What is the purpose of the emergency room? Why can it seem like people have to wait unfairly long? What is the triage system? Does the triage nurse consider military rank for order of priority?
JG: Dr. Nydam, let’s begin with the basics. What is the purpose or design of the Emergency Room?
TN: Well, the Emergency Room is designed and set up for emergency care, and that’s the mission of the Emergency Room. You can really break it down into four main goals for the Emergency Room. If you want to break it into A, B, C and D, that’s a good way to look at it – Airway, Breathing, Circulation, and then Disposition. We need to make sure these people that come into the Emergency Room are stabilized in terms of whatever condition they have. If it’s a life-threatening conditions, that’s our priority number one. After that, we need to get them to the appropriate care after that. Let’s say they come in, a family comes in, and they take their child in. The child has a fever. Is that fever life-threatening? Is it not? In most cases, if they come in as a child with a fever who is otherwise healthy, that fever is probably not life-threatening; in certain cases it is. And that’s where we’re trained, to identify that. And if it is life-threatening, we get them the right treatments, we get them to the right location, whether it be in our hospital here or sometimes they get transferred to a hospital in Kansas City with needed treatments that aren’t available here so that they can get better faster. We’re set up so we take care of Active Duty families, Active Duty Soldiers, and Retirees – and that’s something that we both take pride in.
JG: Okay, so let me see if I understood you correctly. You said that there’s four conditions that the Emergency Room is designed to address.
TN: We’ll take care of any condition that you can think of, but the main focus is to identify anything that is life-threatening.
JG: Life-threatening, got it.
TN: If it’s a condition that’s maybe a simple fever, maybe not a simple fever. It could be someone who has a headache. Is it a headache that’s just a migraine headache that they have routinely if someone has migraines, or is it something a little bit different today? And is it going to be something that’s going to be life-threatening to them? Could it be something where maybe that person had an issue with a blood vessel? And that’s something that we want to identify. If it’s chest pain, is it something where this chest pain is something that maybe you were working out too hard, or was it not related to that? Is it something that is maybe a heart attack? Is it something that maybe they have a collapsed lung, or something like that? Is that something that person can go home with? No, and we identify those cases to the best of our abilities and that’s what we’re trained to do. That’s our specialty. From a physician perspective and a nursing perspective.
JG: Okay, I’m a layman and from a layman’s perspective, the way I see this is the Emergency Room is designed to save people’s lives because their life is in danger in some form. Or they could also be, in say, just severe pain. Maybe their life is not being threatened because of the situation, but they’re just in severe pain then they can come to the Emergency Room. Perhaps there is a threat to loss of limb, eyesight, and I know there’s a third one that I’m missing here.
JG: Loss of life, limb, or eyesight, right?
TN: We use that frequently in a deployed setting if we’re deployed to Iraq or Afghanistan. We break it into life, limb, or eyesight. And someone that is suffering from severe pain, they can’t tolerate that for long, and we want to make sure that their pain is taken care of as well. That’s important for us to do. Life, limb, or eyesight, that’s a good way to look at it.
JG: You mentioned two conditions or symptoms – you said a fever or a headache – that is often a symptom for other things that may be chronic, not true emergencies. Can you describe a couple of situations or conditions that express themselves or render themselves as headaches or fevers that are not true emergencies?
TN: Either a headache or a fever. One example for a headache could be someone that has a recurrence of a known migraine like I was talking about, or if it’s just someone who has a tension headache. We’re hoping to see that. We don’t want to see someone that has some sort of life-threatening headache. We’re trained to identify that, and we hope to find something that is easily treatable.
JG: Melanie, can you explain some of the patients that come with a fever, specifically I know that a lot of new moms are new to having a baby and they don’t understand that perhaps their child may be suffering from a very common fever or should I say body temperature. That is not necessarily a fever, but to them they think of it as perhaps maybe life-threatening. Can you describe a couple of situations like that?
MS: Absolutely. For us, a fever is not necessarily life-threatening. It will not be the fever that is the life-threatening event on a child. A fever means that the body is reacting to something, whether it’s a virus or bacterial, and high fevers are not life-threatening as long as they are not sustained for days at a time. There’s a difference between fevers that are responsive to medication, and that come and go with medicine and then they leave with medicine. Fevers that we’re concerned about are fevers that are in small babies that are two months or less that’s greater than 100.4. For little people like that, those are fevers that are very warrant for concern, so we are more apt to see those very quickly and bring them back because these are very tiny people and they can’t fight fevers and infections like older children do. We take lots of things into consideration when we look at fevers – we look at how the child is eating and drinking, if they’re playful and happy, if they are consolable, if they’re fussy, those are kind of things that we take into consideration when we triage them regarding a fever. Fevers are always scary to people; but, fevers have a purpose, and like Dr. Nydam has said, we know the conditions that warrant life-threatening that would want us to address a fever.
