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First PIT shift... Disastrous...


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There's a reason it's called triage.  This is also where the most basic, but one of the most important pt. skills is developed; being able to determine at a glance as to who is sick and who isn't.  It seems to be a lost art in some circles.  Instant assessment from a simple glance, "hot words" in chief complaint, assessing vital signs (there IS a reason as to why we get them), and skillful usage of basic clinical skills such as auscultation and palpation.  Others feel free to throw me under the bus if you wish but I think this may be one of the better positions with which to learn pt. assessment skills and interaction techniques.  As alluded to in another thread if you haven't had the experience previously before PA school then you have to develop them on the fly.  You know, a mandatory BDLS/ADLS course would not be a bad idea for PA's in the ED who do triage.  It was implemented in San Bern, CA last week as you could see the colored tarps on the ground for triaged patients.  It really doesn't work that much differently in the ED.  You also need to accept that some serious cases will get missed despite your intent to catch everything.  It happens.

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I have done this type of work before and don't really enjoy it. super high volume with minimal interaction = potential for disaster. when I did it we were briefly screening 8 pts/hr, putting in basic orders and moving on to the next patient. you can';t please folks with this. the providers in back think you ordered too much or not enough. in the same day I was yelled at both for ordering a d-dimer and not ordering a d-dimer on similar pts by different docs. make sure you document what you think is going on and any recommendation you have , despite bed availability, etc. "75 yr old male with chest pain worrisome for acs. advised charge nurse and Dr Smith of my concerns, need for stat ekg and the the potentially emergent nature of this pts complaint. recommended ASAP evaluation and treatment in the main area of the dept". that way when the guy is sent back to the waiting room and found to have a stemi 2 hrs later it's not on you. this stuff happens all over. we recently had a pt triaged as "probably gastroenteritis" and sent back to the waiting room who dissected their AAA sitting waiting for a room. didn't go well. I'm glad I wasn't on shift that day.

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This was my experience seeing this first hand for several years as a tech in the ED: they are triaged by the nurse. If there were beds, there would be no need for triage, as they would go straight back. I was working when our hospital implemented a provider in triage. Their purpose was NOT to retriage, that is what the triage nurse is there for.

 

The provider was their to order the appropriate tests from the waiting room so the results would be available when the patient got back to a room and the length of time in a room was reduced. They could also dispo and d/c the few minority patients who are obviously not appropriate to the ED (things like "I had a mild headache that self resolved yesterday, but just want to be checked out". Or, "my girlfriend is allergic to bee stings and I want to know if I am too"). You cannot solve the ED waiting room problem that is prevalent in nearly every ED, please don't try or you will hate life.

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As an aside, in the three years that I was a tech in that ED, I know of two patients we lost in the waiting room. One I was the tech who did the orders for. I don't remember the c/c, but her 12 lead was normal (don't know the labs). In both cases there was a several hour wait in the ED. In both cases the ED was jumping with level I's and II's and there was no room at the inn for full workups. Both "slipped through the cracks". It's a sad state of affairs, but there is only so much that can be done in some situations.

 

I will say that the provider who wrote the orders (then a resident) is still practicing. I never was subpoenaed, and no one went to jail or lost their job. Lawsuits happen, but so does life. You can't focus on that aspect of it. 

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Thanks for the responses. I guess I am terrified of not knowing enough or having the capacity to take care of patients I am responsible for. It's essentially why I quit my first job as a PA a week in (I was the only medical provider around for a whole 100 patient drug rehab and my SP was a psychiatrist who was rarely in the building). I feel uncomfortable about being in another bad situation. I am terrified of causing a bad outcome or getting sued. But now that I've started working as a PA I realize that no matter who you are, PA or MD or NP - everyone feels this way in the beginning.

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Sometimes it depends on where you're working and why you're in triage.  I'm familiar with a system that puts a provider in triage simply for stopping the clock on the door-to-provider-time.  It's a busy system often with multi-hour wait times for a bed and even longer to be seen by a provider in the back.  (Not unlike many of your shops, I'm sure.)  This system has been dinged by a variety of entities in the past for the long wait some patients endure from when they're checked in to when they're actually seen by a provider.  Thus the provider in triage procedure currently in place.

