The Once and Future Triage
Monday February 11, 2002
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"Lally," Eric the charge nurse said one day, "we have to start putting someone in the lobby to tell people where to go. It's always a mess out there. We're gonna call it Traffic Control."
"Uh-huh." I had no idea what he was talking about.
"So get out there!"
"OK." So I went Out There. In those days, it was bad form to ask about how to do something. You figured it out on your own. Besides, I guessed that Eric was sending out the most useless, expendable staff member he had to do something his bosses wanted done - whatever that was.
Sink or Swim
Out There was a seething, spitting, coughing, suffering, bleeding, fighting, and sleeping stew of humanity. It was a public hospital on the edge of the inner city, and it was pretty raw. We saw 85,000 patients a year then, and they all had to line up in front of two ladies with huge old IBM electrics to get their ticket, the ED Chart.
Surrounding and often blending with the amorphous ED registration lines were other citizens on obscure missions, some of them legal. And into the brew swept the arriving ambulance crews, bursting through the often broken double doors, dragging and pushing stretchers upon which there were more patients - some of them actually sick. Often, people in the lines would greet the ambulance patients or start yelling at them, depending on the nature of the relationship.
And there I was. I didn't know what to do next. How do you tell people where to go when you don't know what they want?
Just then, about eight people back in one of the long registration lines, I saw a middle-aged white guy who was far whiter than he should have been. He was sweating and getting ready to pass out. I knew very little about being sick, but he looked sick. As I got next to him, he vomited blood all over himself and me. I didn't panic because blood wasn't a Haz-Mat in those days. I just grabbed him and half-carried him into the ED.
"GI bleed," someone yelled with anticipation. In no time, the guy was on a stretcher with two IVs and a #22 sump GI tube in his stomach getting an iced saline lavage.
I was soon back out front in clean scrubs. I had no clue I had just performed the abridged version of the nursing process or that I had just done an across-the-room survey, a triage assessment, and made a triage decision. But I had figured out what to do next.
I looked around for other people who looked sick and soon found a gray-faced chest pain who was quiet. Then I spied a homeless person missing half a finger. He had the other half in a mug of beer.
Back I went with them.
Eric said, "Where are you getting these people?"
"Out front."
"Oh yeah." Eric looked as if he had blundered, sending me out there to look for trouble.
In the Thick of Things
Weeks went by, and I learned triage on my own, never having heard the word. I went up and down the long lines looking for obviously ill patients and then asking the others what they were there for. And I learned the difficulties of making triage decisions on the less obvious cases, while the patients waited, hoping for that ultimate prize, an ED stretcher, a far better fate than sitting around in the nonacute area for hours.
The system worked. Of course, there was no patient privacy. Everyone crowded around, telling me why they were sicker. But there were also no paperwork, protocols, or acuity levels. Just me.
After around a year, I learned the word triage. I guess someone had read a journal article. Soon the official title of the job assignment became Triage.
Triage "Evolves"
The years spun wildly away, and I ended up doing quite a lot of charge nurse duty, and then I had a relatively long shelf life as an evening shift supervisor in the ED. But I always maintained a great interest in triage.
Triage has evolved into something far different than what I did those long years ago. Now there's the multicopy triage form that demands an ever-increasing load of data collection, far beyond that needed to make a triage decision. It's as if someone arrives to pay a parking ticket and becomes the subject of a murder investigation. Besides the complaint-specific history and assessment, today's triage often involves a full nursing assessment that should be done at the bedside. All this takes an inordinate amount of time, while waiting patients suffer and sniffle and seethe. And now there are offices and desks, which only isolate the triage process from the incoming patients.
Triage has been reengineered into a monster, and it is useless to rage against it. The system is like the Pillsbury Doughboy. Punch it, and it grins and resumes its usual shape. But there are ways to resist, to make the triage of the future a little more like it used to be.
Back to Traffic Control
Good triage is doing three things at once. One: formally triaging a patient, filling in all the little boxes on the forms. Two: eyeballing the incoming patients at the same time. Usually this is when the real triage is done. Three: keeping an eye on the lobby for changes and arrivals that you missed. If something bad develops, leave the person you're interviewing and deal with the problem.
How can you do this trapped in an office? You can't, but you might be able to convince administration to knock a hole in the wall, or you can leave the office door open and sit where you can see what's happening. You don't have to sit at that desk. Better to sit next to the patient. And never stand over a patient. I learned a long time ago that standing over a sitting or lying patient made me look like some white-coated goon from Snake Pit or Lost Weekend.
And never call people over the loudspeaker. Go out into the lobby and get the patients. While you're there, you can do quite a bit of eyeballing. And always carry dressings, ice bags, and a sling or two. The triage nurse is frequently the first responder, and patients deserve some first aid while they're waiting. This is also good PR. Remember, under that bath towel dressing is usually a 1 cm scratch, but the patient thinks it's awful - and once in a while you'll find bleeding arteries or pieces of a finger. And if you have standing orders for ibuprofen and Benadryl, use them! Patients shouldn't have to scratch to death or clutch a football-sized ankle while registration drones on and on.
There is no way to return to the triage I knew from years ago, but even if some things cannot be changed, we can still try to put a human face on the process. There is no better place to do this than triage. It is here that the ED rubber meets the road, where we first meet the patients who seek treatment. Here, we can smooth out the transition from normal life to the ED and give the patients some hope that things will not be as bad as they think.
A patient coming through the door wants to tell someone what is wrong, right away. And after that, they want to see that someone is beginning to do something about it. Doing something does not mean shuffling papers and holding up a sign-in sheet. Good triage means meeting this need despite the institutional complications that have disfigured my original invention. And a good triage nurse can figure out some way to do good triage even if it means doing four things at once.
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