"it's probably nothing"-fast track disasters

[medic25]

Recently had an elderly patient with "abdominal bloating" after eating a burger, triaged as an ESI Level 4.  Markedly hypertensive at triage, past surgical hx of a AAA repair.  I'll let you guess what his diagnosis was....

[EMEDPA]

On ‎12‎/‎12‎/‎2019 at 11:52 AM, medic25 said:

Recently had an elderly patient with "abdominal bloating" after eating a burger, triaged as an ESI Level 4.  Markedly hypertensive at triage, past surgical hx of a AAA repair.  I'll let you guess what his diagnosis was....

were you able to see it on u/s?

[medic25]

were you able to see it on u/s?

No, went old school and whipped him over to CT right away.


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[rev ronin]

On 12/12/2019 at 12:18 AM, SB23 said:

Recently saw a 9mo with “nausea and vomiting” in fast track ESI level 4. Turns out the kid rolled off the bed, landed on the hardwoods and then developed nausea, vomiting and was “acting sleepy.” Well CT showed a large epidural bleed with shift. Had to send her out via helicopter to a children’s hospital.  

Do you believe the stated MOI?

[EMEDPA]

58 minutes ago, rev ronin said:

Do you believe the stated MOI?

my question as well....

[SB23]

2 hours ago, rev ronin said:

Do you believe the stated MOI?

That’s a whole other side to this story. I was skeptical about the story.  So after the mother told me the baby was otherwise healthy and had no complications at birth, I went and saw the patient had some encounters in “care everywhere” In the EMR. Apparently she spent 3 weeks in the NICU after birth for withdrawals at another facility out of state. I asked her about this too and it was more nonsense about her forgetting and that, and “there were technically no complications, the baby did well and even went home early at 3 weeks then originally expected.”  So she Omitted part of her child’s pmh and then got caught and was surprised I knew.  A report was filed with CPS. I figured they can sort out the questionable story. 

[DogLovingPA]

Chief complaint "right leg swelling".  Triage notes says pt stepped in a hole 1 week ago and now complaining of RLE pain and swelling.  Dropped off by family who stated that he "doesn't take care of himself".  That should of been my first clue.  Naive me thinks I'm walking into an ankle sprain or r/o DVT.   Nope...... necrotizing fasciitis of RLE with osteomyelitis of multiple toes complete with full sepsis.  Notable labs include glu 572, Hgb 6, Na 120, procalcitonin 26.9

As a newbie in the ER, this was waaaay over my head.  Obviously got attending involved.  One of the more impressive and horrifying things I've seen.  

[GetMeOuttaThisMess]

You missed the obvious diagnosis. Drop off the problematic family member for admission so family can enjoy their holiday and a couple of extra days.


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[EMEDPA]

10 minutes ago, GetMeOuttaThisMess said:

You missed the obvious diagnosis. Drop off the problematic family member for admission so family can enjoy their holiday and a couple of extra days.


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complete with "suitcase sign positive". 

[CAdamsPAC]

7 hours ago, GetMeOuttaThisMess said:

You missed the obvious diagnosis. Drop off the problematic family member for admission so family can enjoy their holiday and a couple of extra days.


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Granny dump!

[vb315]

I'm a new grad and I work fast track - had a patient, on my first ever shift, triaged with "sore throat". At first glance, I knew it wasn't sore throat - she had trismus and was ttp in the floor of the mouth - neck CT showed a 4cm sublingual abscess and multiple abscesses extending to the hyoid bone. No recent dental work, no medical history. And that was my first ever consult, which I made to ENT haha

[EMEDPA]

6 hours ago, vb315 said:

I'm a new grad and I work fast track - had a patient, on my first ever shift, triaged with "sore throat". At first glance, I knew it wasn't sore throat - she had trismus and was ttp in the floor of the mouth - neck CT showed a 4cm sublingual abscess and multiple abscesses extending to the hyoid bone. No recent dental work, no medical history. And that was my first ever consult, which I made to ENT haha

Great pick up! Strong work!