 

In this particular system this triage provider may or may not place orders.  Most will do obvious stuff (e.g. EKGs, imaging).  Labs are less frequently ordered under the idea that nobody wants to create a situation where a follow up provider has to explain results on labs ordered by someone else.  Triage nurses have the ability to do simple interventions (such as percocet for pain, neb treatments for asthmatics etc...). The biggest thing is to stop the clock, drop a short and succinct note, then move on to the next one.

 

As was mentioned above this is really the place where you need to have your "sick/not sick" abilities down.  No matter how proficient you are, however, you will be fooled on occasion.  It happens.  Do what you can.  Keep moving forward.  As has been mentioned you aren't going to fix them in triage.

 

And keep hanging in there.

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This is not in any way a criticism of you, ERcat, but of the system that put you there, so please don't take it personally.

 

I've said before on here, and I'll reiterate- new grads do not belong in triage.  Period.  This goes for new nurses as well.  

 

Experience and time are necessary for someone to truly develop that feel for "sick vs not sick" and know what to order to identify the pathology.  But, there's another benefit to having experience and doing a role like this- you're less likely to have nurses who are the gatekeepers for the rooms to walk all over you and ignore your concerns.  An experienced PA/NP who is doing a "provider in triage" role that identifies a subtle sign of serious badness can call the charge/flow nurse and tell them this particular patient needs to go back NOW, and they're more likely to listen to someone who the entire ER staff respects because of their experience.

 

We do have a somewhat similar system, but most of the patients are already triaged- it's for lower acuity patients who are ambulatory- 4's and 5's with minor complaints that I can see with a nurse and a tech and do their entire care in a single room and discharge them from there (if they have xrays, they go back out to the main waiting room for the results).  I can give them oral meds in that room too, which it sounds like you can't even do that unfortunately.  We also work in level 2's that need a medical screening exam if they've been waiting longer than a certain time so that someone's at least laid eyes on them and make sure there's nothing that needs to go back right away- for instance, the last patient I saw during my last shift in this role was a 70-year-old on Plavix who was in an MVC and had a giant seatbelt-shaped ecchymosis across their torso but had lower chest wall/RUQ pain on the opposite side of the bruise- that's the person I call up the charge nurse and say that they need to go back ASAP and give me a room now.  

 

We don't hire new grads, though, and even with the people we hire they don't do this role until about 6 months into the job so that the group gets a feel for how they are as a PA or an NP before putting them in this role during a shift.

 

Last thing, in regards to being sued- yes, this is always a fear whenever you're working in the ER or any field of medicine, but the reality is that at some point in your career you're probably going to be named in a suit and many times it's not because of anything you did, but the outcome was just bad and nothing you or a doc or anyone could've done would change it.  A single malpractice suit is not the death knell of a career- a LOT of people would not be working if it was.  A pattern of bad malpractice cases with the provider being found at fault, however, IS the end of a career- and those people thankfully aren't that prevalent.

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This is not in any way a criticism of you, ERcat, but of the system that put you there, so please don't take it personally.

 

I've said before on here, and I'll reiterate- new grads do not belong in triage.  Period.  This goes for new nurses as well.  

 

 

^^^ This

 

It is unfortunate you are in this position. I am a new grad as well.  In the ER that I work in we have a triage shift for the PA/NP's, but we will not be scheduled in that shift until we have been there a year.  There is just too much going on for someone who is still learning the ropes.

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First it is a very stressful position for anyone. It sounds your job is not to triage pts to beds but to get the work up started. First thing to know if most places won't give opiod meds for pts not in a room and that is a policy to protect from pts having respiratory de compensation in the waiting room. So while this sounds harsh, the pt with a broken arm won't die if they wait an extra hour for pain meds beyond Tylenol, but the truly septic or AAA pt might.

 

The experienced triage nurses typically know what they are doing. You can't mainline every suspected PE to the recusitation area because 1) stable VS PE may not need recuss and 2) those beds have to be reserved for the overtly ill or dying on busy days.

 

Your job is to order tests. Yes some people will say you order too many and others too few depending on their personal "style." When in doubt as a new PA I always suggest over testing so long as you break that habit once your confidence builds up. You should be getting the obvious stuff most the time - basic labs on anyone who needs them, UA and or Upreg on child bearing age women, CTs on acute abdomens, x rays on the febrile coughing or truly dyspneic, trop/EKG/CXR/asa on chest painters. CTH and ASA on Neuro deficits. Etc etc.

