Just a question to understand the ER better - page 4

by sheilahdee 10,250 Views | 71 Comments

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... Read More


  1. 2
    I'm sorry about your bad experiences with your parents' care. Clearly, you are very angry about it. That's understandable.

    I can only offer my sympathies.

    However, in this instance, as the OP describes it, the patient was treated appropriately. None of us knows why he had to wait a few minutes to be triaged, and we've given some possible reasons for that here in this thread. I don't think anyone here said that he didn't need to be seen quickly, and this is not a case of someone sitting in the lobby for hours being ignored.

    I don't think we're going to come to any agreement here, so I'm going to bow out of this discussion.

    Take care.
    psu_213 and Altra like this.
  2. 1
    Quote from ~*Stargazer*~
    I'm sorry about your bad experiences with your parents' care. Clearly, you are very angry about it. That's understandable.

    I can only offer my sympathies.

    However, in this instance, as the OP describes it, the patient was treated appropriately. None of us knows why he had to wait a few minutes to be triaged, and we've given some possible reasons for that here in this thread. I don't think anyone here said that he didn't need to be seen quickly, and this is not a case of someone sitting in the lobby for hours being ignored.

    I don't think we're going to come to any agreement here, so I'm going to bow out of this discussion.

    Take care.

    My parent's experience was a personal aside. It has nothing to do with what the standard of care should be.

    It DOESN'T take long to listen for an irregularity of rhythm. If the person's rate was above 120's in an adult, I say, take a FEW SECONDS and do your job with carefulness and excellence.

    If that is appropriate care, then something seriously needs to be changed. For what it is worth, I just had another highly experienced ED nurse of 30 years agree with me.

    Limit the subjectivity by taking a few extra steps (moments) in the triage process--or stand up and seek to change the process. BTW, it doesn't roll that way in every ED. Trust me.

    Why must a hospital get slapped with lawsuits before it strives to do the right thing. It was not the right thing--unless they were TRULY getting swamped with mass traumas.

    Sorry. Nothing personal to you Stargazer. You seem cool. I just strongly disagree, and I will continue to do so.

    Doing the right thing is never wrong. Using the basic nursing process was all that was required. This is NOT rocket science.
    Last edit by Esme12 on Sep 24, '12 : Reason: TOS profanity
    Susie2310 likes this.
  3. 0
    Quote from samadams8


    some corrections"

    Put them in the freaking hall on a monitor near the nurse's station, or better yet, listen for an apical rhythm and get an EKG. You see, if someone had taken the few seconds to listen to the person's heart for a few seconds, when they had heard o the HR is too high for being that of a merely distressed adult patient, one could, at the same time, ascertain if the rhythm was irregular. THEN they would have been justified in running an EKG, which they can take to the charge nurse or a practitioner with some sense so that the patient can be monitored, rather than found down and out on the waiting room floor--as has happened, not infrequently mind you.


    [Triage begins with a general assessment of the patient. The nurse must look at the patient and take note of the patient's condition as he or she approaches the triage desk. For example, the method of movement, noting whether the patient is ambulatory and how the gait is, also not whether the patient is using a mechanical device, is the patient in a wheelchair, is the patient alone, or with a crowd must be considered in the general assessment. The most important question to consider is: does the patient look sick.

    Three other aspects of triage include obtaining a good history of the patient's presenting symptoms, obtaining a good medical history of the patient, and completing an assessment that is based on the presenting complaint. After the history and assessment have been completed, the triage nurse can make a disposition decision.
    While completing the history, the triage nurse should determine if the patient has any allergies to drugs or foods. Make sure to ask about the onset of symptoms. Ask female patients about their menstrual cycle.
    Assessing whether or not the patient is in distress is a significant part of triage. Many families wish to do all the talking for the patient. Having the patient answer the questions allows the triage nurse to determine if the patient is able to speak in complete sentences as well as assess his or her cognitive level.
    When performing the triage assessment, the triage nurse must actually lay hands on the patient and perform a quick head to toe assessment while focusing on the presenting complaint. Much information can be obtained when executing the triage assessment in this manner. For example, touching the patient tells the nurse the temperature of the skin, the moisture of the skin, the regularity or irregularity of the pulse, and the status of skin tenting. The quick head to toe assessment in the process of performing the focused assessment also tells the nurse if there are signs of abuse or neglect and other problems that could be associated with the primary complaint. (Dugle, 2010.) ]

    Dugle, P. (2010). Triage. Triage Course: ceufast.com. Retrieved from: Triage Course - Nursing Continuing Education (CE) - Nurse CE - CEUFast.com


    What is easier in some patients is listening to an apical pulse for regularity, rather than palpating one at the carotid, brachial, or radial regions. Some people with comorbidities and/or who are frail for some reason (elderly) don't give you great palpable pulses, and they can be harder and take longer to appreciate (conflicted with potentially your own pulse) as compared with an apical pulse. When you take a quick listen, at least somewhere around the precordium or 2nd ICS, RSB (not S3-that was a typo or PMI, you should be able to hear for the rate and regularity of the rhythm. Again, I am not asking anyone to be a superstar with auscultating discreetly problematic heart sounds. That can take a long time in both one's overall practice, and while assessing the individual--as say we do in the CCU or CICU, or SICU.

    I am talking about making a basic appreciation of the heart by using your stethescope to appreciate rate and regularity. People have become too dependent on automatic devices--I say this, and I am a person that works with high-tech equipment all the time.

    I had someone close to me code on a cardiac floor that no longer had manual cuffs or suction systems set up in their rooms. I used to work cardiac at this big hospital. I was aghast when they had to run around the large floor for portable suction--and the fact that the nurses didn't know or could not do a basic systolic pressure by palpation. Really???? You have got to be freaking kidding me. The automatic BP machine made the basic process of palpating a pulse nearly impossible. No one was able to tell me if the patient had a palpable pulse--b/c there was no manual cuff--and who the hell knew where these nurses stethescopes were.

    It was a mess. I was ready to kiss the CRNA when she came down, b/c she was prepared. Whose idea was it to take away manual cuffs and wall suction from the patient's rooms?

    Guess what, this person that was coding was my MOTHER. TRUE STORY.

    Don't even let me talk about how my father was often handled in a well-known hospital in my area. He suffered a lot more than necessary over the course of his illness.


    My BP is going up just thinking about it.
    Had to make some corrections..
  4. 0
    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.
  5. 0
    I think the point samadams8 is making is that the patient initially presented to the nurses in the ED with the complaints and medical history mentioned, and the nurses did not do a focused assessment. The patient waited 15 minutes before they were seen, and the OP did not tell us any nursing assessments took place during those 15 minutes. The patient was found to be in A-Fib in the 170's.
    Last edit by Susie2310 on Sep 21, '12
  6. 2
    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.
    canoehead and ~*Stargazer*~ like this.
  7. 3
    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!
    canoehead, ~*Stargazer*~, and Altra like this.
  8. 0
    Quote from ~*Stargazer*~
    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.
    Last edit by Esme12 on Sep 24, '12 : Reason: TOS/profanity
  9. 1
    Great news sheilahdee -- thanks for the update!
    sheilahdee likes this.
  10. 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


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