Triage Decision With Limited Resources
You are the triage nurse in a small district hospital emergency department with two treatment bays and one physician on duty. Four patients arrive within 10 minutes:
- Patient A: 34-year-old man, deep laceration to the forearm from a fall, bleeding controlled with direct pressure, alert, HR 92, BP 124/78.
- Patient B: 62-year-old woman, crushing central chest pain radiating to the left arm, diaphoretic, HR 104, BP 148/92, SpO2 95% on room air.
- Patient C: 7-year-old child, barking cough, audible stridor at rest, sitting forward, drooling, RR 38, SpO2 91%.
- Patient D: 45-year-old woman, ankle injury, able to weight-bear with pain, no deformity, requesting pain relief.
Only two bays are open. The physician is currently suturing a minor wound in one bay.
1. Assign a triage priority to each patient and justify the order.
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Priority order:
- Patient C (child with stridor at rest, drooling, SpO2 91%) - This is the most time-critical. Audible stridor at rest with drooling and tripod positioning suggests impending airway obstruction. Airway always outranks everything else. Do not examine the throat or force the child to lie down; keep the child calm and upright with a caregiver, give oxygen as tolerated, and get the physician immediately.
- Patient B (crushing chest pain, diaphoresis) - Possible acute coronary syndrome. Time is myocardium; needs ECG and aspirin within minutes, but is currently hemodynamically stable enough to wait seconds behind the airway.
- Patient A (controlled hemorrhage) - Bleeding is controlled and vitals are stable. Needs suturing but is not deteriorating; can wait while B and C are stabilized.
- Patient D (ankle injury, weight-bearing) - Lowest acuity; can wait longest. Provide analgesia and ice per protocol while waiting.
Rationale: Triage is not first-come-first-served. It is airway → breathing → circulation → disability, with time-sensitivity of the underlying condition layered on top.
2. Patient B's ECG shows ST elevation. The only monitored bed is occupied by the patient the physician is suturing. What do you do?
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Actions:
- Escalate to the physician immediately with the ECG finding - this changes the acuity of the whole department. The physician must decide whether to stop the suturing.
- Move Patient B to the most monitored space available; if the only monitor is in the occupied bay, place B there and coordinate with the physician to finish or hand off the minor procedure.
- Activate the reperfusion pathway per local protocol (fibrinolysis if PCI is not reachable within the timeframe, or arrange transfer). Time from door to reperfusion is the outcome driver.
- Give aspirin (chewed) and oxygen if hypoxic, per orders; continuous cardiac monitoring; IV access; repeat vitals.
- Communicate with the waiting patients - explain the delay honestly and reassess them; a stable patient who deteriorates while waiting is a system failure, not a patient failure.
The judgement tested: resource scarcity does not change clinical priority. You reallocate the resource, you do not downgrade the patient.