Recently I was in the “fast track” side of the ED (emergency department). You know what this is, right? We’re supposed to see the more minor injuries, so that main ED doesn’t get tied up with simple things like those individuals with the less serious illnesses. Then injuries don’t have such a long wait, and the seriously ill or injured people don’t wait for a bed. In theory, this is a great system, but it all depends on the triage nurse.
The triage nurse can make or break my day, seriously, and I can predict exactly what kind of day it’s going to be, based on who is sitting in the “box.” On this particular day I was alone in the fast track; there was no second provider coming in for the afternoon shift, so right off I knew getting lunch and dinner could be iffy. Then the nurse in the box changed about four times through the day (providers work a 12 hour shift, nurses 8-12 hours). I don’t know what the rhyme or reason is to how often the nurses change from working back in the ED versus sitting at triage, but I know some of the best triage nurses are also the best patient care nurses (do you see a pattern here?) and they would rather be back in the ED than in the box. Every time the person in the box changes my situation can get dramatically better or worse, based on the abilities of the nurse to see the “big picture.”
The best ED nurses make the best triage nurses because they can think through the problem. They anticipate what the patient is going to need in terms of my time and testing, and can estimate how long the person is going to tie up the bed. The really good ones know that I am a less experienced provider, with only a little more than a year in the ED, and so they think about what combination of things I already have in the rooms before they add a laceration that’s going to take me 45 minutes to sew up because it’s huge and needs two layers of stitches. The worst ones just think, “okay, laceration, that goes to the fast track, so do all fish hook injuries, all sprains, strains, and bruises, so do all rashes, “call backs” for repeat x-rays, and little old ladies who say their hips hurt, as long as they are upright and walking, to name just a few.
I swear that they have a list in their heads and if it checks off on the list, the fast track can see them. Conversely, the really good ones ask the mother of the 2-year-old with the head laceration, “did he get knocked out?” and actually look at how deep the laceration is before deciding that the child can come to fast track where there is one provider and one LPN, not an army of nurses to hold said 2-year-old down while he gets those stitches in the cut that’s too deep to “glue” closed with skin adhesive.
A really good triage nurse will think about how many of the twisted and pulled shoulders, elbows, wrists, knees, ankles, and feet that they have already brought back actually looked like they would require me to make ortho-glass (modern plaster) splints, before they add the migraine who is also puking and will need IV meds that I have to give because the LPN can’t and the RN’s in the ED are too busy to do.
So on this particular morning it starts out like this…
30-something guy who has a very large fish hook deeply embedded in his finger. Then an 16-month-old who has a head laceration that needs stitches and is crying like crazy because he’s frightened. Then an 90-something-year-old person who has a history of bone cancer and has a burning pain that occurs while walking and has been a bother for several months. When asked what changed to make the patient come to see me on this particular day, I was told that a person in this situation ‘should always get checked out when there is a problem with the bones.’ Never mind that there had been visits to three different doctors since this pain developed months ago, and the person hasn’t discussed this with any of them, despite the fact that any one of them would be a more appropriate person to have this discussion with than me. This kind of scenario happens a lot and always puzzles me, but it is the subject for another whole post.
These were the first three individuals who were deposited into my rooms right after we opened at 9 AM. Then there were two people with open bone injuries who needed IV antibiotics, and then there was the x-ray call back who was told that there was actually a broken bone; interestingly enough the person seemed to suddenly feel that the situation now required stronger medications for pain than the anti-inflammatories that were given initially. The person had been appropriately treated with splinting and other orthopedic support as required by the injury, and had a follow-up arranged with an orthopedic doctor. These precautions are the way in which all of our patients with potentially broken bones are treated; even if we think they aren’t broken we treat them as if they are until there is an official reading done by the radiologist, or until they are cleared by the ortho. It is safer to take these precautions than it is to risk further injury to the patient.
I bet it comes as no surprise to faithful readers of ED blogs that this person is frequently in the ED seeking narcotic pain relief. Narcotic-seeking individuals sap the energy right out of you while they rationalize their needs, and they take a lot of time unless you go right in prepared to say what you are willing to do (ibuprofen and occasionally tramadol (Ultram), that’s my limit). Too bad someone didn’t warn me about the person first, because I’d never seen this particular individual before. Took me 2 minutes to know that’s what I was dealing with, and another 10 to get out of the room, customer-service politeness and all…
Then there was the situation that even the best triage nurse might not have anticipated. An elderly person with dementia who had a hand injury that had bled a lot. The person needed an IV for medications and then kept bleeding from that site too. This meant labs had to be done to determine whether or not the individual was able to form clots, and if there had had a really significant loss of blood. The patient’s son said that he thought there was a lot of blood loss based upon the appearance at the scene of the injury, but the labs came back ok, much to to everyones relief.
But the best one yet was the person who brought a teenage grandchild in for a rash. The adult had the nerve to give me grief in the hallway in the midst of all this chaos because they had waited so long to be seen. After hanging around in the doorway of the room for awhile hoping to get someones attention, the person began to talk loudly from the door to the grandchild on the stretcher about the wait. Finally I was addressed directly and asked how much longer it was going to be. I answered in my most polite, I’m-so-sorry-for-your-wait manner, letting them know that I was doing
the best that I could with a tough situation, and that they were next. When I saw the crisis was a 1/2 dollar-sized rash in one spot on the teen’s body, it was all I could do not to suggest that this could have waited until the next day when they could have seen their own provider in the office for a sick visit.
I did finally get lunch during short lull at 2 PM, while I also caught up on my charting. The afternoon as much the same as my morning, as predictable as the track record of the nurse in the box. Dinner was taken at 9:30 PM, after we were closed. I truly love my job, but I always pray for both a great nurse to work with in express care and a great nurse in the box.