My ETA/ The Triage Zone

You call in for orders and medical control asks “What’s your ETA?”

That’s an interesting question.

There are several answers.

I am fifteen minutes from the hospital grounds.

I am eighteen minutes from my back door opening.

I am twenty minutes from arriving at the triage desk.

I am anywhere from twenty-five to fifty minutes to getting through registration/triage.

I may be as far as an hour from putting my patient on a bed.

My patient may be an hour and a fifteen minutes to an hour and a half away from being assessed by a nurse.

My patient may be two hours away from being seen by the doctor asking for my ETA.

So what’s my ETA?

***

Every system and every service is different and has its unique challenges. I know some medic services that practice load and go on most patients, rarely treating anything within ten minutes transport unless urgently needed because they have no wait at their EDs and can quickly clear for another, potentially more urgent call. I know other services whose medics will in some cases spend ten minutes or more in their hospital parking lot, providing care and treatment because time to care is not the thirty second distance to the ED door.

Just last week we had a patient with suspected kidney stones and generous orders to give the patient 5 mg of morphine every ten minutes X 3. We had given the morphine X 2 when our wheels came to a stop in the visibly crowded ED parking lot. We talked about our options, and included the patient in our discussion. He was still 9 out of 10 on the pain scale. We can bring you in now, or we can sit here for another five minutes until it is time to give you your last dose. He wanted us to sit. We did. We gave him the last 5 mg of Morphine and then rolled through the ED doors. We were in triage 22 minutes. By the time we had the patient in his room thirty minutes later, his pain was down to a 3.

***

I had an interesting conversation with a doctor the other day. We were talking about nitro paste, which he said was really a bad drug for us to carry because its absorption rate was so variable. I always defer to doctors on these types of questions that are beyond my education, but I raised the one merit of nitro paste was that it provided the patient nitro continuously while they worked their way through the triage zone — the time between exiting our ambulance door and a doctor’s arrival at the patient’s bedside in the ED.

Our conversation lead to his opinion that it was completely acceptable for us, as long as we had the patient on the monitor and an ability to take their blood pressure, to continue to give the patient sublingual nitro while in the triage line, and if we felt that the patient needed care that urgently, it was our duty to cut the line if necessary to get the patient the care needed.

I have often cut the line, and have often allowed others to cut in front of me, and I have never seen anyone object to this practice which we all agree is in the patient’s best interest. I have, on the other hand, heard of medics being scolded for giving meds in the triage line because we are then on the hospital’s turf and not our own. But I would agree with the doctor, and argue that until the patient is put on a hospital bed and care discussed with a nurse or doctor at the patient’s side, there is nothing wrong with continuing to treat. We don’t take them off oxygen. We don’t turn our drips off. What’s wrong with nitro spray?

I wonder if we had wheeled the kidney stone patient in, and syringe in hand, proceeded to slowly push morphine in through the IV port, while we waited in the line of stretchers, if it would have created a stir?

12 Comments

  • evelgeraghty says:

    Indeed it would have created a stir, and indeed it would have been the right thing to do.In an error that still haunts me to this day, I brought a cardiac patient from my unit to the hospital bed without the monitor connected. (in my limited defense, his pain had resolved, and I assumed–wrongly–that we’d get a bed in moments since I knew the ED was slow that morning.)Naturally, the patient arrested as he got onto the ED stretcher. I grabbed a nearby monitor/defibrillator, did a quick-look and lit him up. He opened his eyes and asked who had kicked him. He survived to discharge, though when I spoke to him a few weeks later he had no memory of the time from the 911 call to waking up in the cath lab. Oh well…I don’t mind that he doesn’t know or remember that I saved his life :-)Interestingly, the hospital staff got annoyed with me not because I didn’t bring him in on a monitor (again, a self-acknowledged remarkably stupid mistake on my part) but because I defibrillated him at all while in the ED…I should have waited for them to do it, apparently. This complaint didn’t stick, thank heaven.In any event, you raise a good point about ETA vs. time-to-treatment. I think this varies by service, by hospital, and by time of day…sometimes a combination of all these and more factors. In the end, you have to make a judgement call as to when your paitnet is going to need treatment vs. when he’s likely to get it, and start screeching if the former comes before the latter.

  • Anonymous says:

    I also had a similar call in which I did not medicate an asymptomatic patient who was having runs of v-tach because we were pulling into the ER parking lot. Had I spent the 10 mins putting together the amio in the parking lot he would have had it on board far faster than the ED.It was about an hour after our arrival, 2 12-leads, another IV, a chest x-ray and 2 blood draws later before the amio was hung.Agree this is an issue and one that needs to be taken on a call by call basis.

  • Brett says:

    I look at it this way.. I practice and respond to calls in the city in which the hospital is located… that makes it my turf too

  • brendan says:

    Sorry, brain fart with that last one, lol. Thought I was at a different blog!In any event, give your meds wherever you need to. Tell anybody hassling you about to take it up with the doctor that gave you the ORDER to push that med.

  • Rogue Medic says:

    Excellent post. I agree with all of the comments. I started to write a comment, but I ended up writing a lot more here.

  • cienna2000 says:

    Definitely something to think about. I know I had never considered these topics before.My thoughts are until you transfer the care of the patient over to the the hospital the patient is yours and you should continue to follow whatever orders/protocols you have. Until they have assumed responsibility for the patient you are responsible. While waiting in line for triage you are responsible for the patient so you need to provide care and that includes adequate pain relief for your suspected kidney stone patient.

  • Ta says:

    You have to go through TRIAGE?wow, clearly we spoil our medics here.

  • TOTWTYTR says:

    I think your post speaks to a larger issue and that is triage. Triage is a choke point at many hospitals we transport to. I’d not want to allege that maybe hospitals slow down that process in order to discourage transports, but I find that do have to think about the possibility. There is no way it should take 20 minutes to triage an ambulance patient. Part of the reason that our system only notifies on critical patients is so that we can bypass triage. Still it’s not unknown for a nurse to want to “retriage” a patient we’ve called in. I don’t know how the other medics in my system handle that, but I just push through and tell the nurse to call the charge nurse or attending if they have a problem. Somehow they never do. EMS systems need to work on hospitals to speed the triage process.

  • Thunderchild145 says:

    Where I work, EMS is the same as hospital triage. Patients that have minor complaints go to triage, but most patients I bring through the doors get a room right away. It can still take some time to get care going though, so I’ll definitely think about administering some last minute interventions before turning the patient over.

  • Tom Reynolds says:

    Interesting, here in the UK we would ‘blue light’ in anyone with cardiac chest pain and they would have at least a nurse (normally a doctor as well) waiting for them in the resus room.The standard here in London is that you bring the patient in, chat to the nurse and 8 times out of 10 the patient goes out to the waiting room to be re-triaged. Only those patient who need a trolley get to stay in the main area, and they get their obs taken again and the nurse checks their story to make sure it’s the same as the one they told us.

  • FireResQGuru says:

    You sure we don’t work for the same provider?!?!?! LOL

  • PC says:

    Thanks for all the comments!PC

Leave a Reply

Your email address will not be published. Required fields are marked *