Triage and Basic Instincts
Monday May 20, 2002
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When you've practiced in triage and have had the chance to see hundreds of patients, "gut feelings" kick in. This can best be described as a "knowing" feeling in your solar plexus that makes you aware of something subtle in the patient's affect, appearance, or attitude, that affects the decision-making process in triaging the patient.
Pin-Pointing a Problem
One evening, shortly before the end of my tour, a father came rushing into the ED with his one-year-old daughter. She appeared fine, in no distress. As he spoke to me, the child was playing with her father's hair, giggling and giving him spontaneous hugs.
I made a mental note that they appeared to have a loving relationship. The father said he'd brought in his daughter because earlier that evening when he'd put her to sleep, he noticed there was a teddy bear in the crib that had a note attached to it with a three-inch long pin. He'd gotten distracted and forgot to remove the teddy bear from the area. Later on, during the night, remembering about the pin, he went to the child's crib to take away the teddy bear. He found his daughter sleeping peacefully, found the teddy bear, but the note was now lying on the mattress with no pin in sight. After awakening the child, he searched the mattress, on top and underneath. He looked on the floor and in between the bars of the crib. He found no pin. That's when he decided to rush his daughter to the ED.
After calming him down, I gave the little girl an extensive examination. She was playful, happy, certainly not in any pain. She had no abrasions inside or outside her mouth, no droplets of blood anywhere on her clothing or the blanket she was wrapped in. She had no difficulty swallowing and her abdomen was soft on palpation. I could easily have come to the conclusion that the pin in question must have been overlooked by the father when he searched her room.
However, my "gut" just knew something was amiss. The father was frightfully concerned, but not hysterical. He insisted he'd looked everywhere for the pin. I believed him. It didn't make sense that the little girl could have swallowed such a large pin without feeling any discomfort, without showing any outward signs of trauma, but my instincts told me this child needed to be seen by a surgeon - stat.
You should have seen the look on the pediatric surgeon's face when I told him I was triaging this little girl for a stat x-ray and immediate surgical consult. His face changed rather dramatically, however, when those x-rays were developed. There was the pin - lodged in her abdomen, just about to perforate her intestines. She was transferred to another hospital where they removed the pin via an endoscopic procedure, avoiding both surgery and perforation.
Suspicion
In the early morning hours of a long graveyard shift, a young man came in who had had a motorcycle accident two weeks earlier and had been treated at another area hospital. He said they did a CT-scan, an MRI, and conventional x-rays. Since he hadn't broken any bones, and all of his test results were normal, they sent him home the same day. Now, two weeks later, he decided to come to our ED because he said, he, "just wasn't feeling right."
It was difficult to get any information from him. His vital signs were all within normal limits, he wasn't pale or diaphoretic - but he was very distracted. He did not complain of pain. He denied any drug or alcohol use. When I examined his abdomen, it was difficult to tell if it was rigid or not because he was muscular. There was no rebound tenderness, in fact he didn't display any signs or symptoms of tenderness at all. He had not vomited. But he didn't seem quite "right." My instincts led me to suspect, without any substantiating facts, that this young man might have a ruptured spleen.
It was about 2:00 AM when I called the surgical team but, they came running down anyway. They, too, did not find rigidity in the patient's abdomen, but while they were examining him, his blood pressure took a nose dive. He became diaphoretic and pale. A stat CT scan was ordered and the surgeons invited me into the room to observe him and monitor his now descending vitals. Sure enough, the CT scan showed a ruptured spleen. They rushed him up to surgery and by the next day, he was sitting up in his bed. When I visited him, he knew me immediately by my ID tag. He said all he remembered about the ED was my name and the fact that I briefly held his hand before they took him up to surgery. He thanked me as I left the room with a smile on my face.
Listen to the Inner Voice
I feel it's important not to hesitate to listen to that gut feeling - that surge of basic instinct. All nurses develop it over time and I believe it's important to pay attention to such feelings and not rely solely on what we can monitor. Most nurses have had similar experiences of positive outcomes based not only on their assessments, but on their willingness to listen to what their gut feelings said.
Although I believe that triage is the area where these basic instincts are exercised frequently, bedside nursing also offers opportunities to improve a patient's outcome by becoming more attuned to our inner voice.
Whether we refer to this phenomena as basic instinct, gut feelings or inner voice, these feelings are an accumulation of everything we've learned in nursing school combined with nursing experience. Every time we nurse, consciously and subconsciously we assess how patients present - pale, ashen, flushed, diaphoretic, alert, obtunded, intoxicated, sober, in pain or discomfort, malnourished or obese. We see how they behave, how they walk, how they relate to us, their environments, and to their loved ones.
When our instincts kick in, they are the result of all of these observations, conversations, bits and pieces of information collected during the course of our practice as nurses. It's as if we have, within us, hundreds of patient information puzzle pieces, just waiting for the right fit. But, since we cannot consciously remember absolutely everything we've ever been exposed to, these information tidbits stay with us in the form of gut reactions.
I believe it's possible to hone these basic instinct skills simply by acknowledging that they exist. Many nurses are hesitant to question a medication order or to call the physician simply because they "feel" something is awry. If we accept that these feelings are valid we can add one more valuable tool to our nursing tool boxes.
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