Just a question to understand the ER better

[sheilahdee]

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, feeling of fist in throat and constant burping." (that is exactly what she wrote down). two nurses are behind the window, one seems concerned and the other says, "well we will get to you we can". in a not so nice tone. there was about 3 other people waiting to be seen in the waiting room, 3 in peds waiting. and nobody was in the back being seen by triage. he waited for 15 minutes before being seen. I am still a student, and have not had experience in triage, but wouldn't they be a bit more urgent and concerned with him? again, i know it all depends on whatever else they have, but their attitude just really kind of sucked. (well the one nurse). anyhoo, turns out he was in afib. his HR was all over the place but seemed to be fond of the high 170s.

my father is the said patient.

[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!

[Guest343211]

I know, I know, I said I was bowing out.

Samadams, what about those EDs where they have up to 150 people in the waiting room, and the average wait time is 24 hours or more?

I'm not excusing shoddy care. I guess I see it as a larger issue of how messed up our health care system is, that this happens on a regular basis.

Google "Patient dies in emergency room waiting room" and you'll get over 20,000,000 hits! I repeat: Over 20,000,000 hits. That's seven zeroes. That's crazy!

My response here was not in any way to excuse shoddy care. I don't think the OP's Dad received shoddy care just because he had to wait a few minutes for triage, and that's where you and I disagree.

ED overcrowding is a huge issue, and it was one of the issues that led me to leave the ED, even though I *LOVE* emergency medicine, and I love being a part of the access point to health care for the underprivileged. I do not resent people with no health insurance who use the ED as their primary care, because I know we are in it together as a society to solve this problem. Besides, I could be them; there but for the grace of God and all that. What I resent is how the system is set up. How fragmented it is. How we can have EDs with >100 people waiting to be seen, and no beds to put them in and no staff to take care of them, and instead of figuring out how to change this, people just blame the nurse.

That did not happen in the OP. I know you don't agree with that, but maybe you agree with some of the other stuff I said.

Okay, off my soapbox now, and on with my evening.

Try ****** ED. Nurses in that ED will tell you it's like working in freaking Vietnam.

People in the hallways, you name it. My best friend, who was an ED RN for 20 years before going into research totally agrees with my position here. She's an excellent nurse, and she has worked just about every ED in the tri-state area.

I agree that there are MAJOR problems in the system. But these nurses that I've worked with and spoke with literally bust/busted their **** off-absolutely no breaks. People coming in with knives in their chests, babies with their guts hanging out after car accidents, all kinds of horrifying ****. Makes the show ER look like a freaking cartoon. Really terrible inner city ****.

Advocacy costs something. The nurse or doc that is a strong patient advocate will not always be liked, and some people may try to weed you out; but you live and die with your conscience and doing what it right.

How many people have you had in severe anaphylaxis from a yellow-jacket sting? How many minutes does any triage nurse have to play with a patient like that between? No long. They can drop like a fly if you don't treat them ASAP. There are certain patients you have to take right away. Why should angina or a potentially lethal dysrhthymia be any different?

You want to take your chances with Rapid AF or another potentially dangerous rhythm, be my guest. I'm not doing it, and I won't allow any loved one of mine to be treated like that.

Mark me down as a troublemaker or any darn thing you choose. I'm going to do my best to do the right thing--even if that means I may end up ******* some folks off.

The problem with nurses anymore, IMHO, is that business mgt models have stifled the advocacy role that should be the hallmark of what it means to be a professional nurse. Guess this makes sense from the higher ups end, since many of them aren't nurses or physicians, or in actuality if they were, they didn't function in a clinical role for very long.

Now I don't give a rat's **** if anyone weeds my **** 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.

When units or hospitals don't support good nursing advocacy, they are crap to work in, and not really worth a lot of my time, experience, and energy.

Everyone is cowtailing to these business-focused adms and mgt people. Nurses are so intimidated, and they feel like it would be hard to get another job, so they don't rock the boat. That's part of the problem.

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.

[Altra, BSN, RN]

Great news sheilahdee -- thanks for the update! :)

[Guest343211]

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? 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.

[Guest343211]

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!

[Altra, BSN, RN]

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.

[Anna Flaxis, BSN, RN]

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 orifice if anyone weeds my orifice 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.

[Guest343211]

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.

[Guest343211]

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.

[Altra, BSN, RN]

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.

[Guest343211]

. 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.

[Altra, BSN, RN]

What part of the triage decision - this patient needs to go back - is it that you have a problem with? I've lost track.