Tuesday, June 19, 2012


It's still just bad and worse most of the time up at Hood Hospital, but Monday being a Monday, it fell into the worse category.  Maybe even a worst.  Probably for this month, at least.  Hello, 8 hour waits.  It doesn't all completely suck.  ER BFF and I are team triage.  That means one of us is given up as a sacrifice to the anger of the waiting room at the desk, while the other hides in the booth and makes the life-threatening-or-not decisions.  Most of the time I make a run for the booth (mostly due to the fact that I am the least authoritative sounding at looking person here), but I couldn't do that to a good friend. Desk it is.
Days like this are a little frightening.  Triage is all caught up, but you're dealing with a waiting room full of people you haven't seen before, and you're responsible for all of them.  You're responsible for trying to decipher the computer notes of whoever the hell was triaging before you, which is extra fun if they don't include a lot of information and/or you don't trust their judgement. My nursing spidey-sense (which I rely on greatly in triage) really can't come into play here.  It's nerve wracking.
I'm getting my stuff together and scanning the waiting room to see if there's anyone I can place with the list of names on my computer screen and if there's anyone who just doesn't look right, even from across the room.  No red flags here, just a lot of dirty looks. In my scan of the crowd, an average chronically sick looking guy in no apparent distress meets my eyes and smiles.  I smile back, somewhat surprised and a little suspicious that anyone out here is directing any sort of good energy my way.  I go about my business, checking people in, explaining waits, fielding questions from the charge nurse about dozens of patients I know nothing about.
About an hour in, smiley man wheels himself up the the window to say he's been waiting a while and he thinks he's going to go ahead and check himself out and go somewhere else or see his doctor tomorrow.  I'm looking for his name on my list just as my charge nurse comes out to fill the handful of empty rooms and see that it's close to his time. "Hold on just a second for me.  I think they're coming to get you in a room right now. Can you wait for just a few minutes more?" He reluctantly nods, smiles and wheels himself back a few feet so another group of people can check in.  They come to collect him a few minutes later.  I think nothing of it and take some verbal abuse disguised as questions.
A couple of hours later I'm running back for my first bathroom break of the night when one of the friendlier doctors grabs me for some quick education. "Hey Hood Nurse, have you ever seen a dissecting triple A on a CT before? No? Come here for a second." He's showing me the space on the CT and talking about how this is one of the really bad kinds when my eyes wander up to the name at the top of the screen. It's familiar.  Did he come from the waiting room? Yeah.
I go back up to my post and look his chart up.  Oh. Shit.  It's the friendly little guy that was just about to leave. It makes me a little anxious that nothing about his appearance set off any alarms for me.  I look through his triage notes and vitals- nothing terribly notable there, either. I start to wonder if I would have suspected anything even if I had been the one to check him in.
This could have been pretty catastrophic for everyone involved. But he was fine.  It kind of makes you wonder how many close calls like this we see everyday without realizing it, or how many of the people that come in as CPRs might have been fine if they'd been seen a few hours earlier. Sometimes among all the toes pains and toothaches we forget the gravity of what we do.  It's actually some pretty scary stuff.


  1. We had a 50ish guy on the floor last year- ON THE FLOOR mind you that was one of these cases. Had been there for a couple of days for unexplained syncope. Normally the docs would have sent him home by now, but there was something that just wasn't right. On the second day he went into afib with no history- you know, that type of thing.

    On the third day they ended up doing a CT. Turns out that he had been in a car accident 2 days before he came into the hospital. Incomplete aortic dissection with a sllllooowww leak. Not sure when it started leaking or how he was still stable 5 days after the accident.

    Needless to say, we got him to the OR, pronto. He lived. One of the luckiest outcomes that I have ever seen.

  2. I took care of a guy a few years back. Kinda rough, vague back pain, no risk factors, no trauma, seemed to be drug seeking at several ERs- refused PT etc, just wanted pills. Did get X-rays in the ERs but no CT. My hospital did one pretty much to make him go away. Yeah. Spiral ascending aorta tear. When they cracked his chest a coronary artery had just detached. He was 30 something.

  3. Triage will definitely humble you. I too think I have a pretty well honed spidey sense, but every once in a while we all get that kick in the ass that reminds you how dangerous it can be. Example #1: early 50s male complains of acute exacerbation of chronic back pain from an old mvc injury and just wants triage rn to check his BP because he also has a headache...something just doesn't seem right...one very long argument and an EKG later and we're treating our ER doc for an acute MI. He's fine and back at work giving us hell daily. Example #2: older well loved floor nurse presents to ER complaining of sciatica gets an X-ray which of course shows nothing acute so we treat her pain and send her on her merry way because what nurse doesn't have a sciatica issue..three days and as many visits later and ER doc decides to do a ct...turns out she had malignant cancer not sciatica at all. Moral of the story...never get complacent and if you do it's time to roll on out of the ER.

  4. It's always the nice ones who are actually dying.

  5. Key concept here was that: (1) He'd probably never been there before or the last time he was there, it was for something that required surgery or admission and (2) He was nice and polite.

    Those two things are ominous signs nowadays, especially if over age 60.

  6. Triage still scares me silly even though I do it all the time. You can never ever get complacent there. When they invent xray vision for triage nurses, things will be much better for everyone.

  7. It is pretty scary. I remember several years ago getting an admit on a tele floor that the report from ED stated he had been doing some breathing like cheyne stokes. He was talking although drowsy when he got there. Tele wasn't ordered on him for some reason but when I talked to the charge nurse about him she said I could put him on pulse ox and it showed up for the monitor tech. I hooked it up and the patient was a/o talking and asking questions. Monitor tech bitched about having another patient on her board since he was "fine and sating 100%". 20 minutes later I looked up at her monitor that she was ignoring while she visited and noticed his sats were 0%. Went in to check the monitor and found him gray with agonal breathing and called the code. It still haunts me that if we had done something different he might have lived.