Behavioral Ecology Blog

As many of you know, my 1st career was in nursing- specifically, I am an ER nurse by training/interest. I have over 7 years experience there, so I feel qualified to make statements like to one’s I’ll make below.. I was led to this truly shockingly believable story by John Wilkins, over at his blog Evolving Thoughts. In a post there, he describes a story (Fulltext here)where in a Los Angeles area ED, a woman was left laying on the ground, writhing in pain for literally hours. This woman, only a short time later, was dead- never having received the attentions she needed and deserved.

Terrible yes, but John jumps the gun and suggests:

Was it because she was obese? Or Hispanic? Or because the US health system, and in particular this hospital, is so stretched that triage is by rapid prejudice rather than medical criteria?

So 1st off, there are racist/sexist/fat-people-haters all over the place- some of them are even nurses. But regardless of this- seems as if the racist/sexist/fat-people-hater triage nurse would have found this lady a room in the back ASAP- not because she cared, but because sending her back to a room means the patient was no longer in triage- bothering the triage nurse… It seems hard to believe that this is a hate based problem. Even if the the triage nurse was a hater- other people are around- other nurses, nursing assistants, MD’s, etc.. They are surely not all racists…

Now in a statement released by the hospital, they say:

“…the preliminary investigation suggests that the fault primarily rests with the nurse who resigned. “I think it’s a tragic, tragic incident, but it’s not a systemic one.”

Now this is a load of crap. Let me explain briefly how the average ED works..

1. People come into triage, and are evaluated by a triage team that consists of nurses, receptionists, and nursing assistants.
2. People are classified on some priority scale from high to low. High priority patients are this who have cardiovascular or neurological complaints, or this in severe pain. Low priority patients are this with chronic complaints, sore throats, fevers, etc.. These are internationally accepted standards- they do not vary greatly between hospitals.. Go to any ED with severe pain, and you’ll likely see a doctor quickly.
3. High priority patients go to see a doctor ASAP- wait usually minutes.
4. To place patients, the triage nurse usually communicates with the charge nurse, who assigns the actual room.
5. Lower priority patients wait in the waiting room and are reassessed at least every 1 hour until a room becomes available.

Now in this case, the triage nurse is clearly at least partially responsible for this persons death- but so is the charge nurse, and the attending doctor. The charge nurse is supposed to be on top of things in the ED, and triage is one of the main places where potential problems can exist. As the charge nurse- you go to triage, look around, see the waiting room, etc. A competent charge nurse would have seen this patient.. Next, the attending MD is legally responsible for everybody registered as a patient- whether in triage or in a room. Attending doctors should (and often do) visit triage and the waiting room at least a few times during the shift..

One of two scenarios likely happened here.. 1st- the triage nurse knew the patient was just seen and discharged, and didn’t believe her pain… It’s pretty common for people to keep coming back- usually in search of narcotics.. You get to know these people, and these types of patients. But even though you “know” what these patients are here for- people who come in with severe pain are triaged as high priority.. It’s the whole “crying wolf” thing, but you are trained to never dismiss the patient in pain.. For this patient, the dead one, this time there really was a wolf…

Second- it is possible that the triage nurse did everything correct- identified the patient as high priority, and called the charge nurse for a bed. The person in charge might have discredited the triage assessment, and asked that the patient be held in triage.. This is also possible- and happens all the time.

Point is, it’s not likely a hate issue that killed this lady, nor is it likely the singular fault of the triage nurse. This is a systems issue.. In a well operating department/hospital this never happens. To really fix this, one needs to look at the flow of patients in this ED, and all the people involved. Everybody with roles in this process is to blame, and as such, it qualifies as a problem of the system..