[vb315]

16 hours ago, EMEDPA said:

Great pick up! Strong work!

Thanks, EMED! One of my physician colleagues said he'd only seen it once before, so I thought it was interesting to see

[Apriori]

In fast track yesterday I had:

A pt with splenic lac, an acute limb ischemia, new diagnosis of CHF in a 40 year old, and a psoas abscess.  

All triaged as 4s. All in the same day. 

A couple months ago I had mentioned to my director that too many sick patients were getting sent back to FT and was told " If the triage nurse sees the patient and deems them a 4, then nothing is going on. You need to trust your nurses".

 

 

[EMEDPA]

12 hours ago, Apriori said:

I

A couple months ago I had mentioned to my director that too many sick patients were getting sent back to FT and was told " If the triage nurse sees the patient and deems them a 4, then nothing is going on. You need to trust your nurses".

 

 

Um, no. If the nurses could make a dx from triage 100% of the time the patient wouldn't need to see a provider. This whole thread is literally proof of that. Feel free to share this thread with your medical director. We have lifeflighted patients who were initially triaged as low acuity to fast track on more than one occasion. 

[ARinaldi3]

A lot of what's being mentioned above I could see triage nurses not being well versed in significant mechanisms, why pain out of proportion to exam isn't always anxiety, and the importance of vitals/intuition. The education of a nurse and a clinician is different and triaging is not an easy job--many nurses have to manage the flow of the department with limited beds and many acute patients in the waiting room. Instead of complaining to an administrator, I'd attempt to educate why a patient needs to be brought back sooner/brought in the main ED. 

Assessing of what a "bad miss" is more practical in understanding what nurse should definitively not be in triage--something like not taking vitals properly, not thoroughly looking over a patient, not getting pertinent history. Most of these I feel are derived from laziness rather than education. A triage nurse waited to bring back an unaccompanied man on blood thinners with an unwitnessed head injury with LOC until there was a room in the main ED available--well he had an open frontal bone fracture, midline shift. Waited 30 minutes until I ran into the waiting room once I saw head injury-blood thinners sheerly off of intuition that someone else needed to lay eyes on him. She stated that she could not tell he had an open fracture as he was bleeding and had been covering up the wound. She never looked at the wound as it was VERY apparent that there was bone involvement as you could see brain tissue. THAT is something I would bring up to an administrator.

On the other side, there are a lot of issues with a triage that is overly cautious and that usually results in clogging up the ED and all patients waiting longer (OUCH PRESS GANEYS!). Many hospitals think that replacing the nurse with a PA could be more effective. For the most part--I don't feel like a PA triage is a good system as you lose another provider and an experienced nurse may be as effective/more effective than a PA anyway.

From my experience, I find that most of my nurses have difficulty with triaging pediatric patients even with very specific guidelines for age, vital signs, and such. No one wants a child to be sick--but anyone can be sick. The whole "sick" vs "not sick" cliche is good and all but patients are dynamic and the best advice I give to any nurse that wishes to discuss a triage is to err on the side of skepticism. If that child is a borderline 4--well then it's surely a 3. If that child is a hard 3, well maybe it should really be a 2. Medicine isn't to point fingers or demonstrate an ego---we are all learning and we all make mistakes. 

Edited March 3, 2020 by ARinaldi3

[EMEDPA]

Part of this as you mention is selection of which nurse does the triage. It should not be the new grad RN....many places do that...

[jmj11]

On 12/12/2019 at 9:50 AM, EMEDPA said:

one year old infant Bounce back yesterday, previously seen at another facility and dx as conjunctivitis. Funny, but I didn't think conjunctivitis involved vesicles all over the lids and periorbital area. Transferred emergently to peds ophtho at peds tertiary care hospital. Currently in ICU undergoing workup for disseminated herpetic infection +/- encephalitis. So Far LPs, blood cultures, etc done. Peds anticipates minimum 2 weeks inpt...