JG: Let’s clarify one thing aside from the babies that are two months or younger, what constitutes a fever?
MS: Anything above, for us, is a baby is 100.4. Anybody else, Dr. Nydam would say…
TN: If they’re over 90 days old, then it’s a different category as far as the level of temperature we consider a fever.
JG: Let’s say a six-month old baby. What would be a –
TN: If they’re six months old, then we consider a fever to be 102.2.
JG: What if they are four or three years old?
TN: It’d be the same thing.
JG: Okay, so, what about anywhere from an eight year old, nine year old child? What’s the temperature at that point that’s considered to be a fever?
TN: There’s one category in terms of kids with age groups that we look at for fever being 102.2, and that is anywhere from 3 months to 36 months of age. Once you’re above that and you’re an adult, 100.4 is what we would say you are starting to have a fever response.
JG: Let’s transition to a headache. At what point does a headache become an emergency?
TN: That’s a really tough question, and even after you’ve been in the field for years and you’ve been training for years, you can’t always just paint the same picture in terms of what is a headache that needs worried about or what’s a headache that you don’t need to worry about. But, by large, if it’s a headache that they are worried about, that’s what we’re open for. We’re open for them 24/7. If you have a headache that “I just haven’t had a headache like this before” or “I’m just worried about this headache,” “I have symptoms that I’m concerned about,” that’s what we’re open for. Okay, if they have a fever associated with that headache, that can be a concerning sign. If they have neck stiffness associated with that headache, that can be a concerning sign. Lots of vomiting, if they have sudden onset like it’s a bolt of lightning when it came on; those are all things that we look into. We look at other things, but, if I was to go into all of those things, we wouldn’t have time.
JG: Sure. Now here’s a situation that I conceive of: let’s say a patient has a headache, a throbbing headache, and comes to the Emergency Room. It turns out that his situation is not life-threatening, but he’s going to be inconvenienced with a headache. What do you do with him at that point? Do you still go through the normal as if it were another primary care appointment, or do you set him up with an appointment to be followed up by his primary care physician? What’s the protocol?
TN: I would ensure to diagnose exactly what it is, and hopefully for their case, for their sake, it’s not a worrisome headache. It’s something that’s going to come and go, hopefully as fast as it came. The next priority, and at the same time we’re trying to do this, we’re trying to get them comfortable. If they’re having a lot of pain from the headache, we’re going to treat that pain – so we’re going to get them feeling better. And once they’re feeling better, they’re feeling good enough to go home, if they feel good enough to go home, we’ll help them and say you can follow up in this time frame or we would help get them appointments. If it’s too bad and we can’t control it, or if it’s some kind of headache where it’s not safe to go home with, we’ll have them come to the hospital.
JG: Let’s talk about the triage system. When we have a new patient arrive, what will happen? Tell me about the triage protocol and what happens.
MS: When someone comes in through the Emergency Room doors, we have a triage process. They check in with our front desk, then they are what we call triage which we basically gather a history of what’s going on with their illness, we do a set of vital signs and we observe this patient. At that point, the trained triage nurse makes the decision on whether the patient needs to be seen on the main emergency room side, which could mean that they are emergent or need a bigger work up or are going to use more resources like labs and x-rays and time – those can be bumped to the Emergency Room. The other ones that we deem are non-emergent or don’t need a big work up will go to the Urgent Care Clinic that opens at 1100, or we are deemed to make them appointments with their primary care to get them back to their primary care, not as punishment but for continuity of care with their providers. And so they have several options during the day time to come, they all get triaged, everybody that walks through our doors gets triaged by a trained nurse in order to make that decision. And after that, then the decision can be made to go to an appointment, to wait for UCC, we send Soldiers back to their Med Homes also to be seen by their providers, or they are seen in the Emergency Room. After you are triaged, life-threatening 100% life-threatening will be brought back immediately, quickly. They don’t necessarily even get through the triage process, they come back when it is deemed life-threatening. When we deem it is life-threatening. Others that go to the Emergency Room may wait two to two and a half hours to be seen back in the Emergency Department, not knowing that they’re not emergent and we know that they’re uncomfortable and there for a reason, but they’re not life-threatening, that there are sicker people in front of them. What people need to remember when they come through the doors is once they’re triaged, the triage process, the sickest get seen first in the main emergency room. The sickest get seen first. In the Urgent Care, it is first come first served – they open at 1100 and stay open until about 2230 at night. And they are first come, first served – so those are one or two at a time, so you may wait a while to be seen in the Urgent Care because it doesn’t matter if you’re a little person or a big person or a Soldier or anybody, those all go first come first served. But in the main Emergency Room, the sickest get seen first. And that’s why it’s called an Emergency Room, because we bring the most sickest people back in a quick amount of time.
