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.
Specializes in Emergency Medicine, Injury Prevention.
I was working one night with a fellow nurse that kept complaining of a terrible toothache and jaw pain, my gut kept nagging at me so I asked her if we could just to an EKG on her (she did have a family hx of cardiac disease etc) .....she was having a huge MI , coded on us as we tried to get her up to CCU (this is before we did interventions and took people straight to the cath lab). She did survive, barely. Lesson learned, always listen to your gut..
Specializes in Emergency Medicine, Injury Prevention.
Some really terrific responses and information, I do usually put down the patient's complaint and then add other information in the triage note. I too would have made this patient a Level 3, without a history or significant changes in VS he would have gone back to the WR. The coldness, blueness of his hands may have concerned me enough to get that EKG at triage, just to satisfy my gut (your gut is always right, listen to it)
Many of these things do come with experience at triage, dealing with family members can also skew your thought process's, You are the triage nurse, don't let rude doctors or snarky nurse comments get you down. Unless they are the person on that front line with you, they should not be judging your intuitions.
Your on the front line. Go with your gut instincts and like others have said, if your in doubt over triage. I wold rather have an over triaged patient than an under triaged patient.
I would have put Epigastric pain, which in our system we have a free text area to add in Chief complaint.
Be able to back up why you did what you did, and CYA with at least the EKG and sending the labs.
I would have made him a 3, had the tech do a quick EKG, send his labs off and thanked him for waiting patiently till we had a bed for him.
Thanks. I've only been in this er for about 3 months. This particular dr is very much into pointing out EVERYTHING that you did or didn't do.... If you take initiative and do something it's why didn't you wait for orders, if you don't do something it's why are you waiting? I feel the more I try not to screw up around him, the more I am.
This kind of behavior can be so detrimental to good teamwork and morale, but unfortunately, it happens all too frequently. In my experience, the best doctors are the ones who understand how important it is to have a mutually respectful, supportive, and friendly relationship with the nurses. They are approachable and don't make you feel stupid for asking a question or making a mistake. Don't get me wrong - we should all be held accountable to practice to a high standard (I am not advocating sloppiness or suggesting we should be cavalier), but how we treat each other in the workplace has a direct effect on patient care. If every time I approach a doctor with a question or a concern, he or she makes belittling remarks or barks at me, I'm less likely to approach that doctor with a question or a concern.
Triage is not an exact science, and while the ESI algorithm is helpful, so many presentations don't dovetail neatly into it. To triage well, good judgment, critical thinking, and experience are imperative.
I think your rationale for assigning a chief complaint of abdominal pain with an acuity of 3 in this patient is sound. I agree with others that you might have called it "Epigastric Pain" rather than abdominal pain. If there isn't a chief complaint of epigastric pain built into your EHR, can you free text it in? If it's something you use frequently, you might ask for it to be added.
I should also add that it's true that 20 year olds can have MIs, and that 12 lead in triage would not have been unreasonable in this situation (and, in fact, if it were normal, would underscore your assigned acuity of 3, and if abnormal, would have bumped up his acuity).
As others have stated, as long as you have solid clinical rationales for your triage decisions, you should be okay - and a doctor giving you a hard time or a patient's mother being upset are NOT solid clinical rationales. Be sure that you document any exceptions from normal and your rationale for either considering or excluding them as significant, such as in the case of the dusky fingers, "Patient states this is normal for him, "This happens every winter when it's cold out", or whatever he said. Paint the picture that you saw that made you make the call you did.
As far as the doc giving you a hard time for taking initiative vs. waiting for orders, just follow protocol. If you follow protocol, you cannot be faulted. If protocol for abdominal pain is line, labs, and a liter, then do it. If the presentation doesn't fit neatly into a protocol, that makes things a bit more of a challenge and you have to use judgment to decide to either wait for orders, or choose elements from the patient situation that a protocol can apply to. Either way, if you have a defensible rationale, you can't be faulted.
Triage is not for the faint of heart. It is a huge responsibility and there is a lot of liability involved if you make a bad call and there is a poor outcome. But, it's better to err on the side of over-triaging (assigning a higher acuity) than under-triaging (assigning a lower acuity). What's the harm of over-triaging? The patient is seen sooner, and turns out to not be as sick as you thought they might have been. What is the harm in under-triaging? A sick patient waits too long, and their workup and treatment are delayed. It's my understanding that under-triaging is a significant factor in delays of patients being transferred to the ICU, with a correllating higher morbitidy and mortality. So when in doubt, triage up.
You will make mistakes. Triage is NOT an exact science. There is no formula that's going to make everything black and white and eliminate your responsibility to use your clinical judgment. The important thing is to learn from your mistakes. That's why they call nursing practice a "practice".
Anyway, that was all probably more than you wanted to know.
blockmomRN
5 Posts
I was working one night with a fellow nurse that kept complaining of a terrible toothache and jaw pain, my gut kept nagging at me so I asked her if we could just to an EKG on her (she did have a family hx of cardiac disease etc) .....she was having a huge MI , coded on us as we tried to get her up to CCU (this is before we did interventions and took people straight to the cath lab). She did survive, barely. Lesson learned, always listen to your gut..