Triage is Tricky

Definitely one of the hardest jobs in the Emergency Department is Triage. "Triage" comes from an old army term meaning "to sort". It's the triage nurses' job to determine who needs treatment the quickest and who is ok to wait. On a busy day you may be eyeballing a line up of people at the check in desk, and plucking out the ones who looks like they're about to drop to get them help right away. It's the psychological pressure and potential for disaster that really makes the job stressful. If there are not a lot of people checking in and there are plenty of open rooms, the job is a snap. But when the tidal wave comes and there are no rooms and a line out the door, a lot depends on your critical thinking skills and clinical judgement.

There are plenty of scary stories from ERs around the nation of triages gone wrong. The nurse that didn't have mom and dad take their baby out of the car seat to check him properly, and by the time they got to a room the baby was almost dead. There are plenty of extreme, news making cases out there, but the ones that scare you most are the easy misses. A benign seeming headache that turns out to be bleeding in the brain. The shoulder pain that turns out to be a massive heart attack.

Even aside from the fear of missing something deadly, there are the daily stresses of making good decisions for the patients, the other staff, and the general flow of the department. In our department the triage nurse decides to start IVs, order basic blood tests and radiology studies in order to help decrease the length of stay for the patient. Some cases are clear cut and decisions are easy, others you feel like could go either way depending on which doctor ends up treating them. Younger doctors tend to order as much as they can, older doctors tend to be more minimalistic. Some order based on what could potentially get them sued (CYA philosophy), others based on what they think the patient really needs.

For example I check in a guy in his 30s, low risk factors (nothing that particularly predisposes him to a heart attack), who experienced 5 seconds of palpitations (extra heart beats) and felt his left arm "tingle" while he was driving. Um... ok. We do an EKG - perfectly fantastically normal. So I have a few choices, each with different consequences. What I know (pretty much) is that he is not really having any heart problems whatsoever, maybe he had an energy drink, and it's really unfortunate that the tingle event had to be his left arm, because that's the one classically associated with heart attack. I can do what would be most helpful for the nurse that will inherit him and start the IV and send off labs to check his heart status, because most doctors do operate under the CYA philosophy (why take the risk??), and he'll probably get a full meal deal work up, even though we all know he's fine. Or, I can wait until a doctor sees him because I know we have a few minimalists on today who might actually save him the 500$ IV start and 1000+$ work up (hope you have insurance!) that a cardiac rule out would involve. I chose to wait. Wrong decision! He got the whole work up, and his nurse was annoyed that I hadn't started anything because let's face it - you can be the healthiest young person on the planet, but if you say anything about your heart and your left arm together in the ER - you will get a big, costly work up.

This little rant is all to say that a job where a lot rests on your decision making, and where sometimes the right decision can be pretty hard to know, can be a little bit stressful. My triage days start with a lot of prayer for wisdom and protection (for me ( there are crazies out there!) and for the patients) and I have a lot of reassurance knowing that I have a God who watches over (and out) for me. In all of life's tricky situations.