Surviving the Emergency Room, Part 2: What To Expect When You Arrive

cartoon of triage nurse

The gatekeeper

Welcome to the next installment of “Surviving the Emergency Room,” a user’s guide to what can be an intimidating and sometimes frightening experience. In Part 1 of this series, we talked about the best times to go to the emergency room, assuming your problem is such that you actually have the luxury to choose. In this part, we’ll cover what to expect once you’re there.

When you first arrive in the ER you will be greeted by someone sitting behind a window made of something transparent and bulletproof. That person will be either an admitting clerk, or, possibly, a triage nurse. You will be asked to give your name and the reason you’ve come. This latter bit of information will determine what happens next.

“Triage” (FR. trier, to sort) is a word for the process of sorting through battlefield casualties to identify those who will benefit from immediate treatment, those who can wait, those who can do without treatment, and those for whom there is no treatment and who are “goners”, (ENG. slang, one who is doomed). Once you’ve given your name and stated your problem you will be triaged.

This function is usually performed by a nurse with sufficient training and experience to be able to tell the difference between someone with a minor problem, who can wait if necessary, and someone at risk of dropping dead if not taken to the treatment area immediately. The triage nurse’s opinion regarding the severity of your ailment could well be at odds with your own. In the vast majority of cases the nurse is correct.

Your vital signs (heart rate, respiratory rate, blood pressure, and, more recently, your degree of pain) will be measured and recorded. You will be asked to provide details about your problem. How long have you had it? Have you had it before? And, if your answers are “for a while” and “yes”, you might be asked “why now?” No one is trying to be snide here. Why you’ve chosen this moment to seek attention for a problem you’ve had “for a while” is useful information.

If the triage nurse has by this time determined you are not at risk of dropping dead any time soon she (it could easily be “he” but for our purposes we will use “she” when referring to the nurse) will ask additional questions about your past medical history, what medicines you are taking (more about this later), and whether or not you have any allergies. Based on this information you will be assigned a “severity scale” and placed in the queue waiting to see the doctor—the higher the degree of severity, the closer to the front of the line.

Certain complaints will allow you to bypass the queue altogether. Chest pain, difficulty breathing, and massive bleeding will get you into the ER immediately. Grossly abnormal vital signs will also do the trick. If your “severity score” is low but the department isn’t busy, (see Pick Your Spots in Part 1 of this series), you will be taken right back. If, however, the place is a madhouse and you’re there with a sore back after a minor traffic accident you can count on spending some time in the waiting room.

The waiting room of an urban ER can be a fascinating place, anthropologically speaking. People of all ages, walks of life, and cultural backgrounds, anxious and in various forms of misery, in one room, with a TV turned to the one station the fewest people there have any interest in watching with no remote anywhere to be found, surrounded by old magazines and “helpful” pamphlets describing what they or their loved ones are about to undergo. And a vending machine. For hours.

Fortunately, many hospital administrators and ER medical directors have learned that keeping patients diverted and the process moving is good for “patient satisfaction” and good for business. Patients who leave without being seen are lost revenue and bad press. They will tell everyone they know how inefficient the ER is, how uncaring the staff. That their wait may have been affected by the steady stream of seriously ill people coming through the back door courtesy of the paramedics makes no difference.

So the triage nurse has also become the waiting room ringmaster. She lets the doctor know who’s there and what their problems are. Evaluations can then be started while the patient waits. Blood is drawn, urine samples collected, x-rays and ultrasound exams ordered. Patients are ferried back and forth from lab to radiology and the wait seems less. Then, by the time they finally do get back into the ER, everything the doctor needs, theoretically, is done.

Next Time

Next time, what happens now that you’ve made it through to the inner sanctum of the ER itself.

Dr. Jim Pagano, MD, FACEP, is the chief medical officer of Precision Scribes and has over thirty years of emergency medicine experience. He’s seen everything an emergency physician can see, and more than a few things they should not.