 

Your job is not to work these patients up, catch zebras, or even do a thorough exam. Your job is to order tests so by the time the pt is roomed, most their tests results are back and the ER can get caught up.

 

If you see someone who needs to be seen stat and the RN doesn't think so, chart your findings and that you requested the pt be roomed ASAP. Never chart dismissive things like the above poster pointed out about gastroenteritis - there is NOTHING to be gained from that.

 

It is stressful but also a good learning experience. Sounds you have a close relationship with your docs which is great but as you get more confidence and autonomy to work on your own more you will gain comfort in these challenging areas. When I was in ER I also found it to be incredibly stressful so you are definitely not alone.

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Thanks for all your responses. They helped me to reframe my perception of provider in triage. I am not there to take care of everyone in the waiting room and call all the shots about who goes where. The reality is basically what I've been doing - standing back, listening in to the patient's chief complaint and history, doing a quick physical and figuring out what tests to order while the triage nurse runs the show (sadly). That in itself is a tough job - it requires quick thinking and quick ordering skills (tough for me because I haven't even mastered the EMR yet). To try to take on more than that and watch over everyone in the waiting room is unrealistic.

 

To sit and worry about liability and getting sued is just not productive either. But ever since I started this job two weeks ago it's CONSTANT worry. I've been waking up throughout the night several times thinking about patients, remembering physical exam points I forgot to do, pain meds I forgot to order, key differentials I might have missed, crappy and incomplete admission orders I've submitted because I just don't have the experience yet. Instances where I felt I should have really stressed proper follow up rather than casually mentioning it and documenting it in the patient's discharge papers (I.e. a symptomatic and stable GI bleed). Feeling dumb in front of nurses because they seem to know a hell of a lot more than I do. My resting heart rate has always been around 50-52 but ever since I started this job it's in the 60s - crazy! It's exhausting and disconcerting to think about the mistakes I've made thus far - yesterday when suturing up an old lady's arm I somehow forgot to irrigate it and I also used iodine, to which she has an allergy. With another dude, I thought I irrigated his leg laceration adequately but when I was suturing a little piece of gravel popped up. Now I am obsessing about whether or not a posterior splint in a boy with a supraocondylar fracture was placed properly - when reading Tintinalli's tonight I can't remember if his arm was oriented in the correct way. Little things (or rather, big things) like this are driving me insane. I am loving this job but I can't help but feel like a fraud! Lots of faking it. Lots of ducking into the bathroom to quickly look something that should be obvious on my phone. I feel haphazard and hectic and I am not even taking on that large of a patient volume - maybe one new patient each hour. It has been a rough transition and it's hard to believe other PAs have started out this roughly! On the other hand, the docs seem to like me and trust me, and I am getting incredible feedback from patients ("Thank you for being the only one in this hospital who actually cares," "You have great beside manner," "I think you have found your calling," "I can tell you really love what you do," Etc) - but what does it matter if I feel like I am messing up and forgetting things left and right!?

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What's the old adage: "it takes 10,000 hours to master a skill". That's five years of full time work to start to master a discipline. As a cop, a cop is a rookie for about five years. After that, they've seen enough to make the right call on tough calls without assistance.  I don't care how long school or training is, one month working is nothing. 

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Sounds like you should get your feet wet for a few more months before doing triage. We don't have provider in triage but typically the nurses we use are the more experienced ones. Its hard to be able to tell sick/not sick/etc during a 5 min exam when you haven't regularly taken care of patients like that in the main ER. Plus it takes time to get a feel for what tests to order.  

 

Maybe they can give you some time to get comfy before putting you in triage. It took me about a year to get comfortable in the ED and for that feeling of general uneasiness to go away. For some people it never goes away and they move on to another specialty. We have only had a couple who found EM wasn't for them, but most folks get in the groove after 6-12 months. Things will get better with time/experience

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Pretty much everyone here covered it beautifully, but since its such a big part of my job (triage, I'm a tech) I feel compelled to chip in. 

 

Triage sucks. Its the worst. You basically had no idea what you were in for. It happens to all new people. Triage, when done right however, is not nearly as frightening (although you have to keep your head ON. A. SWIVEL.) It also takes a lot of practice.

