Just a question to understand the ER better - page 4

so a quick run down. just wanted opinions. 59 yr old male patient in ESRF comes into the ER. wife signs him in and describes that he is "finishing dialysis (home hemodialysis), rapid heart rate,... Read More

  1. Visit  samadams8 profile page
    0
    Quote from Altra
    samadams8, I'm sorry for your troubles.

    Put the patient in hall? OMG, what a breakthrough you've given us! Never would have thought of that. Oh wait ... all hallway spots in my ER are typically occupied from about 1pm - midnight.

    For the sake of your own understanding, I am strongly suggesting that you consider the very realistic possibility that there was no space for the patient without some shuffling ... which does take a few minutes.

    A head to toe assessment in triage? <sigh> I'm sure I could come up with a textbook reference to support many unrealistic and unhelpful chestnuts of supposed wisdom. If I spend more than about 4 minutes per patient ... at busy times of the day things will quickly get so backed up that newly arrived patients may wait for 30 - 40 minutes or more for triage. Which seems to be one of your issues with how the patient in the OP was handled ...

    Triage is decision-making. Chief complaint of chest discomfort, feeling of rapid heartbeat, dialysis patient ... end of what I need to know, really, in triage terms. The patient needs to go back.

    The patient in this discussion went back and got appropriate treatment.

    OP, I applaud your effort to understand a specialty area you know little about - it's commendable.

    Once again, I seriously doubt if that ED was in a MASS CASUALTY mode of functioning.
    No. Too many roll this way without true justification. It's sad.



    For the sake of your own understanding, step back and put yourself or your loved one in that patient's situation.

    The truth is, that patient could have gone down in the waiting room. God was looking out for him or he just lucked out.

    I didn't write the part about head to toe--that came from the source cited.

    What I said was if someone like that adult has a HR that fast, why can't you take a couple of seconds to assess the regularity of his rhythm?

    This is a no brainer. Problem is, people don't want to go too far; b/c if something is found in that time frame, then they have to go against resistance in order to deal with it.

    That's the bottom line.

    Your triage skills do not match what is taught (as was shown by the previous poster, Susie) if that is as far as you'd go--and/or THE SYSTEM NEEDS TO BE REVAMPED OR CHANGED.

    Now maybe you don't care about that. Maybe you are burnt, or maybe you just worked in a place where it's always rolled that way.

    This is NOT how all EDs are run, to be sure!

    Yes, the man got treatment. He also was very lucky. This could have turned out not so well for him. I advise persistent advocacy for such matters in the future, OP.



    Altra, just b/c the system sucks doesn't mean we should practice in way that justifies its continued suckiness.

    We need to step away for a second to consider this.


    Now, I don't want a war leading to the thread getting closed.
    Last edit by samadams8 on Sep 21, '12
  2. Visit  samadams8 profile page
    1
    Quote from sheilahdee
    That really was the point of my post, was to understand better. Not too much to complain, it was just bad timing for me to post since I was still emotional. but I really appreciate everyone's opinion and experience. It really does help. triage is not my first choice area, not out of the question, but I guess that's what clinicals are for, to kind of figure out your niche! lol. Thank you all again!!

    ps. my dad was discharged yesterday. he is feeling much better, and very glad to be home!

    That is great news!

    Take it from a 2 decade and counting nurse veteran. Advocate persistently, strongly, but not disrespectfully (even if the nurse, doc, whoever is being disrespectful) for your loved ones and yourself when you know something is seriously wrong. Don't be offensive, but be persistent and don't back down.

    People that go into hospitals today really need a loved one that will watch over them and advocate for them.

    Advocacy is a dying thing in many areas anymore. And no one makes it easy to be an advocate; and it often costs something.

    You and your family members are worth it. And at least for me, so are my patients.

