dear tms/advice nurse
yeah telephone triage is a tough job. i am at it now for past 7 years and working remote out of my house x 3 1/2 years. telephone triage is a job that by it's nature involves sensory deprivation.
triage without seeing or touching
you can't see the rash/skin color, can't visualize the size of the lump/bump. leave it up to the pt. to determine if their is any angulation or out of place joint or if it is just swollen. you can't touch nor feel over the phone. if phone quality is poor you may not be able to hear barley audible wheezing nor stridor.
you can't put a stethascope to a child's chest and they tend to breath hold or push the phone away when you try and listen to them breath, can't observe gait or pupil size.
you may be dealing with a deaf patient and have no verbal from him and openly be talking to the interpreter who is signing or typing back and for to the patient. with this pt. you can't really sense how much distress hie is in by his voice nor hear any breath sounds!
identity/confidentiality issues/misrepresentation issues
you never really know who you talk to because people lie allot. i mean you have confidentiality issues/hippa laws and when you ask am i talking with joe palooka they answer yes! if you ask with whom am i speaking to they will give the patients name. they don't even have the courtesy/honesty to tell you they are not the patient! till after a few triage questions you hear them asking your questions to someone else (the real patient) and confront them about it and get the real pt. on the phone. imagine if you went into a bank and try to cash someone elses check and identify yourself as that person!
and quite often you are talking to a caregiver who identify their selves as a nurse! they are not nurses! they are impersonating a nurse. try pulling that working in the ed and pt. asks what you are and tell them you are a doctor! see what happens!
pt's have the speaker phone on so all their friends and buddies can hear your private examination of the pt. plus you have the patients looser friends and relatives telling them what is wrong with them (like the pt. can't talk for their selves)
then you have the other control freak husband or wife of patient who refuses to give up control of the question answering and wont put the pt. on the phone "well i can answer your questions" "he can't talk", "he doesn't want to talk", "he is to weak to talk" "he is sleeping" "he is eating" "he is in the shower".
i insist on getting the pt. on the phone i don't need any thrid party info till after i speak with the pt.
half the time the audio quality is crap, quite often the phone disconnects.
not willing to wake the patient/non compliant parents
you always have to be ready to give a rationale for any question you ask the patient or parent. one of the major 911 questions "is the pt. arousable" and you have to give rationales so they will wake the patient because they don't want to wake up their kid. have the patient stand and walk "he doesn't want to" "he was walking 10 hrs ago fine". pt. feels feverish "what is his temperature"? they either feel his head and make up a number or never took it or don't feel it's necessary to check it until you insist on it. or dealing with a patient who weights 20 lbs "take his temperature please" "he wont let me" "he doesn't want me to" if this kid is in control of his parents at 1 year old and 20lbs weight how will they ever control him as a teen?
phone control, redirection, diffusing
you are stuck with these terrible time constraints to complete your call in, have quotas so many calls per hour (some times i feel like a cop handing out as many tickets as he can at the end of the month to meet his quota). so you have to keep your pt. focused by redirecting him when he talks to much or goes off topic. you also have to deal with allot of angry patients and be able to diffuse and redirect them. "why didn't that **&^% doctor give me an anti biotic" "you people *&(()^$%$$%" "i waited 2 hrs for you to call me back and now uc is closed and i can't seen and have to go to the ed" you have patients that are experiencing both physical as well as emotional pain.
advice, recommendation's, disposition
as a nurse we don't diagnose, based on your symptoms and history i reccomend that you........
as far as advice/recommendations/disposition very tight parameters/policies and protocols to adhere to. very little room for deviation from the protocols.
when you downgrade the "recommended disposition" ie your computer program advises you "recommended disposition" to hang up and call 911 you send him pov to ed you better be very sure of why you are doing it and sure he can last the car ride to the ed with out crapping out. your clinical judgement and years of experience better be sound or you will hang in court if he or she goes south on the way via car to the ed
every thing in telephone triage is recorded on real time tape with playback that shows your typing as well as your paperwork and verbal so if you screw up you are really hung!
when you have questions you have a lead nurse and a supervisor. things are improving i remember back in the day 3 years ago when you were on a call and asked the supervisor a question they were useless "look it up in your notes" "but i already did and couldn't find the answer" and they were very rude in their useless response instead of answering your question and help expedite the completion of the call, they are oppositional and rude and belittling you like you should know that and not have to answer that.
but after numerous complaints from me and others to administration about this issue and also that all the supervisors used to do was sit on their lazy butts and listen to your calls as you do them, and not contribute to reducing call volume by talking calls- now they are helpful and allot more pleasant!
we are getting better internet med link sites but internet is not as fast as it could be with our system
i am pretty good at deffusing angry/volatile patients so i can usually turn a figher around and get an apology from them at the end of a call for being so difficult with me. but asside from that it is nice to get a thank you at the end of the call!!
Dec 9, '09
mike, i just wanted to say you are right on the money about everything you discussed.
Dec 17, '09
Yes, you gave a good picture of what triage at home is like.
Wondering who you work for. I do the same thing, at home for McKesson Corp.
Looking for other telephone triage opportunities to work FROM HOME.
Who do you work for, if you don't mind telling me...?
Dec 24, '09
I agree. Sometimes I have to remind the person they have to describe things to me. I can not guess or see so they have to be able answer my questions. I love when I tell some middle aged, overweight, hypertensive, diabetic, who has COPD continues to smoke and is having chest pain and severe shortness of breath that they need to go to the ED per 911. Telling then that it could be your heart and they think not.
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