November 16, 2005, 12:11 am

Triage Tirades

I’m always happy to give advice on “heat- energy units”! Especially when I am standing in what appears to be a restaurant. In full uniform. Including cap and cape.

Aren’t “heat-energy units” now called “calories”?
So, according to Cherry Ames, Restaurant Advice Nurse, the more you feed your kid in the winter the warmer he stays. If that were true for adults I could run around in a thong in a snow drift….

Oh, but look! This Wheaties breakfast is sponsored by none other than Beulah France, RN! Of New York! You remember her! She went from inspecting toilet paper to sponsoring breakfast cereal! I hope she washed her hands…

Since when did nurses get endorsement deals?

Unfortunately I don’t think this is the last we will see of Nurse Beulah.


A few years ago, it became a JACHO requirement to document how ERs were addressing cultural diversity. In the ER I was working at the time, the question, asked during triage, went something like this: Are there any cultural or religious beliefs that would affect your care today?

The usual response: a blank stare. Followed by, “What?” or “Huh?” or “I… don’t… think… so”. Apparently the general public did not find the concept of cultural diversity in health care as important as JACHO did. I’ve been asking that question for about three years now and in all that time I’ve had only three requests:

  1. A Jehovah’s Witness (no blood products)
  2. A Muslim (who was observing Ramadan and while able to take medications if needed, would prefer a medicine that could be taken once a day)
  3. A woman from Iran who would prefer a female doctor if possible.

Three positives out of literally thousands of triages, all of which would have been addressed during the course of the visit. No, instead we add it to the increasing number of questions/assessments required at triage. Oh, and don’t forget to chart “negative” on this one. If you leave the section blank, they think you have not addressed it.

Oh, and don’t even get me started: the gospel according to JACHO says that we have to measure the circumference of the head of anyone under the age of one. And then chart whether it is normal or not. What are we going to do about it in the ER? Acute head expansion in Bed 8A? Never mind that pediatric triages take forever! Oh, just work it into the triage, they say. Uh….. after we’ve worked to develop a rapport with the child, the trust of the parents, a full set of vitals including rectal temp done while listening to screaming that makes Dolby Surround Sound seem like an old RCA grammaphone, and obtain an entire medical and immunization history while the patient proves that a pissed-off infant has the vocal strength of thousands. Now we’re going to wield the tape measure. I worked in an ER where this was an actually watched in Quality Assurance. You could write up a triage worthy of Kipling himself and they would still find that damn little empty box-with-no-number. The hospital I work in now got around it in a rather interesting fashion. The nurses refused to do it! And somehow we still passed JACHO. Amazing.

Then there was the ER that required, for any patient coming in with a complaint of shortness of breath or cough for any reason, including infants, a ten-item questionaire to test for TB. Questions like:

  1. Have you had a fever in the last 48 hours?
  2. Were you born in this country?
  3. Have you been in a homeless, in a shelter or incarcerated in the past year?
  4. Have you had a cough?
  5. Have you had night sweats?
  6. Is your cough productive?
  7. Do you smoke?

You get the picture. Imagine having to ask these of a two-week-old. Obvious MI? If the words “short-of-breath” came out of the patient’s mouth, you had to do the screen. Croup so loud you could hear it three floors up? You had to do the screen. Status asthmaticus? Yep, the screen. Six week old with RSV? Screen ’em. Now there was nothing wrong with the screen itself except that it was a pain in the derriere when added to the triage. Most of the time, a waste of time.

And the icing on the cake? There was a separate sheet with SARS questions on it.

I bet Beulah France, RN from New York had something to do with it.


  • kenju

    November 16, 2005 at 6:42 am

    Hey, Kim, I’ll be in that thong surrounded by snow too!

  • Bardiac

    November 16, 2005 at 8:40 am

    I saw a student walking to class in shorts and sandals today… in the first real snowstorm of the year. Maybe he had the right idea?

    (I’m STILL not wearing a thong!)

    ps. Your link to DrBarbados is missing the f in butterfly, and so doesn’t work. (I like to follow links around and thought you might like to know.)

  • Kim

    November 16, 2005 at 10:17 am

    Kenju: we can start a new business, winter thongs!

    Bardiac: oh my goodness, I thought it was just Firefox being tempermental and THAT was why I always had to retype Barbados’ address in a new window. Now I find out it’s me – never missed tht misspelling in a million years! Thanks, I’m fixing it now!

  • Catherine

    November 16, 2005 at 7:19 pm

    Kim — You should never have mentioned “winter thongs” . . . unfortunately, you set off my hair-trigger brainstorming function: fuzzy thongs; faux fur leopard skin thongs; thongs with matching ear muffs; thongs that come with a battery pack to keep the family jewels warm and toasty; one-thong-fits-all (yeah, right); thongs that twinkle like Christmas trees . . . see, it just spews out. I can’t stop it . . . like a bad song, I’ll be thinking of variations all night.

  • Heather

    November 16, 2005 at 7:39 pm

    Don’t even get me started today. Let’s just say I feel your pain!

  • Anonymous

    November 16, 2005 at 10:48 pm

    Huh? We don’t do any of that diversity or head measuring crap here.

  • Kim

    November 17, 2005 at 12:24 am

    Anon: don’t forget, I’m near San Francisco, the United Nations in miniature….

  • angry doc

    November 17, 2005 at 4:55 am

    This post has been removed by the author.

  • angry doc

    November 17, 2005 at 4:56 am

    Incredibly, the health declararion form used during the SARS period at healthcare establishments in Singapore had the question:

    Did you come from a country where there are known cases of SARS?

  • Anonymous

    November 17, 2005 at 6:20 am

    MMMmmmmm…I hear the triage angst. We’re trialing a a VOLUNTARY, non-enforced patient masking for all those with “new cough & new fever”. Starts at triage…funny thing…compliance is LOW!! (Ooooh, and the kicker…we only have oral thermometers to use with the masks………) Now if only I could a peak flow meter, the study information sheet parents re-presenting their children, the pager for the temporary service plastics chief….

    Jr ER-RN

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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