for us, she was Gravida 10, Para 7.*

And no ma'am, she didn't call her OB. WTF.


Some creaky, squeaky memory deep in my brain from about 40 years ago whispered that with that number of pregnancies and deliveries, she was the most fearsome and feared of all OB patients, the Grand Multip

She was having inconsistent contractions; or maybe they were Braxton Hicks. No rupture of membranes. No history of precipitous delivery. She just "didn't want to go all the way downtown to be told just go home, you're not in labor".

As if.

As she was using the toilet she remarked, "Gee, I almost feel like I have to push".

"No you don't!", I shot back. Saying it makes it true, right?

Finding a fetal heart rate is not my strongest skill set, but I managed. This was followed by quick check by Bobo who insisted on sending her downtown in an amb'lance even though she was only 2-3 cm.

I know, I know. Why?


L.I.A.B.I.L.I.T.Y. The bottom-most rung of the bottom line.


Rather irksome in an otherwise successful turf was the bored and superior-sounding L&D nurse to whom I gave report. She had no idea that we are in the sticks without so much as a baby warmer which is why the hot-potato treatment.


When I was younger and inexperienced, I might have been made to feel badly. Now, I just recognize this kind of behavior for what it is; the "Eat your young" mentality rears its ugly head. We all have our strengths and weaknesses, comfort levels, and skills; it is important to remember that. Different specialty and critical care areas require different knowledge and education. In the ER, we have lots of knowledge and a variety of skills; we know a little bit about some things and cover every age from cradle to grave. That doesn't make me an expert on everything, but it does give me enough knowledge to have a healthy respect for what is most dangerous, and, most importantly, what I don't know.

In fact, that is kind of the point, isn't it? Every patient we see in the ER, every patient we triage we think, "What is the worst case scenario here?". Then we go about ruling it out, right?

Chest pain: having a big MI, or costochondritis?

Shortness of breath: pneumonia, PE, or anxiety?

Rectal bleeding: a big GI bleed, or hemmorhoids?

Rash: poison ivy or necrotizing fasciits (flesh eating disease, so called)

This is why most people go to the ER in the first place, they think of the worst thing it could be(or have determined that they have it, thanks to the magic of the internet) and count on us to rule it out. We often don't have to hunt Zebra,** the patient has conveniently done it for us.
But it's nice when we can help minimize their fears and allay their anxiety.

We certainly would never tolerate anyone who made the patients feel stupid, no matter how trivial the complaint may seem at first glance. That is one reason why it is sometimes so difficult to calm people with non-urgent complaints who can't understand why they are being made to wait. We don't make them feel stupid. It would be really nice if the culture of nursing was such that we go out of our way to extend the same courtesy to our colleagues.




*10 pregnancies, 7 births. This would be her 8th child.
**Zebra hunt: "If you hear hoof beats think horses and not zebras". A rephrase of Occam's Razor: All other things being equal, the simplest answer is usually the best.