JG: It often appears to some of our patients think as if they are unfairly having to wait long periods of time and they see others in the same waiting room, and they’re looking at them and they’re assuming that they don’t appear as sick or as in such pain as they themselves. Why is that? I know that we can’t speak on behalf of our patients, but what’s happening? Why does it appear as if people are having to wait long periods of time?
MS: I think what people don’t see from the behind-the-scenes is they don’t know what’s happening in the main Emergency Room; and they assume if there’s no one in the waiting room, that there’s nothing happening. Or they assume they heard someone come in and their ankle hurt, but that person got seen ahead of somebody else. It’s not for their job when they all sit in a small proximity, everybody hears what everybody’s complaints are and make judgements on those. And at any point somebody feels like something has gone amiss, we ask the public to please come and talk to the charge nurse or ask for one of us in charge to explain what’s going on. We’re working on communication of that, so when you leave my triage room, you should know whether you’re going to go to the Urgent Care, whether I plan to find an appointment for you, or whether you’re going to go to the Emergency Room – side of the deal. That way the communication is better and you’re not wondering why some people are going ahead of you and why they’re not.
JG: Anything you want to add to that?
TN: Yes. In certain situations, it may be the Urgent Care side of the emergency room, where they come in and are triaged by one of the Emergency Room nurses, they could be seen in the Urgent Care. In certain parts of the day, the afternoon, whatever it may be, maybe the Urgent Care is flowing faster for a better period of time – as opposed to the ER. Maybe someone’s having CPR done, maybe there’s multiple patients that require a lot of attention. And so things can slow down on this side of the emergency department, as opposed to the urgent care as to what you may see in that situation is someone could come in, didn’t have to wait very long, and they could go in the urgent care possibly if that was allowable. In terms of how fast they’re getting through, they might get seen before someone who’s getting seen in the Emergency Room. We try to avoid doing that, especially if they are someone who needs to be seen right away; or if they’re, let’s say what you were talking about like with the headache or the fever, something less life-threatening, we’d want to get them in right away.
JG: Let’s clarify the rumor out there, or the perception out there. Are some people seen sooner because of their military rank? Or because of the fact that they are a Soldier versus not a Soldier?
TN: I think that’s a good question. I’d be happy to answer it; but I don’t sit in the triage room – I sit in the back in the Emergency Room. Just from my perspective, I would say no.
MS: From the nursing perspective, a lot of our nurses sometimes don’t even know military ranks, they see patients. We see them as individuals. A lot of us are civilians, so we see them just as the patients that they are. So when you come to the Emergency Room, once again, the sickest will be seen and triaged first. And it doesn’t matter what your rank is. You can be higher ranking, and come for an ear ache; and I have a Private that is coming in and they are short of breath and wheezing and they’re oxygen level is low, and that Private is going to be seen. The sickest come first. So we do have patients that feel like their rank should be used in order to expedite their care; but, once again, we expedite their care based off their chief complaint of why they’re there, their vital signs, the whole picture is painted. And it has, and should have, nothing to do with rank at that point.
TN: If you have a situation where someone comes in that has a high rank and has an illness that is not life-threatening versus someone that comes in with a rank that is not high ranking and has an illness that needs to be seen right away or is going to be a threat to their life, limb, or eyesight, if we say “okay, we have someone here who is high in rank, let’s get them back right away,” when that person has a real life, limb or eyesight illness is sitting back in the triage room, we don’t want that to happen. That’s what we want to avoid.
JG: So when somebody walks in through the doors of the Emergency Room department, they are a patient, period.
JG: And the only thing that you as a triage nurse are concerned is their level of sickness or their level of pain or their level of threat to life, limb or eyesight. And then based upon that, they’ll be seen by either the Emergency Room, or they’ll be referred to the Urgent Care Clinic. If they go to the Urgent Care Clinic at that point, it’s a first come first served. Right?
MS: Yes, sir.
JG: So still rank has no play, no factor in the order or sequence of patients being seen. Essentially, when they come into the Emergency department, they are stripped of their rank and they are stripped of their uniform, figuratively speaking.
MS: Figuratively speaking, yes. They are all patients that need to be triaged and addressed. And we also know when everybody walks through our doors, nobody feels good or they would not come to the emergency room. So it’s up to us to discern how concerning their complaints are when they come in, and how badly they feel based on their emergent condition.
JG: Okay, so let me ask this question about the Urgent Care Clinic, especially for those patients who may have called the Nurse Advice Line, and the nurse on the other end of the line said to go ahead and check in to the urgent care clinic. What is the situation when they come to the triage nurse, will they immediately be able to step into the UCC?
