Assessment, Triage, and Clinical Decision-Making
The first ten minutes
Triage is a sorting decision, not a diagnosis. The candidate must know the difference between acuity scales (five-level systems such as ESI or CTAS, three-level military-style systems) and the principle behind all of them: physiologic instability and resource need outrank the chief complaint as stated by the patient. Learn the objective discriminators that escalate a patient regardless of how well they look: abnormal vital signs for age, altered mental status, severe pain, uncontrolled bleeding, and high-risk mechanism of injury.
Primary and secondary survey
Use an ABCDE primary survey with simultaneous intervention - you do not finish assessing before you start fixing. Reassess after every intervention. The secondary survey is a head-to-toe examination with a focused history; the classic history mnemonic covers symptoms, allergies, medications, past history, last meal, and events leading to presentation. Document trends, not single values: a systolic pressure that fell 20 mmHg over twenty minutes matters more than one reading.
Traps in questions
- A patient with normal vital signs and a dangerous complaint (chest pain, thunderclap headache, testicular torsion) still needs rapid escalation.
- Pediatric and geriatric patients compensate and then decompensate abruptly; tachycardia may be absent in a child with shock and in an elder on beta blockers.
- Pain score alone should not drive triage level; physiologic findings and risk factors should.
- "Reassess in 30 minutes" is wrong when a red flag is present; the answer is escalation now.
Rule of thumb
If two patients have equal acuity, treat the one whose condition can deteriorate fastest first. A useful worked example: an adult arrives with a 2 cm scalp laceration, ambulatory, blood pressure 88/50, heart rate 118, and a history of vomiting after a fall. The laceration is minor, but the vital signs and mechanism make this a high-acuity presentation requiring immediate provider notification and monitoring, not a fast-track suture.
Documentation and handoff
Structured handoff (situation, background, assessment, recommendation) and closed-loop communication are examinable safety behaviors. Verbal orders should be read back.