Triage learn by fire

Wuzzie · Jul 28, 2018

It does get better but we didn't call it "the penalty box" for nothing.

Trauma Columnist · Jul 28, 2018

It does get better as Wuzzle states. The biggest and most important skill is telling sick from not sick....

Trauma Columnist · Jul 28, 2018

Moved to ED nursing

JKL33 · Jul 28, 2018

Oddball here - this is one of my favorite roles. There are a few things that make triage easier, some are clinical and some are more personal. I'll mention a few things.

- You can only go as fast as you can go. AND, you will never make everyone happy (whether referring to coworkers, patients, or both). Therefore, you have to be determine to do your best, communicate very well, and then emotionally be prepared to let the rest go.

- People talk about gestalt (spidey sense/whatever). I myself thought it was a special gift of mine, until I realized that "he just doesn't look good" was actually stuff like slightly "off" skin color (pallor, etc.) or maybe mentation not quite right, work of breathing a little increased, skin just a little moist, etc., etc. My point is that we can get so anxious we forget to be systematic. Put a name to what you're looking at (in your own mind). When you call the next name and the patient appears and you "sense something not right" well, what is it that isn't right? This will really help you in assigning acuities, and you'll learn to integrate information so fast that someday soon you'll be tempted to think it's pure gestalt.

- I don't know if it can be arranged in your setting or not, but it's nice when the triage nurse isn't the one essentially making assignments. Triage nurse doesn't know what the heck kind of craziness is going on in the back - - and craziness in the back should be accounted for when filling people's rooms.

- Back to #1 for a second: It is absolutely essential to not get riled up in response to patients who become upset with the wait. There are real pitfalls with doing so - such as failing to triage carefully just because you don't like their demeanor (or their family's). Or, another risk - personal emotional injury ("burnout"/resentment/increased anxiety, etc.). You've got to learn how to invoke internal peace and calm. This is probably the biggest hurdle in all of nursing regardless of setting. Really put some effort into it. Use silent mantras, deep breaths, smiles, pleasant tone of voice. Never absorb OPPs (other people's problems). You are not required to "rise" to others' levels of emotional distress.

- YOU direct the triage encounter. Do not listen to what has been going on since 1983. Learn to pleasantly redirect a patient. "[smile] Let me interrupt for just a second so I know how to help you today. This morning when you woke up......"

TLDR: Stay calm (always, always). Work systematically. :)

Best of luck ~

psu_213, BSN, RN · Jul 28, 2018

I usually loved triage, but it certainly comes with it down sides. We had a section of the ER that opened at 11 am, and things tend to get busy around then, usually earlier. If the other section is full, then it means this newly opened section is going to get lots of patients back to back. Have been a nurse in the newly opened section, I know it stinks. As a triage nurse, you can't take it personally when other nurses express their frustrations at you when it is 100% out of your control. Try calling the charge nurse and say "I have given 5 patients in a row to the green section, and the nurses there seem to be getting bit overwhelmed. Where should I go with this chest pain?" Hopefully something has opened up in another section.

Also, pt's have to wait for a reason. If things are busy, the routine abd pain or the twisted ankle is going to have to wait while the chest pain and the severe respiratory distress patients are taken back. That is the whole point of why the triage nurse is there--sort the patients by acuity and decided who needs to be seen right away and who can wait some amount of time. Pt's may be upset, I don't always blame them if they are; however, it is the job of the triage nurse to make the decision of who waits, and be confident in you ability to make that determination.

Wuzzie · Jul 28, 2018

JKL33 very astutely described what you need to do to make triage tolerable. Thick skin and not allowing nasty people to rent space in your head is a must. You need to learn that fast! Sadly an injury put me in triage for nearly 6 months and it fostered a burgeoning hatred for humans. Fortunately I got out in time for it to not take hold but my BS-Ometer is still finely tuned and I find it very difficult to suffer fools, or really anyone, lightly. I seriously think I have some PTSD related to my experience.

