This past week I had an incident in which the concept of triage became very real to me. Let me first set the scenario. A lot of the nurses had called out sick, there was a bug going around. So there were only 7 RNs on staff that day, including myself, an orientee on my first week, working with my preceptor. We were also short on Physicians, and had only one attending and a couple of PAs at work. We were waiting on staffing to send us help, and we had placed our ED on a temporary divert/bypass, which meant that we had asked the EMTs not to bring us any more patients unless it was an airway emergency or a cardiac emergency. In my assigned area were two patients.

Patient 1 was a young female in her 20s, who was in very apparent distress due to pain. A CT scan had just revealed that she had a kidney stone of significant size, and from the way she was writhing in pain, it was clear to me that the stone was migrating, hence the pain. The ED physicians were completely tied up at the other end of the hallway with several emergencies that had rolled in all at the same time - two MIs, a patient in respiratory distress, and a code, and so had not reviewed this patient's CT scan results. I had started an IV and she had a bolus of normal saline going in, and was waiting for the doctor to order something for pain.

Patient 2 rolled in a few minutes after we had discovered patient 1 had a stone. This was a gentleman in his 70's who was presenting with all the classic symptoms of a CVA. We begun to get him settled in, changing him into a gown, obtaining a history from the family, performing an assessment, preparing him for a CT scan, drawing labs, and such. Because of the immediate interventions needed in the case of a stroke, we had to move fast, and the process was involving and lengthy.

In the meantime, my patient with the kidney stone was screaming bloody murder, and her understandably agitated husband was yelling from her door for us to do something for her pain, but we were all split between the stroke, the two MIs, the code, and the respiratory distress patient who eventually had to be intubated.

I finally turned and asked my preceptor - "what do we do about the patient in bed X with the stone? She's really screaming in there." And very calmly, my preceptor said to me, "At this moment, we do nothing. We have explained to her that she has a stone and it has to pass, and we have told her that we have several emergencies going on and the doctor will order something for pain as soon as she can." Then after a few minutes, as we were drawing labs, she told me "This is where your prioritization skills will be tested. A patient like this who has come in with a stroke is a higher priority than a patient in pain. There's not much we can do with the kidney stone, except wait for it to pass, but a stroke can be permanently debilitiating, and we may have a chance to intervene and change something, but we have a very small window to do it in, so we ignore the screaming for now."

That made a huge impression on me, because she was absolutely right. I remember how many times I hear people complain about waiting for hours in the ER to be seen, and since they don't really know what's happening behind the scenes, I can't really blame them for thinking that ER staff are unfeeling and uncaring. But it's all about triage, it's about ABCs. And to be an effective ER nurse, I will need to learn and master the concept of triage so that I can discern between what is emergent, and what is urgent.