 

That being said, to get anywhere in EM, you'll have to toughen up. Its gonna sound crazy, but you'll have to stare people that are "only" in pain and not dying (or dying slowly) right in the eye and let them sit out there and marinate. People will yell at you, threaten you, fake seizures/pass out, drunkenly sleep out there through an MI/CVA/badness. You will look at them, make the call to let them sit out there longer, and have to be able to sleep on it. I will go ahead and make a point here that I'm not a provider and that I understand the angle is slightly different, but it doesn't change the fact that when there are no beds, there are no beds. Think about it; did all 4 trauma bays have patients in them (the last beds that get filled)? That's common in my shop - meaning if you walk up with a GSW to the chest I'm still gonna have to move people around to get you where you need to go. Agree with the providers in here; prioritizing patients based on actual vs. perceived resus needs is a hugely important skill for those of you practicing medicine. 

 

I noticed it mentioned earlier in the thread but I'll reiterate it, since its one of my favorite points. Nothing compares to the gestalt training you get in a busy ED triage. Nothing. I don't care how badass the medic runs are, seeing 100+ people pouring through your doors over 12 hours completely undifferentiated is prime, prime experience. I make sure all the new hires get this point when they complain about their assignment. I hate it too, but learning the eye test through practice is priceless. 

 

One quick point (might have been covered already). Are you well versed with triage ordersets? Tests that can be run quickly and can help rule out major issues, or improve patient flow? 12-leads, trops, head CTs, extremity/ortho films at earliest indicated time (AC separation vs. dislocation would change bed placement here), HCGs, type-cross, probably a bunch more I forgot or don't know. Likely someone at your ED already knows this cold; find this person (who could be the cranky charge) and learn the system. It can only help. 

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Triage provider is thankless work; unfortunately to your boss it's probly the most important part of your job as it shortens door to provider time and make the hospital look good. You seem knowledgeable and like you really care so you'll do fine ; learn what you can . Hopefully triage will be a small part of your job.

 

Some advice: make sure a patient is stable before having them go to x-Ray/scan. You don't want a septic patient at some X-ray , have the spot open up in the ER for them while they are there, and having the attending wonder where their septic patient is who needs abx/fluids ( which you cannot administer in triage).

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having a provider in triage shortens time to provider, but can artificially make your length of stay look huge. if someone is "seen" at noon and doesn't make it to a room until 1700 (not uncommon at my primary job" then has a typical 3 hr ER workup with labs, CTs, etc their length of stay after provider first contact is 8 hrs...

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As an update... Looks like I am not going to be doing much triage, at least for now. I'm the only PA at my ER… The rest of the advanced practice providers are nurse practitioners. And for some reason those NPs absolutely love triage shifts, because in their mind they're easier and less cerebral. So I have them left and right wanting to switch regular shifts for my triage shifts. I talked to my boss about it, and he has no problem with me doing that and doesn't even see the point in me doing any triage if so so I have them left and right wanting to switch regular shifts for my triage shifts. I talked to my boss about it... I didn't complain or anything but simply said the NPs want triage shifts and I want less...and he has no problem with me doing that and doesn't even see the point in me doing any triage if I don't want to!!! I will still have to do a couple hours a week because some of my shifts requires triage in the morning for a couple hours, but It looks like I won't be doing many of the all day triage shifts as long as they have NPs.

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  • 2 weeks later...

Thanks for all your responses. They helped me to reframe my perception of provider in triage. I am not there to take care of everyone in the waiting room and call all the shots about who goes where. The reality is basically what I've been doing - standing back, listening in to the patient's chief complaint and history, doing a quick physical and figuring out what tests to order while the triage nurse runs the show (sadly). That in itself is a tough job - it requires quick thinking and quick ordering skills (tough for me because I haven't even mastered the EMR yet). To try to take on more than that and watch over everyone in the waiting room is unrealistic.