MS: Every patient that has called from the Nurse Advice Line that is told to go to the urgent care, they are still triaged exactly the same as anybody else due to the location of the urgent care. So everybody gets triaged appropriately, then they may or may not go to the urgent care. It’s hard for the Nurse Advice Line to be able to diagnose over the phone, so there are times when they come in and they end up being seen on the emergency room side because they are sicker than what we would feel for the urgent care. And they may also go to the Urgent Care; but they can’t just walk in to the urgent care, they still have to triaged and then, once again, it’s first come first served in the urgent care. So they may not just get to walk in or schedule an appointment for the Urgent Care, that’s not possible. So they will wait for the Urgent Care.
TN: And they get triaged not by an urgent care nurse. The only type of nurse they would get triaged by before they got to go to the urgent care is an emergency room nurse. And the reason for that is it goes back to what’s the life, limb or eyesight threatening process? Is it something that is safe for them to go to Urgent Care, or is it something that has to go to the Emergency Room? So we have to have someone who’s trained to identify those, whatever in terms of life, limb or eyesight, injury it may be – we have to have someone who’s going to identify that before they would go to the urgent care. We don’t want something going to the urgent care where they’re not getting the treatment they would need or the diagnostic testing done they would need. So they’d have to first go to the Emergency Room first if they needed to; and if they didn’t have to, then they can safely go to the Urgent Care.
JG: Let’s talk about the Emergency Room here at IACH versus going to an emergency room off post. Is the quality of care that they’re going to receive here any less than what they would receive off post or any other hospital?
TN: No it’s not. And, in fact, the physicians, the PAs that we have here, the nurses have gone to all the same schooling – the same medical schools, the doctors in the Army have gone to world class training programs for Emergency Medicine, they are trained in Emergency Medicine residencies, specifically; and they’re board certified in Emergency Medicine. This is their specialty. They spend their whole life doing it. They perform at the top of the heap in terms of academics; when they go through the training programs they have performed at the top in terms of the amounts of procedures they do, the level of acuity they see. So these are doctors that are in the now and they’re really at the tip of the spear in terms of what this field is. And some physicians across the country don’t do training in emergency medicine, and that’s really common. We make sure we have Emergency Medicine doctors that are fully capable and trained in the field.
JG: Melanie, how long have you been a nurse in emergency medicine?
MS: I have been in nursing 32 years, and of those 32 years, over 25 of them have been emergency room nursing.
JG: And how long here at IACH?
MS: This is my tenth year here at IACH.
JG: What’s it like for you serving Army families?
MS: It’s the best job I’ve ever had. I love serving Army families, and I always tell people in the civilian world, I don’t get much back from the patients I take care of, but in the military world I do because their families are willing to sacrifice their lives, their home lives, their actual physical life so that I can live in a free country. So to me, taking care of Soldiers and their families gives back to me every single day.
JG: Dr. Nydam, give us a little bit of background. What brought you to become a doctor and then an Emergency Medicine doctor?
TN: Well in terms of background, I grew up in the Midwest; and I didn’t know right away when I was in grade school, high school that I was going to be a doctor. It was a slow process, and for everyone it should be a slow process. But at one point, somewhere along the way, I knew that this was what I wanted to do. And I also wanted to go into either the Army, Navy, whatever it may be. I would really second what Melanie was saying, you get to take care of the sons and daughters of America. The families that have raised the Soldiers, their dependents, and also the Retirees. For generation after generation. And this is something that we have chosen to do. I could be practicing, either one of us, if we wanted to practice at any hospital in the country we could. But we choose to be here, because we value what we do, and we like taking care of the people who come here for what they do. We value what they do. When I’ve been deployed to Afghanistan – I was deployed to Afghanistan in 2010, years before coming here; and I wouldn’t say it was a privilege going there, but I was very humbled to see that there were 18 year olds, 20 year olds, all the way up to whatever age, whatever rank. Rank aside, ages aside, backgrounds aside, I was taking care of troops that were putting their life on the line for me. And I had seen on multiple occasions where our perimeter was being stormed, and I was being kept safe, the staff I was working with was being kept safe by these young men and women wearing the uniform. And I can’t really say that there’s a much better job than that that I can really perceive.
JG: Taking care of some of the best patients in the world, I suppose, right?
JG: Well I thank you both for taking the time to give us a better understanding of the Emergency Room. And for you listeners out there, our Ft. Riley Army Families, I hope you have found this program useful. Kindly consider leaving us feedback on our Facebook page, or let me know what you would like to hear. What are the topics important to you? Check us out on facebook.com/irwinarmycommunityhospital