Some Emergency Department nurses hate being assigned to
Triage. This patient encounter may mean the difference between whether the
patient enters the Main treatment area or has to wait in the crowded waiting
room. A difference between life and death. It is a stressful assignment.
A triage nurse is at the front lines, in the front-line
department of the hospital. The word “triage” came from the French word
“trier,” which means sorting out. In a big, urban community hospital, the
Triage area is like a marketplace, where everyone clamors for the Triage
nurse’s attention. With a long list of walk-in patients waiting to be seen and
a long line of EMS stretchers, the nurse sorts the patients according to their
level of acuity. It is neither an assembly line nor a first-come, first-served
process.
A Triage nurse cannot be easily frazzled. She needs to be
the most level-headed and calm person in a sea of disjointed conversations and
screams that beg for attention. In an environment fraught with tension, worried
relatives, pushy EMS personnel, and harried and overworked staff (doctors,
nurses, technicians, and registrars), patients demand to see the doctor ASAP.
Actually, it is those non-verbal patients who are the sickest, not like those
asthma patients who state “I cannot breathe” while speaking in complete
sentences and carrying on a loud conversation on their phone.
A new grad should
not, must not be assigned to triage. It is a disservice to them and to their
patients. Distinguishing between Level 1 (likely to die) and Level 2
(high-risk) patients from Level 3 will require the clinical expertise and
knowledge that an experienced nurse, with their “gut instinct,” can easily
provide. Some doctors even question the nurse’s decision, despite not being
trained that a Level 5 does not require any resources and a Level 4 needs only
one resource. No, oral antibiotics and tetanus injection are not a Resource. It
would be beneficial to post the Emergency Severity Index (ESI) triage algorithm
and the Resource table at both the Triage room and the Doctor’s lounge to
prevent such microaggressions.
Emergency Severity Index (ESI) Triage: Prioritization
Despite the stress, I actually enjoyed my stint as a Triage
nurse. It was fun sometimes. Indeed, full of surprises, interesting, and weird
stories for the lunch discussion in the nursing lounge.
ER nurses are superstitious
Beware: Never say the word “Quiet” in the middle of the ER,
unless you are ready to incur the wrath of every single ER personnel who
finally had time to take their bathroom break, or even to take a breather. That
word will bring in a swarm of locusts, or worse, a busload of patients. Mass
Casualty events are not fun, unless you’re doing just a drill, complete with
moulage and badly-trained actors and a roomful of C-suite VIPs who get in the
way.
Foreign Bodies
ER nurses live for the simple pleasures. We keep a running tab on what’s the weirdest
thing we found in any body cavity. With every Triage class I teach, I poll the
nurses on what foreign objects were found in all orifices (oral, ear, vagina, rectal,
and penis). The inquisitive kids put anything and everything in their mouths
and ears, including lithium batteries (medical emergencies that can cause life-threatening
internal chemical burns).
As experienced as I am, I am still amazed by what others have discovered. It has almost become a contest on who can come up with the weirdest thing that “accidentally” went in “there (front or back)”. Sometimes, patients say, "I just slipped and fell, and that thing got pushed up into my rectum."
The trusty Wikipedia (smirk) wrote: "Polyembolokoilamania is
the act of inserting foreign bodies into orifices such as the rectum, urethra,
and vagina. It is often exhibited by patients with Smith–Magenis syndrome. When
motivated by a desire for sexual gratification, it can be considered a
paraphilia.”
Here’s a more reliable article from the National Library of
Medicine: https://pmc.ncbi.nlm.nih.gov/articles/PMC3357565/
Foreign bodies found were “eg, beans, dried peas, popcorn kernels, hearing-aid
batteries, raisins, beads, coins, chicken bones, fish bones, pebbles, plastic
toys, pins, keys, buckshot, round stones, marbles, nails, rings, batteries,
ball bearings, screws, staples, washers, pendants, springs, crayons,
toothbrushes, vases, razor blades, soda cans and bottles, silverware, hinges,
telephone cable, and guitar picks.”
More sensational pieces were found for sexual gratification,
including a live vibrator that kept buzzing, and the patient had to stop her
narrative because of orgasmic bursts. Now, all these points are discussed, not to make fun of the patients, but for the purpose of nursing education. No patient identification
disclosure, I promise.
Truth is stranger than fiction, and it has never become truer than in the ED.
Virgin births and surprise pregnancies
Case #1:
“Are you pregnant?"
the triage nurse asked the female patient who rushed into the room. The
patient was puffing hard and writhing in pain.
"No way! I'm just fat. I take birth control pills."
Minutes later, the patient's spandex began to sag at the crotch. The nurse barely had time to catch the baby.
Case #2:
Patient: "I swear I'm not pregnant. Shouldn't be. I’m
not sexually active. But my belly hurts soooooo much!"
Parent: “She’s only sixteen. She’s a virgin.”
Nurse: "Let me just put you on the stretcher."
Minutes later, the patient screams, the nurse lifts up the
sheet, and finds a baby on the stretcher.
Patient Teachings
There are always opportunities to teach patients about misconceptions and harmful practices, such as overreliance on herbal medications that can interact with their drugs and polypharmacy.
Workplace Violence- Felony Assault Law
Zero tolerance for workplace violence. According to the New
York State Penal Code, “Assault in the Second Degree in New York allows felony
charges, instead of misdemeanor charges, to be brought against someone who acts, “with intent to cause physical
injury to a registered nurse or licensed practical nurse…while such employee is
performing an assigned duty.”
EMTALA
In 1986, Congress enacted the Emergency Medical Treatment
& Labor Act (EMTALA) to ensure public access to emergency services
regardless of ability to pay. As a Christian and as a nurse, I stand in support
of this- hospitals should provide a medical screening examination to anyone
seeking emergency care, regardless of their ability to pay, insurance
status, or citizenship. I would have never allowed a dying patient to wait
for services to check their immigration status. It is inhumane and un-Christian
behavior.
