Five Arrivals, One Resuscitation Bay
At 22:10, a 28-bed emergency department has 19 admitted patients boarding in hallway beds, two nurses, and one physician on duty. Five patients arrive within ten minutes. Patient A: 62-year-old man with 40 minutes of crushing substernal chest pain, diaphoresis, HR 112, BP 150/90, SpO2 94% on room air. Patient B: 28-year-old woman at 36 weeks gestation with heavy vaginal bleeding soaking a perineal pad, BP 88/54, HR 128. Patient C: 45-year-old man with a 3 cm forearm laceration after an assault; he is intoxicated, shouting, and threatening staff. Patient D: 70-year-old woman with sudden dyspnea, RR 32, SpO2 86% on room air, speaking in three-word phrases. Patient E: 8-year-old boy with fever 39.8 C, lethargy, and capillary refill 3 seconds. The triage area is full.
1. Assign an Emergency Severity Index (ESI) level to each patient and justify the ranking. Which patient should be seen first, and which assumption about ESI could lead to an error?
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| Patient | ESI | Reasoning |
|---|---|---|
| B | 1 | Heavy vaginal bleeding at 36 weeks with BP 88/54 and HR 128 indicates hemorrhagic shock. She needs immediate IV access, blood products, obstetric activation, and likely delivery. |
| E | 1 or 2 | Lethargy, fever, and capillary refill 3 seconds suggest septic shock with poor perfusion. If immediate fluids, antibiotics, and oxygen are required now, ESI 1; if they can begin within minutes without a procedure, ESI 2. Do not let the number delay care. |
| D | 2 | Hypoxia and inability to speak in full sentences indicate severe respiratory distress; high risk but not yet requiring immediate intubation. |
| A | 2 | Chest pain with diaphoresis is high risk; ECG and troponin within 10 minutes. |
| C | 3 or 4 clinically | The laceration is low acuity, but the behavioral threat requires security and a safe location. |
See B first. The common error is to see chest pain first because of the cardiac label. ESI is based on acuity and resource needs, not diagnosis. A second error is reserving ESI 1 for unresponsive patients only; a pregnant patient in shock who needs immediate blood and delivery can be ESI 1.
2. Outline the first 15 minutes of operational actions, including staff allocation, space, and security, without abandoning the other patients.
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Activate hospital surge and call security. Move C to a secure monitored area with two staff, not the main waiting room. Assign one nurse to B: two large-bore IVs, blood draw, type and screen, warm crystalloid, O-negative blood if crossmatch is not available, fundal assessment, and obstetric and neonatal teams. The physician sees B first, then D.
Give D high-flow oxygen, prepare noninvasive ventilation, and obtain blood gas and chest imaging. Place E in a monitored bed, obtain IV access, blood cultures, lactate, and give antibiotics and fluids per pediatric sepsis protocol. For A, obtain a 12-lead ECG within 10 minutes, give aspirin if no contraindication, and monitor. Use hallway space for lower-acuity patients and assign a nurse to reassess every 15 minutes. Document capacity and request additional staff through incident command. Security needs must not delay B or D.