Editorial Team / Moderator · Jul 28, 2018

I also enjoy triage. I became a fast/accurate triage person. I also developed a very necessary skill: the ability to keep patients focused. What brought them in TODAY? What is different TODAY? I don't care about your sprained ankle 5 years ago.

I smile a lot and I am kind. If someone raises their voice, I keep mine low and calm. I room patients as soon as I can, I don't believe in a therapeutic wait time. The sooner a patient is seen, the closer they are to dispo.

The only time I have invited a patient to leave our ED while working in triage was when a patient expressed the need to see a doctor of a specific skin color. I told the patient we were fresh out of that color of doctor but there was the door, and I advised the patient to try another ED nearby. I will not put up with that or subject my docs to that kind of hate.

We also called triage the "penalty box," but I liked it! As a newer nurse it was scary. My head would snap around every time the doors opened and patients would come in. Yes, there were times that awful stuff came in the front, but I knew my team was in the back and ready.

Never let a patient get between you and your means of egress. I worked in a couple of poorly designed EDs where the triage nurse was essentially trapped in a corner. I always thought it was handy to keep a chest tube with a trocar out there. Pointy things would potentially be helpful for self-defense.

That Guy, BSN, RN, EMT-B · Jul 28, 2018

You will miss something in triage. It is a given. When you think you have nailed them all and you are doing good, you will get thrown curveball and it feels awful but you do the best that you can. I once had a totally benign headache and she didn't say any of the magic words. Turns out HUGE bleed with 2cm shift. Honestly I always viewed triage as doing the best you can and having fun with the jerks.

JKL33 · Jul 29, 2018

JKL33 very astutely described what you need to do to make triage tolerable. Thick skin and not allowing nasty people to rent space in your head is a must. You need to learn that fast! Sadly an injury put me in triage for nearly 6 months and it fostered a burgeoning hatred for humans. Fortunately I got out in time for it to not take hold but my BS-Ometer is still finely tuned and I find it very difficult to suffer fools, or really anyone, lightly. I seriously think I have some PTSD related to my experience.

That most definitely would've been rough. ED work and triage sure does come with some contemplation about big things like the meaning of life after you've been exposed to it for awhile. I have no doubt that such a prolonged assignment in triage did have the effect you describe. Glad you're okay, seriously.

JKL33 · Jul 29, 2018

I smile a lot and I am kind. If someone raises their voice, I keep mine low and calm.

Excellent. This is important. I've proven to myself over and over that it is THE difference between patients that feel like they're gearing up for battle and patients who are willing to go with the flow. There are some people you can't win over, but there are a LOT who you can. I've dealt with some very contrary individuals who looked like they literally lost the will to be evil/hateful to me once they were treated with an ounce of respect. And they were not nice people...but they tempered themselves.

Staying pleasant in triage is not really much different than the way we were trained for careful communication in other volatile situations. Rule #1 is to not escalate the situation.

Guest1025459 · Jul 29, 2018

Pre student, but honest to God...

Why would a coworker get mad at you for sending too many back? I mean, is it not your job to be a triage nurse or something? You send back first the 3 patients with cx pain. Nothing comes to light on each. Panic attack, GERD, whatever. You tried right?

You are the professional, most likely not the patient crying that they sprained their ankle.

As to wait times, if I fall and break my ankle I expect to wait 8 hours while those 3 chest pain patients get monitored. Who doesn't?

I'll limp out to my truck and pop 2 Aspirin's and play with sample NCLEX exams to kill time, or read my Lippincott manual in the waiting room. Chances are, I'm there to get it popped back in, and get sent home hopefully with an RX for some extra strength Tylenol for that amount of pain. 99.9% Chance I'm gonna walk out of the place alive. The ones with maybe a 20% chance, I'll happily give up my time of care for them :)

Guess everyone doesn't think the same