Triage: When You Are the Sorting Hat
I triage a lot. I don’t like it. The triage nurse has to be able to use x-ray–vision assessment skills and ask the right questions in a circus environment while juggling about 20 balls and keeping a bird’s-eye view of an entire ER. People get really mad in ER waiting rooms. It is maddening to have to wait when you’re sick. I hate even waiting in line at the grocery store. I get it. But it’s worse when you’re sick, especially when you see people going ahead of you. I explain at least a dozen times a night that we see patients in the order of severity of illness and not in the order of arrival, but sometimes sick people don’t look that sick to the untrained eye.
Triage (“sorting”) doesn’t occur only in emergency rooms, though. Any nurse who has more than one patient and one task has to sort through everything and decide what goes first, and everyone and everything else, by definition, has to wait. That means every nurse has to be a wizard at those x-ray–vision assessment skills and knowing which questions to ask to figure out who is sickest and who needs treatment first. We are all sorting hats! But most people get irritated at having to wait, especially because we can’t exactly say, e.g., “You have to wait on your warm blanket because I have one man who is having trouble breathing and another lady having chest pains.” It’s just not good customer care to effectively tell patients, “Other people are sicker than you.” It makes it sound as if they are less important. It’s a difficult issue.
Sometimes triage issues are much worse than just deciding who gets the first warm blanket. Sometimes we have to shift into disaster triage. Ask the nurses and doctors in Joplin, MO. Sometimes we have to totally reverse everything in our instincts and education and NOT treat the sickest patients first. Sometimes we have to reverse into utilitarian triage—save the most people. Do the greatest good for the most patients. That means leaving the sickest patients untreated and probably dying. I have not yet had to do this, but I have to think about it periodically during various educational modules and certifications. If it’s hard to explain to someone why he has to wait for a cup of pudding, how hard is it to explain to someone why you’re going to have to let her die? How do people react? Do they understand? It’s impossible to put myself into the situation of the triager or the patient, having been in, thankfully, neither situation in a real disaster thus far in my career. But any nurse at any time could be faced with just this situation, because disaster, unfortunately, can strike at any time.
Triage is an underemphasized, undertaught skill in both nursing education and in actual on-the-job orientation and training. It is formally taught in the ER, but it should be done for all nurses. We all need to be able to know the system for triage and be able to implement it, and by that I mean be able to implement our facility policy and be able to personally do it. We have to be emotionally prepared, as much as possible, to do what needs to be done. No nurse likes or wants to feel mean or leave any patient in pain, but we are all sorting hats, like it or not. At some point, probably in our very next shift, we are going to make a decision that leaves one patient in discomfort at the expense of another one who is in more discomfort.
And as I said, I don’t like this part of my job. It feels like playing God sometimes. Maybe that is why nurses don’t like to talk about disaster triage; we don’t like to remember that it is we who decide, literally, who lives and who dies. Fortunately, most triage decisions are informal ones implemented minute-by-minute at the bedside and not full-out disaster triage decisions. But every nurse should theoretically be prepared for a call for all hands on deck and a need for disaster triage. Are you?
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