This article on emergency triage for writers is part of the Science in Sci-fi, Fact in Fantasy blog series. Each week, we tackle one of the scientific or technological concepts pervasive in sci-fi (space travel, genetic engineering, artificial intelligence, etc.) with input from an expert. Please join the mailing list to be notified every time new content is posted.
The Expert: Rachel Berros
Rachel Berros is an emergency physician assistant who works closely with a virtual visit development team for her healthcare organization. During her spare time she writes speculative thrillers that mix the laws of science with magic, or just skirt the edge of possibility. You can check out her website, or follow her on Twitter for more information. She’d love to connect.
Emergency Triage for Writers
Over the years I’ve worked in Emergency Departments (ED) in remote Wyoming, rural Oregon and California, inner city Maryland and Pennsylvania, and even on a remote Alaskan island. As a physician assistant, I’m often placed in the front end of the departments as well. So, today I’d like to go over what happens when a patient enters my domain. (Please note that while I’ve worked in many places, this description is still a generalization and by no means an exhaustive description of every ED everywhere.)
The First Step: Registration
The first window a patient sees is the big registration desk with hopefully smiling people waiting to take your information. As those registering the patients have no medical training, if the patient appears to be in distress, is bleeding profusely, or appears dead (it’s happened), they will either call the charge* or triage nurse for assistance. Someone will then come out to evaluate the patient, and if warranted and able, bring them straight back into an exam room. Everyone else has a seat in the lobby and waits for the triage nurse to call their name.
*The Charge nurse is the person who stays (mostly) at the main ED desk and directs the flow of the department regarding beds and staffing–and puts out all the proverbial fires an average ED has hourly.
Legalities of Triage
There’s always a legal something, right?
In an ED in the United States it is illegal for an ED to turn away a person without providing a screening medical evaluation regardless of their eventual ability to pay. (You can look up EMTLA laws if you want specifics) Most locations stay on the safe side and don’t get full insurance information until after the patient has been seen by a provider.
It’s also a No-No to tell anyone any information about patients in the department or their treatment. If a person asks for a patient by name, the staff can say if that patient is currently in the department but cannot share any other information about their condition, care, or location. Even if consent is given by the patient either verbally or by prior written consent, a staff member will be sent to either speak with the person directly in a private setting (as with the case of a critically ill patient being actively cared for, if the patient is headed to emergent surgery, or if the patient passed away), or to bring the person to the patient’s room.
The staff cannot even say if the patient was seen there earlier or not and we try to not give details over the phone unless absolutely necessary—and that’s usually only in the case of a death, but even then, we try to find a way to give the news in person.
Finally, the interesting stuff! Though there’s still a lot of waiting ahead.
In its purest form, triage is our way of determining who might die first and how we can use what resources we have to save the highest number of lives.
This process starts in the ED as soon as a patient’s chief complaint is listed in the computer. A complaint of chest pain or shortness of breath will come before those of sore throat or earache. And an 84-year-old with chest pain will come before a 21-year-old with the same complaint. Only if all complaints are equal risk of death will we start looking at Time of Arrival to determine who is called into the triage room next.
Once in that hallowed room, someone, usually an ED tech or a medical assistant, will take the patient’s vital signs while a nurse asks questions about the complaint, other medical problems, medications, allergies, and social habits.
Based on this information, the nurse then assigns the patient a severity number that allows the rest of the department to prioritize this patient’s care. While these are not the official definitions, they are how I think of them. (Note: some locations reverse the number order, but I’ve found this is most common)
1 = Mostly Dead but may or may not have a small chance at becoming not-dead
2 = Trying hard to survive but quickly going toward not (many staff call it trying-to-die)
3 = Uncomfortable and stable but could try to die if left undiagnosed/untreated for too long
4 = Sick or injured but could have gone to an urgent care for treatment
5 = needs a Return-to-Work note or short-term medication refill
Results of Triage
Now the patient can go one of four ways based on those numbers.
- “1”s usually come in by ambulance, as they’re major trauma patients or cardiac arrests with CPR in progress. Occasionally, a stable-enough “2” or “3” will collapse in the lobby and become a “1” or “2” depending on if they still have a pulse (“1”s generally don’t). Oh, and there’s always those patients some people call “home-boy drop-offs” where a nearly-dead patient is dropped off at the department by someone who doesn’t stick around. Those are usually messy.
- I’ll note here that about half of the “2”s and “3”s also come by ambulance, but I have had people arrive via EMS, foot, and private vehicle for every level of complaint.
- “2”s go straight to the main department for as immediate care as possible and usually include patients with severe breathing problems, altered level of consciousness either from injury, infection, or stroke, lots of bleeding, unstable vital signs, or a story that could signify internal injury despite their current presentation being unimpressive—like complaining of road rash (layers of skin torn away by the battle between inertia and friction when a body goes skidding down a road) after crashing a dirt bike going 45 mph without any protective gear, when in fact they have a punctured lung slowly leaking air into parts of the body not designed for said air.
- “3”s usually go to the main department, eventually, but often are sent back to the lobby for varying lengths of time. These patients are those with abdominal pains, muscular-sounding chest pains, severe headaches without neurologic changes, or COPD or asthma flares with mild to moderate trouble breathing. Often, these patients have orders such as lab tests, x-rays, and EKGs ordered in triage and performed in an adjacent room. These tests may not be everything the treating provider eventually wants, but they do usually speed the disposition of the patient.
- The “4”s and “5”s are where facilities have the most difference. Some hospitals have a provider (physician, physician assistant, nurse practitioner, or resident) waiting in triage to evaluate, treat, and discharge the “4” and “5” level patients straight from triage. Other facilities will send them and the lower risk “3”s to an urgent care-style part of the department for assessment and care. Some facilities have both, a provider discharging many from triage and sending the broken limbs, lacerations, and other lower acuity but higher time patients for another provider to care for. Still others simply send everyone to the main—only—department to have everyone seen as able.
From here, everyone receives some level of evaluation and treatment with the eventual determination of transferring to another facility for higher level of care, admission to the hospital, or discharge home.
For More On Triage
I am happy to discuss any questions you might have about this process and to discuss the details of the various models discussed about the treatment of the “4” and “5” level patients if desired. Please feel free to reach out via twitter so we can DM or email as needed! You can also just reach out and say hello, I’d love to hear from you!
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