Hi, so I have a long question about a pt I triaged the other night and was hoping to get some insight from some experienced nurses. On a side note, I've been an ER nurse for almost 2 years, only been doing triage for the past few weeks. I have a doctor at work who is very hard on me, so when I was triaging this particular pt, I heard his voice in my ear. A 20 year old male came in c/o chest pain x2 days. Denied SOB, nausea, vomiting, pain going down left arm or up his chin/neck,said pain 5/10. when I asked him where his pain was he pointed straight to his epigastric region, right under his sternum. I asked him several different ways, the pain was not in his chest, not on the left side of his chest, right in the epigastric. He had dusky colored fingers, when I asked him about this he said his hands were always cold and looked like this in the winter. Because of this I was not able to get a SPO2, but I palpated a pule of about 70. He had no complaints of his hands, because as he put it this was normal. I put chief complaint as "abd pain" and put him at ESI of 3. I wrote in my initial note that pt was c/o of "chest pain" but that he pointed to his epigastric region, that it was ongoing for 2 days, and denied other symptoms. I told the charge nurse, it was change of shift, and then told the oncoming dr what was going on. The pt waited longer than I guess the mother thought he should have given that he said chest pain, she though he should've had a ECG immediately. When the other nurse told her that he was put down as abd pain she was angry that he was not in as chest pain. Now this would have been the case had I put chest pain down at the complaint, but I did not think it really was. So my question, is would you have put chest pain down because that's what the pt said, or when I did my assessment and thought it was abd, would you have put that down? Also would the raynauds have had any play, and that I didn't get an SPO2 initially? The doctor that was oncoming gave me a problem on a previous night because I put down chest pain because that was what the pt said, when it was really epigastric pain. I'm still learning and looking for input.
Just curious and want further information. If I a 40 something diabetic came in with chest pain, I would be treated after a 70 year old with chest pain due to age?[/quote']
For me that would depend on EKG, vital signs and clinical presentation.
Just curious and want further information. If I a 40 something diabetic came in with chest pain, I would be treated after a 70 year old with chest pain due to age?[/quote']
If this was all the history that was available, like it was a question on a test, 40 y/o diabetic versus 70 year old - both complaining of chest pain - who goes first? Yes, I would triage the 70 year old to be seen first.
History and physical assessment might not prove that out, however, as offlabel mentioned above.
Wow thanks all for your input!! Like I said I'm new to triage so still unsure. The reason I didn't put "chest pain" is because the day before while working with a full of himself dr, he got annoyed at me for putting chest pain for a pt who was pointing to epigastric. That one I put cp as chief complaint, but than wrote a note about pointing to epigastric region. Once the word chest pain is written, it starts the cascade of ekg within 10 minutes, so I had this dr in my ear when I saw this kid. The spo2 I was thinking it would be quicker for me to get him into the back than start messing around with different probes, esp for a 20 year old who had no history and was in no distress and had no complaints besides the burning in his stomach. The mother was annoyed because they were waiting in the cubicle. It was change of shift and the dr was literally going to be in there in 10 minutes. When I went back the next day and asked the nurse who took him the kid got a Gi cocktail, normal ekg.
Don't worry about it. It's unusual to go through an entire ER shift without ruffling somebody's feathers. Just rely on your assessment and go with your gut.
Just curious and want further information. If I a 40 something diabetic came in with chest pain, I would be treated after a 70 year old with chest pain due to age?[/quote']
You might... it could depend on the 70 yo's risk factors.
Just curious and want further information. If I a 40 something diabetic came in with chest pain, I would be treated after a 70 year old with chest pain due to age?[/quote']
if I triaged you, unless your EKG was worse than the 70yr old, then yes the 70 goes first
with that said, a 18yr old chest pain can be taken before you as a 40yr old diabetic, depending on their remarkably abnormal ekg
Wow thanks all for your input!! Like I said I'm new to triage so still unsure. The reason I didn't put "chest pain" is because the day before while working with a full of himself dr, he got annoyed at me for putting chest pain for a pt who was pointing to epigastric. That one I put cp as chief complaint, but than wrote a note about pointing to epigastric region. Once the word chest pain is written, it starts the cascade of ekg within 10 minutes, so I had this dr in my ear when I saw this kid. The spo2 I was thinking it would be quicker for me to get him into the back than start messing around with different probes, esp for a 20 year old who had no history and was in no distress and had no complaints besides the burning in his stomach. The mother was annoyed because they were waiting in the cubicle. It was change of shift and the dr was literally going to be in there in 10 minutes. When I went back the next day and asked the nurse who took him the kid got a Gi cocktail, normal ekg.
it might take a little while, but you definitely need to develop a relationship with your doc to show that they can trust your judgement
The 20 year old could have an undiagnosed clotting disorder and a pulmonary embolism. It's too easy to get burned when just looking at the age of the patient.
I noticed that you expressed concerned that a particular nurse was angry, and that a doctor got annoyed. Neither of those are ESI criteria.
Seriously considering printing this and putting it up next to our ESI algorithm poster!
It's one thing to learn from colleagues, including physicians. It's another thing to start altering your assessment just because someone yelled at you.
I'm not quite following the expenditure of energy devoted to should we call this CP vs. abd. pain. Could you not list epigastric pain as the chief complaint? That would seem to be the most accurate capture of data provided by the patient, and establish the framework for this patient's differential diagnosis -- GI vs. cardiopulmonary.
And as an aside -- I agree with Raynaud's as a likely explanation for the patient's cold, vasoconstricted extremities. But if you're trying to build a case for not pursuing a cardiac workup on a 20-year old ... that's made a lot more difficult in a patient with no recorded SpO2 to demonstrate good perfusion and with observable peripheral cyanosis.
ScrappytheCoco
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