To sit and worry about liability and getting sued is just not productive either. But ever since I started this job two weeks ago it's CONSTANT worry. I've been waking up throughout the night several times thinking about patients, remembering physical exam points I forgot to do, pain meds I forgot to order, key differentials I might have missed, crappy and incomplete admission orders I've submitted because I just don't have the experience yet. Instances where I felt I should have really stressed proper follow up rather than casually mentioning it and documenting it in the patient's discharge papers (I.e. a symptomatic and stable GI bleed). Feeling dumb in front of nurses because they seem to know a hell of a lot more than I do. My resting heart rate has always been around 50-52 but ever since I started this job it's in the 60s - crazy! It's exhausting and disconcerting to think about the mistakes I've made thus far - yesterday when suturing up an old lady's arm I somehow forgot to irrigate it and I also used iodine, to which she has an allergy. With another dude, I thought I irrigated his leg laceration adequately but when I was suturing a little piece of gravel popped up. Now I am obsessing about whether or not a posterior splint in a boy with a supraocondylar fracture was placed properly - when reading Tintinalli's tonight I can't remember if his arm was oriented in the correct way. Little things (or rather, big things) like this are driving me insane. I am loving this job but I can't help but feel like a fraud! Lots of faking it. Lots of ducking into the bathroom to quickly look something that should be obvious on my phone. I feel haphazard and hectic and I am not even taking on that large of a patient volume - maybe one new patient each hour. It has been a rough transition and it's hard to believe other PAs have started out this roughly! On the other hand, the docs seem to like me and trust me, and I am getting incredible feedback from patients ("Thank you for being the only one in this hospital who actually cares," "You have great beside manner," "I think you have found your calling," "I can tell you really love what you do," Etc) - but what does it matter if I feel like I am messing up and forgetting things left and right!?

I would swear this was written by me at any given point in my first 6 mo out of school. I'm now a couple years into EM and I promise it does it get better. I also woke up several times a night every night remembering things I should have said or done, worrying about the next day, and generally feeling like I didn't know what I was doing. I spent every shift feeling like I was going to hurt someone or get sued. I think this is a natural experience and it gets so much better as time goes by (although I didn't believe it at the time). Trust your education, your nurses, and obviously your docs. Consider the first few years like residency and keep the learning going and never be afraid to ask questions. Stick with it if you're enjoying it which it sounds like you are and you'll eventually feel more confident. We haven't started our provider in triage yet but it's on the horizon. I agree with what many have said: it's impossible to predict what every doc will want ordered for every pt. It's ok to order too much sometimes particularly when you're new. And while things like fractures are terrible to watch suffer, triage is there for a reason, and the unstable life or death pts take precedece. You're there to make sure they have CMS and can wait safely for furather treatment, which is great because many facilities don't have someone doing this. Let me know if you ever need someone to talk to about the stresses of being a new grad. Hang in there.
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Thanks NCEMPA. I'm in such a weird spot no one can seem to relate to, and it's nice to know your experience so I know I'm not alone. Glad to know that the waking up in the middle of the night thing is normal. It is literally the most bizarre thing in the world… I will wake up out of a dead sleep in the middle of the night and have an answer to something I wasn't even thinking about. Like my subconscious is critically thinking things through and digging deep into my knowledge base and bringing up knowledge I don't even consciously remember during my waking hours. For example, I might wake up in the middle of the night and think, "Whoops, you didn't check Mrs. X for scaphoid tenderness when she presented with her wrist pain. Don't forget scaphoid fractures." Or "You probably should have gotten ahold of this patient's PCP for that weird lesion. Why don't you call the PCP tomorrow?" TOTALLY BIZARRE. Reminds me of biblical times when God came to people in their dreams and gave them all the answers. Haha.

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I'm actually also a new grad in the ED for close to 2 months now. I can totally relate to what you're saying. I've been having dreams/nightmares about things I may have missed and didn't do/document. In fact one night before bed I actually recalled I forgot to order patient's methadone (the EDPAs run the obs unit too) even after verifying with methadone clinic, and called it in for my night shift colleagues to put in. Totally bizarre and insane just hit me at night prior to sleeping. 

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  • 2 weeks later...

EMEDPA, 

I noticed that you were saying you were yelled at for both ordering and not ordering a d-dimer in triage. I was wondering what is the protocol at your job regarding this. At my ED it is "consider d-dimer with consultation of physician." Is there a way that you can document for instance "Patient has a X Well's score for PE" in order to bypass this? Thanks

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EMEDPA, 

I noticed that you were saying you were yelled at for both ordering and not ordering a d-dimer in triage. I was wondering what is the protocol at your job regarding this. At my ED it is "consider d-dimer with consultation of physician." Is there a way that you can document for instance "Patient has a X Well's score for PE" in order to bypass this? Thanks

we don't have any mandatory physician consultations except admissions. this is more a personality thing. there are docs I work with who order a d-dimer on every chest pain even with zero risk factors and docs who never order one and just order u/s or cta if they have clinical suspicion and I have no way of knowing who will eventually see a pt.we staff 3 pas and 3 docs at any given time, so it's a crapshoot.

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