Yeah, errythemia okay, vesicles bad.

Different from this, but I saw a guy with a recurrent unilateral periorbital headache that came about once a  month to every few months, lasting 5-10 days. He mentioned his eye turned red and was diagnosed by a neurologist as "cluster headache." The character of pain made no sense for cluster headache. I asked if he had any lesions around his eye and his eyes lit up, "Yeah, I get a couple of blisters on my lower lid." I had him come in with the next outbreak and he did. I unroofed a cluster of small vesicles on his lower lid and did a viral culture which came back as herpes type II.

[ARinaldi3]

11 hours ago, EMEDPA said:

Part of this as you mention is selection of which nurse does the triage. It should not be the new grad RN....many places do that...

Though if that was occurring I fear that the administrator who allowed this/implemented this situation may not understand how horrid that situation could get.

[DogLovingPA]

"Sciatica"

[EMEDPA]

On ‎3‎/‎14‎/‎2020 at 8:49 AM, DogLovingPA said:

"Sciatica"

does sciatica cause a pale pulseless leg?

[DogLovingPA]

3 hours ago, EMEDPA said:

does sciatica cause a pale pulseless leg?

This one was subtle surprisingly.   Cool foot, pulseless but not pale and still with cap refill.  I got very lucky.  Could of been easily missed if pt hadn't been wearing sandals.  Was eye opening for sure.  

[EMEDPA]

1 minute ago, DogLovingPA said:

This one was subtle surprisingly.   Cool foot, pulseless but not pale and still with cap refill.  I got very lucky.  Could of been easily missed if pt hadn't been wearing sandals.  Was eye opening for sure.  

good catch then!

[sk732]

Been away for awhile...mid 40's dude, triaged as anxiety (despite temp of 39.8C) c/o of pleuritic CP, cough and recent exposure to a returned traveller.  PHx of chronic LBP, smoker 1ppd x gajilliion years, but hardly anything past 2/7.  Tachypneic, really quiet (L) lung and junky (R).  Sats 91-93% RA, WBC of 2.1, CXR shows MAYBE 2/3 of a lung field between the two sides (white out (L) to just below 3rd rib and patchy infiltrates throughout the (R) side).  I swabbed him and admitted to the COVID unit...was sent to MICU in our urban referral centre that night.

Was thinking back to another favorite...late 60's fellow, in a chemo cycle for NHL, pre-syncopal and "peeing sand"..."This is just a UTI" the triage nurse tells me...without having seen the urine sample, which was literally 2ml of wet sandy sludge.  He stood up to transfer to the bed and fainted on me...from anuric dehydration courtesy of the chemo induced AKI...

39 yo male "this is just a man cold" severe abd pain and histrionic spouse - rock hard abd, ^ WBC and imaging showing a necrotic gall bladder...

 

On 2/24/2020 at 11:33 AM, Apriori said:

A couple months ago I had mentioned to my director that too many sick patients were getting sent back to FT and was told " If the triage nurse sees the patient and deems them a 4, then nothing is going on. You need to trust your nurses".

The problem is you can't always...while there are many incredible triage nurses out there, there are many that are too busy trying to second guess you or diagnose a problem instead of eyeballing the patient, gathering pertinent data into a compact and cohesive narrative and then assigning a category to them based on that data and clinical acumen.  I THINK an issue we're seeing collectively is that many newer triage nurses don't actually understand their role properly and haven't been around long enough to ask the right questions...(forgot to add) or some are getting incredibly CRISPY and need a break.

 

SK

Edited April 12, 2020 by sk732

[sk732]

 Lady with lower abd pain, month of PV spotting/bleeding, scapular tip pain, low positive quantitative BhCG AND a past ectopic.   I did order an US to be done from the WR though...they went to the OR within an hour of the scan.  The triage nurse called me negative when I said that based on that history, they had a belly full of blood and wasn't minor or low acuity...is that negative?