22 February 2011

Triage (originally posted 24 January 2011 on Tumblr)

Last week I caught a segment on NPR while I was driving that I’ve continued to think about in the days since.  In the wake of the shootings in Arizona, there was a flurry of news coverage.  The program I heard that day moved past the mere reporting of the facts and asked the question:  How do medical personnel respond to a disaster of that magnitude?  With multiple casualties, how do they triage their resources and efforts?

This is a question that is asked often in medicine, and not just on so grand or terrible a scale.  I triage every day I work, both in the Emergency Room and up on the floor.  I divide the tasks that must be performed immediately and those that can wait.  I learn when to ask for help.  My husband, in the law firm he works for, does this as well (except, perhaps, asking for help).  We all do.  For him it is more about paperwork and less about stitching up cuts or giving IV fluids but the principle is the same.

The part of the program I remember best went as follows.  I couldn’t find a transcript of the story online, so you’ll have to forgive me any errors, but nevertheless here’s the gist.

An EMT called in to tell a story about a time he responded to the scene after a bomb explosion.  A man driving a car had been pulled over by two policemen.  They asked him about a suspicious package they then noticed in his backseat.  The man claimed to have no knowledge of the package, which only increased their concern. Upon examining the package it exploded.  The two policemen and the man driving the car were each injured.  What the first responder who called in wanted to discuss was how hard it was for him to treat the driver of the car, to fight to save his life when the lives of the men he had injured were still in danger.  He did treat the man.  He followed the same rules of triage we all must and he gave care without judgment.  But it was difficult. 

Months later, the EMT learned that the bomb had been placed in the man’s car in order to injure him.  He was the target of a violent attack and not the perpetrator of it.

I am not generally called on to care for patients upon whom it might be tempting to heap blame or pass summary judgment.  That is one of the beauties of pediatrics. Not only do we get to take care of adorable babies, but we don’t have to have the hard conversations that internists do.  We don’t have to tell the man who has had three heart attacks and still eats steak for dinner each night that he is slowly killing himself.  We don’t have to threaten the diabetic who refuses to take insulin that her feet will fall off. 

Still there is a segment of our patient population that does make incredibly bad decisions on a regular basis, just because they were designed that way. Teenagers drink sometimes.  They do drugs.  They come into the Emergency Department to get anti-nausea medication and fluids after doing too many shots of tequila.  They have sex without condoms and they pass around STDs.

So I was not particularly inclined to be sympathetic to the fifteen year old who came to me after having gotten drunk at a party and having sex with a number of different partners.  She wanted STD prophylaxis.  She asked for the morning after pill.  I would of course provide these to her as it was the standard of care.  It was my job.  But I was also gearing myself up to give her a talking to, to judge her for her actions and demand that she change.  Then I noticed that her heart rate was just slightly higher than it should have been.  I stopped.  I looked at her more closely.  Her hands trembled slightly when I asked her to reach out for my pen. 

“Are you anxious?” I asked her and she said yes. 

“Are you often anxious?”

She nodded again.

“Does drinking make you feel better.”

She said that it did.

“I’m going to do a blood test,” I told her.  “Then we’ll get you the other medicines that you need.”

As I left the room she began to talk to the wall, as if there was someone there. An hour later she was admitted to the hospital to be treated for hyperthyroidism, an excess of hormone that was causing the fast heart beat, the feelings of nervousness, the psychiatric disturbances, and the bad behavior that I so nearly chalked up to being a teenager.  Nothing more. 

There were many other patients waiting for me on the night I met this girl.  There are always other patients waiting.  And had I failed to make this diagnosis, I think my colleagues would have agreed that I had done nothing wrong.  The signs were subtle.  Her presenting complaint of bad behavior is rarely the result of a serious medical condition.  Nevertheless she had one.  And had I not been paying attention, had I already made up my mind about her when I walked into her room, I would have missed it.  I would, in making such a snap judgment and failing to gather all the facts, have hurt someone where I might have helped them.  Which is wrong.  No matter how you look at it.

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