    Stay strong Sheilahdee!
    Last edit by samadams8 on Sep 21, '12
    Susie2310 likes this.
  3. Visit  Altra profile page
    3
    Quote from samadams8
    Once again, I seriously doubt if that ED was in a MASS CASUALTY mode of functioning.
    No. Too many roll this way without true justification. It's sad.
    I, too, doubt that this was a MASS CASUALTY situation. The reality is ... ERs are filled beyond capacity daily with people with concerning symptoms/presentation like the OP's dad. I gave the example of the ER in which I work ... all available hallway spaces are filled daily with chest pains with associated concerning symptoms, abdominal pains suspicious for bad juju in the abdomen, etc. etc. ... Why are they in the hall? Because in actual rooms are traumas, patients currently getting central lines inserted, patients undergoing pelvic exams (unless you'd like to move them to the hall ...), stroke patients, patients with head bleeds getting EVDs inserted, etc.

    I'm not sure why you are reluctant to see the big picture instead of fixating on whether or not the triage nurse assessed by palpation/auscultation whether or not the patient's rhythm was regular -- this was not required to arrive at a triage decision. And the triage decision was -- this patient needs to get out of the waiting room.

    The very fact that he was not triaged in the triage office tells me that that was the decision made.

    I'm at a loss for how to better explain this to you.
    canoehead, psu_213, and Anna Flaxis like this.
  4. Visit  Anna Flaxis profile page
    0
    Quote from samadams8
    Try **** ED. Nurses in that ED will tell you it's like working in freaking Vietnam.

    [snip]

    Now I don't give a rat's arse if anyone weeds my arse out of their unit or ED. And I don't know how long you have been a nurse. But I'm going to live and function by my conscience--nag the charge nurse, doc, whomever.

    [snip]

    Just like in voting, I guess in practicing nursing or medicine, you have to do so by way of your own conscience. To know to do better, and not do it, is just plain wrong.
    I worked in a Regional Trauma Center serving 8 counties and close to 80,000 people per year.

    Nobody weeded me out. I left of my own accord because I did not want to be a part of a system that I fundamentally could not believe in. I miss it. I want to go back, but knowing that someone could die on my watch because of the decisions made by the higher ups is not something I can live with. Do not DARE accuse me of not caring about the patients or question my conscience.

    This in mind, I stand by my opinion that the OP's father received appropriate care.
    Last edit by Esme12 on Sep 24, '12 : Reason: TOS/hospital name
  5. Visit  samadams8 profile page
    0
    Quote from ~*Stargazer*~
    I worked in a Regional Trauma Center serving 8 counties and close to 80,000 people per year.

    Nobody weeded me out. I left of my own accord because I did not want to be a part of a system that I fundamentally could not believe in. I miss it. I want to go back, but knowing that someone could die on my watch because of the decisions made by the higher ups is not something I can live with. Do not DARE accuse me of not caring about the patients or question my conscience.

    This in mind, I stand by my opinion that the OP's father received appropriate care.
    I never said anyone weeded YOU out. I was speaking in generality.

    I didn't accuse YOU of anything.

    I did not question YOUR conscience.

    Please don't tell me I dared to do something I did not. Chill out. Generalities are generalities. I don't know you from Adam, so I wouldn't have said something about YOU like that.

    Step back and chill.

    Stand by what you want.

    Again, the sucky system shouldn't be supported by doing what is less than what should be done.

    By the standard of care, no the father did not. I stand by this. Just as those professionals brought into court with regard to the previously mentioned case did. Again, the hospital LOST, big time, and the case was almost to the "t" similar.

    Listen, it is when people take things personally on these forums that problems arise, and then threads get closed. It's very sad when that happens.

    So if they do end up closing this thread, just know, I was in no way referring to you personally.

    I strongly disagree with you, and you certainly may disagree with me.

    In the meantime, I hope things will change in some of these places for the better. It's clear that they need to.

    Good luck to you.
    Last edit by Esme12 on Sep 24, '12
  6. Visit  samadams8 profile page
    0
    Quote from Altra
    I, too, doubt that this was a MASS CASUALTY situation. The reality is ... ERs are filled beyond capacity daily with people with concerning symptoms/presentation like the OP's dad. I gave the example of the ER in which I work ... all available hallway spaces are filled daily with chest pains with associated concerning symptoms, abdominal pains suspicious for bad juju in the abdomen, etc. etc. ... Why are they in the hall? Because in actual rooms are traumas, patients currently getting central lines inserted, patients undergoing pelvic exams (unless you'd like to move them to the hall ...), stroke patients, patients with head bleeds getting EVDs inserted, etc.

