Four Patients in Eight Minutes, One Resuscitation Bay, One Nurse
At 22:15 in a 60-bed district hospital, you are the only emergency nurse on duty with one physician, two general beds and one resuscitation bay. Four patients arrive within eight minutes.
Patient A: a 58-year-old man with crushing central chest pain for 40 minutes, grey and clammy, BP 96/60 mmHg, pulse 48 and regular, respirations 24, SpO2 93% on room air, saying he feels 'like I am going to die'.
Patient B: a 26-year-old woman, 34 weeks pregnant, with sudden painless vaginal bleeding; she has soaked two pads in 20 minutes, BP 86/50 mmHg, pulse 128, pale and anxious; the fetal heart rate is 158 bpm.
Patient C: a 7-year-old boy with asthma, sitting forward, speaking in single words, audible wheeze, respiratory rate 42/min, SpO2 88% on room air, marked accessory muscle use.
Patient D: a 31-year-old man with a 6 cm forearm laceration from a fall; bleeding is controlled with a pressure dressing; BP 132/80 mmHg, pulse 88; he is walking and asking how long the wait will be.
The physician is in the resuscitation bay with a patient who is being intubated.
1. Rank the four patients and justify the ranking using a triage framework, including where reasonable clinicians could disagree.
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Ranking: B, then C, then A, then D.
B - obstetric haemorrhage with shock. Two pads soaked in 20 minutes means ongoing major blood loss. She is hypotensive (86/50), tachycardic (128) and pale, which in pregnancy can understate the loss because of increased blood volume. There are two patients here - mother and fetus - and the interventions (two large-bore lines, blood, theatre) take the longest to organise, so she must start first. This is a red category.
C - imminent respiratory failure. Speaking in single words, SpO2 88%, respiratory rate 42 and accessory muscle use indicate severe asthma with a real risk of a silent chest and cardiac arrest. He needs oxygen and nebulised bronchodilators within minutes.
A - suspected inferior myocardial infarction with complete heart block. Crushing pain, bradycardia at 48, hypotension and a sense of doom. He is also time-critical and may arrest from a bradyarrhythmia; he needs a 12-lead ECG, atropine at hand and the cath lab pathway activated.
D - controlled haemorrhage, stable observations, walking and talking. He can wait with a pressure dressing and reassessment.
Where clinicians disagree. If the physician is still intubating, B and C are close. A case can be made for C first because airway and breathing kill fastest, and for A because atropine can be given by a nurse under protocol in seconds. The ranking should be revisited after every intervention rather than fixed at the door. What is not defensible is leaving B or C in the waiting room because the obstetric or paediatric team has not arrived.
2. Describe how you would spend your first five minutes, given that the doctor is still intubating and you are working alone.
Read the worked answer
First, control the flow. Put patient D in a chair with a pressure dressing and tell him plainly that he is stable and will be seen after the sicker patients - a short, honest sentence prevents an angry escalation later. Ask the receptionist or a porter to call the on-call obstetrician, the paediatrician and the medical team, and to bring the difficult airway trolley to the resuscitation bay.
Patient B (first):
- Two large-bore (14–16 G) IV cannulas, draw blood for group and crossmatch, full blood count and coagulation.
- Start warmed crystalloid and get O-negative blood if it is available; do not wait for crossmatched blood in a shocked obstetric patient.
- Oxygen by mask, left lateral tilt to relieve aortocaval compression, continuous fetal heart monitoring if a second pair of hands appears.
- Inspect for the cause of bleeding, but do not perform a vaginal examination outside the obstetric team - placenta praevia is the classic painless bleed and examination can provoke catastrophic haemorrhage.
Patient C (immediately after):
- High-flow oxygen to keep SpO2 above 94%, sitting upright.
- Salbutamol nebulised with ipratropium via a mask, continuous SpO2, and prepare intravenous steroids and magnesium sulfate as the doctor directs.
Patient A: attach the cardiac monitor and run a 12-lead ECG the moment a machine is free; keep atropine drawn up and the defibrillator nearby.
Document times of arrival, observations and interventions as you go - reconstructing them later is a source of error.
3. What would make you re-triage patient D, and how would you communicate the wait to him?
Read the worked answer
Re-triage triggers for D. Reassess him at least every 15–20 minutes and immediately if anything changes:
- The dressing soaks through or bleeding restarts, or the hand becomes pale, cool or pulseless.
- He becomes pale, sweaty, dizzy on standing, or his pulse rises above 100 or systolic BP falls below 100 mmHg.
- Loss of sensation or movement in the fingers - suggesting nerve or tendon injury.
- New severe pain, swelling or a tight compartment.
- Any change in consciousness or behaviour.
Explaining the wait. Use plain language, a name and a reason: 'Mr Ahmed, your cut has stopped bleeding and your blood pressure and pulse are stable. The three patients who came in with you are in a life-threatening condition - a woman losing blood in pregnancy, a child who cannot breathe properly, and a man with a possible heart attack. That is why they are being seen first. I will check your arm every 15 minutes, and if the bleeding restarts or your fingers go numb, call me immediately.'
Practical care while waiting: keep the arm elevated, check the dressing, provide analgesia as prescribed, document the re-triage checks with times, and put the call bell within reach. Acknowledge the wait again if it exceeds an hour, and explain the next step so he does not feel forgotten.
If he deteriorates, he is no longer D. Re-triage him as an emergency and interrupt the physician.