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.

[Guest343211]

No one asked the triage RN to start tx. Someone tells you those symptoms and rapid hr, you take a look and listen. It doesn't take that long. I am not even asking you to listen foe murmurs or other untoward hear sounds.Look at it this way. If the client stated he has chest pain, you don't bloe if off, even if it tired out to be an anxiety attack. It's the same thing in this instance. No excuses. This gets a fail from me as well as some ED docs I know.Sorry.I have been a nurse in adults and critical care and you name for over two decades. Rapi AF doesn't necessarily frak me out either. That is not the point.This is suboptimal screening. The exception would be if there were numerous traumas or the like.This bull, and if it were my parent, you better believe I'd have something to say.

[Guest343211]

I agree. In the OP the patient's wife reported the patient had a rapid heart rate, feeling of fist in throat and constant burping, and was finishing dialysis. Sheehy's Manual of Emergency Care, 6th edition, published by the ENA, states on page 73 that "The triage nurse performs a focused physical assessment related to the patient's chief complaint . . . Inspection, palpation, and (occasionally) auscultation can be used to gather information related to the chief complaint."

THank you Susie. Hugs and kisses. You can take care do me and my family anytime! :)

[Susie2310]

THank you Susie. Hugs and kisses. You can take care do me and my family anytime! :)

Thank you samadams8. The feeling is mutual.

[Altra, BSN, RN]

The OP was more concerned with one nurse's attitude, that her eyes did not "bug out" and that she *appeared* unconcerned. I'm here to tell you, my eyes would not "bug out" either, and it might appear as if I am unconcerned. I've taken care of a lot of people with arrhythmias, and I have a very calm exterior. To me, the fact that the one employee (we don't know that it was a nurse; she could have been a CNA or a Tech) appeared frightened tells me that that person is inexperienced and not very knowledgeable about cardiac arrhythmia. I'd rather have the experienced crusty old nurse out there in triage (and working triage often enough can make even the nicest, sweetest person crusty, LOL!) than the fresh, green one.

We don't really know why he waited 15 minutes from the time he entered the lobby until he was officially triaged (I say officially, because the moment the triage nurse laid eyes on him, the triage process had started), despite the triage rooms being empty, because we don't know what was going on in that ED at that time. It could be that the triage nurse had been specifically instructed to hold off with the exception of anything emergent because they had something going on in the back. They were full, they were on divert, they were coding a child, they had just received a trauma, who knows. We don't.

Completely agree -- the OP describes, at some length, treatment for her father that seems appropriate. The motivation for the post, as best I can interpret, is her perception of one triage nurse's "attitude". One person's calm, capable demeanor is another person's attitude ...

My eyes have "bugged out" exactly once - and that was when a woman handed me a gray, cold, lifeless infant.

Rapid a fib needs to go back *immediately* ... but we need some place to put them, now don't we? I strongly suspect there had been communication between the triage nurse and the charge nurse, and people were being shuffled. It's a judgement call whether to initate the whole triage process out front, or just hang tight for a minute to get the patient back into a room, on the monitor, and do everything in the back.

[Guest343211]

I want to apologize for my last few posts. I posted from my iPad, and it autocorrects and so forth. So there are typos and spelling errors.

I have to say that this is basic nursing assessment--even focal. It's just good sense and critical thinking.

To the OP, you were right in your initial concern, but don't worry about the attitude of the idiotic nurse. Screw her. It's your dad. Excellent nursing is about advocacy. Push for what you know is right. They took a risk with YOUR dad. It ended up being OK; but it just as easily could not have been a serious problem for your dad--and blowing it off for even 15 minutes could have caused your dad harm. It could have just as easily have been a bad situation w/ a bad or at the least, sub-optimal ending. Something similar occurred in an ED near me. The patiente ended up being found dead in the waiting area. Guess who got a BIG lawsuit slammed against them???? And the triage nurse got named and slammed too. The patient's family won the lawsuit; and it was not settled out of court. Bad situation all around. The guy was around the same age as YOUR dad. It was a *(&%ing embarassment. It shouldn't have happened, and it could have been prevented.

[Guest343211]

Rapid a fib needs to go back *immediately* ... but we need some place to put them, now don't we? I strongly suspect there had been communication between the triage nurse and the charge nurse, and people were being shuffled. It's a judgement call whether to initate the whole triage process out front, or just hang tight for a minute to get the patient back into a room, on the monitor, and do everything in the back.

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 an assistive 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 S3 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 ausculating discreetly problematic heart sounds. That can take a long time in both practice, and while assessing the individual--as say we do in the CCU or CICU, or SICU. I am talking about taking a basic appreciation of the heart by using your stethescope to appreciate rate and regularity. People have become too dependend 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.

[Anna Flaxis, BSN, RN]

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.

[Guest343211]

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.

[Guest343211]

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..

[Anna Flaxis, BSN, RN]

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.

[Susie2310]

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.

[Altra, BSN, RN]

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.