    I'm not sure why you are reluctant to see the big picture instead of fixating on whether or not the triage nurse assessed by palpation/auscultation whether or not the patient's rhythm was regular -- this was not required to arrive at a triage decision. And the triage decision was -- this patient needs to get out of the waiting room.

    The very fact that he was not triaged in the triage office tells me that that was the decision made.

    I'm at a loss for how to better explain this to you.

    Got it. I see the big picture fine.
    The lack of a simple extra step could have caused the patient to suffer or die needlessly. That's the reality. I can show you similar court cases.

    No excuses.

    Apparently you missed Susie's presented data on what should be expected. If your ED doesn't expect it, it's sad.

    And I am telling you that that triage decision was neglectful.

    So, I kindly disagree with you, and you may do the same with me.

    How long does it take to use sound clinical judgment and do the right thing? In this instance, it would have taken no time at all.

    If that point alone stands out for one nurse and it makes a difference in his or her practice, then this whole discussion was truly worthwhile.

    We will agree to disagree like reasonable people.

    Good luck to you as well.
    Last edit by Esme12 on Sep 24, '12
  7. Visit  Altra profile page
    2
    Given a choice between getting the patient out of the waiting room and adhering to some author's printed statement that a head to toe assessment needs to be completed in triage ... I will get the patient out of the waiting room every time. And I am quite comfortable with that.
    Last edit by Esme12 on Sep 24, '12
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  8. Visit  samadams8 profile page
    0
    Quote from Altra
    . Given a choice between getting the patient out of the waiting room and adhering to some author's printed statement that a head to toe assessment needs to be completed in triage ... I will get the patient out of the waiting room every time. And I am quite comfortable with that.
    I never said head-to-toe; although I'm not necessarily against it. It depends on what's going on. Someone did vitals on this person. Was he not tachy to begin with--if so, then quickly think? How tachy? I mean, as I said, if the man was >130, dude, it's probably more than anxiety. Do a very quick apical listen. It takes less time than palpation of pulses can--as I said, for a number of patients, palpating takes more time than a quick apical. If triage is simply throwing someone on the VS machine, what in the world do they need a RN in that role for? Of course it MUST be about more than this.

    Given the choice of practicing with excellence, as every pt deserves (Yes, even the vomiting drunk that comes in the door) I will strive for excellence. I may not always make it; but I'll give it my best shot.

    I see this as a system problem more than anything else--like the other nurse addressed.
    Last edit by Esme12 on Sep 24, '12
  9. Visit  Altra profile page
    1
    What part of the triage decision - this patient needs to go back - is it that you have a problem with? I've lost track.
    hiddencatRN likes this.
  10. Visit  Robublind profile page
    2
    First, glad your dad is ok
    I maybe late to this but can we agree
    1) this guy (even without looking at him) should have been triage at a level 2 and not a level 1?

    2) the person with an attitude at the front desk most likely needs to find a new job?

    Question: is 15min for a level 2 (no chest pain, no SOB, alert) to be registered, triage and in the back, too long?
    My opinion, No but I would not be dragging my ****, drinking coffee or shooting the ****with the other nurses on this guy neither.

    If you think this guy is a level one, please explain because I don't see it.
    Last edit by JustBeachyNurse on Sep 24, '12 : Reason: add on lab to blood already drawn
    canoehead and hiddencatRN like this.
  11. Visit  VICEDRN profile page
    1
    Quote from tami101481rn
    I have to disagree with all of you saying 15 minutes is not a long wait time. If EMS brought in a patient from a dialysis clinic with these symptoms, he would be high priority. Dialysis can cause to quick of a shift in electrolyte imbalances, namely K+. That would be the best explanation for rapid heart rate, the feeling in his throat etc. A shift in k+ leads to cardiac problems, MI etc. I have an issue with any high level acuity patient going to triage, whether it be chest pain, difficulty breathing, or a patient with ESRFbwith a rapid heart rate. I understand busy, trust me, but there is always a stable patient who can be shuffled.
    In my er, er get patients from dialysis centers all the time like this from ems. We send them to the waiting room to have labs drawn, EKG done and chest film taken. We barely bat an eyelash at them. Sorry but we have 100 beds in my large urban teaching facility that is stuffed to the gills with sick as heck people. We can't reshuffle. We won't reshuffle and even in afib, unless unstable, the patient is going to wait. 15 minutes would be a miracle for this guy. Cant imagine how you guys manage to see all the chest pains either. Every patient says chest pain because they know they can stay and be seen. It may be a high acuity complaint but it can be addressed in waiting room with labs and film unless vitals are unstable.
    psu_213 likes this.
  12. Visit  VICEDRN profile page
    1
    Should have added that we do ekgs on all dialysis patients and I would have sent him to charge nurse when he resulted with a new onset afib with a rate that high. He wouldn't have waited after EKG.
    samadams8 likes this.
  13. Visit  Esme12 profile page
    1
    OP....I am so glad your Dad is feeling better. Triage nurses are NOT supposed to show panic or extreme concern (unless tha patient is coding and to call for help) Their job is to remain objective and professional......even when being screamed at....to remain in absolute control of any situation. That triage nurse was rude.......if she were a staff member in my department she would have some explaining to do about her attitude....but her triage and the 15 min wait is within all guidelines of safety and standard of care. Her attitude however...should never be the standard.

    Would you have felt differently if she stated...I'll be with you directly we have xyz pending and it will take us 15 min...you will be monitored by me closely and we will get you a bed ASAP....your heat rate is elevated but your B/P is xzy. We will get this ASAP.

    I see both sides. I have worked/managed/directed Emergency Departments. Here I personally feel the triage nurse needs an attitude adjustment. The first encounter with the patient sets the tone of the entire visit Patients need to be greeted with kindness and courtesy......no matter what. I have always told the staff that the sign of a great triage nurse is to convince the parents of a toddler that their babies first chin laceration is NO an need for a trauma alert and the chin laceration is a survivable injury....... WITHOUT ENRAGING THE PARENTS.......is the triage nurse of the year.

    Every year at our Christmas party we had a tongue in cheek triage nurse of the year.......the one with the least complaints wins.

    What/how/when a patient is triaged depends on the facility and what is going on at any given time. I have worked facilities that a multiple gunshot wound doesn't automatically a trauma alert and if the have an 02 Sat and a heart rate less that 150.....they waited. I have worked facilities that would call a trauma alert just because gunshots were heard....nearby. It all a matter of perspective. The perspective of the staff....not the patient or family....but again the goal is not be diversive and rude and it appears that his nurse was .....and that set the tone, not only of that patient visit but this entire thread.

    I have also worked/managed/directed ICU's and see the point of an ICU nurse. These two specialties are polar opposites in the care of the patients and priority. A ED nurses idea of "Head to Toe" assessment is seeing that they are not missing any limbs and nothing is turning blue. An ICU nurses idea of head to toe is palpating every pule and hearing every click and his of muffled heart tones. An ED nurse idea of heart tones is are the there or not. An ICU nurse know exactly where every IV is and what is infusing where an ED nurse just makes sure they are compatible and not infusing on the floor after being pulled out but x-ray, lad, or CT. It the nature of the individual areas.

    I think a patient with an extensive dialysis history, ambulatory to the ED with a heart rate of 150 need to go back ASAP but is by NO means emergent....which in the ED is reserved for active resuscitation. If this patient with a heart rate of 150 with that full feeling in their throat that is not diaphoretic AND hypotensive....can wait and 15 min is well within an acceptable amount of time to register/triage and prepare a room.

    ED triage nurses are trained to be the very unpopular traffic cops and should be the nurses with extensive training in Emergency medicine so they are qualified to make these borderline decisions. The AHRQ.....Agency for Healthcare Research and Quality......... and The Joint Commission......recommends a 5 tier triage system that is utilized by most facilities these days as they relate to more reimbursement. That clearly breaks down the triage mentality/procedure.

    Overview of the Emergency Severity Index


    With all this being said....... This thread has been extensively edited. We can agree to disagree without becoming rude and diversive. We are professional after all. If "we" can't respectfully disagree the thread will be closed and points assigned.
    canoehead likes this.

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