A Fatal Triage Error
A case in point is the premature death of a thirty-eight-year-old mother of three. One Friday morning during the summer of 2000, Mrs. K. was traveling with her husband via the subway on their usual commute to their respective jobs in Manhattan when she fell and hit the back of her head against a pole as the train jerked forward. She grappled with the intense pain for a moment and then regained her composure. Mr. K. asked his wife:
"Are you all right? Do you want me to bring you to the hospital?
- No, I'll be okay. Just walk me to my job."
Mr. K. accompanied her to the bank where she worked as a loan officer. Mrs. K. spent most of the day fighting headache and dizziness, unable to focus on her work. After she told her boss what had happened, he advised her to go home around 3 P.M. She called her husband and he brought her to their home in Queens. The rest of the weekend, Mrs. K. stayed in bed with a slight headache, but she was able to sleep after taking Tylenol.
When Monday came, Mrs. K. went to work again. She was still dizzy and unable to focus on her job. She called her husband again, and he took her to the emergency room in one of the several world-famous New York City medical centers.
When they arrived at the hospital, the waiting room was mostly full, with only a few vacant seats. They went into a small cubicle on the side to see the triage nurse. The nurse wrote in the triage notes, "Complains of headache since Friday. She claims she hit her head on subway." The nurse then took Mrs. K.'s vital signs (measurement of temperature, pulse rate, respiratory rate, blood pressure, and oxygen saturation). The readings were all within normal limits, and the nurse observed that Mrs. K. walked in with a steady gait. Thinking that the patient should have gone to her private physician instead of wasting the emergency department resources, the nurse assigned the lowest priority level and told Mr. K. to take his wife to the walk-in clinic down the hall, saying, "There's going to be a four-hour wait. They are crowded and we are short of help today."
When Mrs. K. tried to get up, her legs buckled. She was still conscious but was unable to get out of the chair. The nurse, convinced that her initial assessment was correct, believed that Mrs. K. was putting on a dramatic performance in order to get faster service. Therefore, she reluctantly offered a stretcher and helped Mrs. K. to climb on to it with the husband supporting her other arm.
Then the nurse rolled the stretcher out into the hallway and went back to her desk. She called the charge nurse in the main emergency treatment area to report the case and said:
"I've got a drama queen here who claimed that she is too weak to stand up after I told her she would have to go to walk-in and wait a few hours for a doctor. Her vitals are fine. She walked in with her husband and said she has a headache after allegedly hitting her head in the subway three days ago. Where do you want her?
- Did you put her on a stretcher?
- Yes, what else could I do?
- I have no space in here. It is a zoo. Where is she?
- I put her in corridor A, and I sent the husband to registration.
- Okay, we'll come and get her as soon as we have an opening, if no real emergencies show up between now and then. She'll probably end up waiting longer than she would in walk-in."
About thirty minutes later, Mr. K. came back from registration and could not find his wife. He had to wait five minutes for the triage nurse to finish with another patient before she would show him where to find corridor A. When he went up to his wife, she was lying on her back and not moving. He nudged her shoulders, and she opened her eyes and spoke with slurred speech, looking confused. He went back to triage and found the nurse with yet another patient. He blurted out:
"There is something wrong with my wife! She is difficult to arouse and she has slurred speech!" The nurse replied:
"I'll take a look at her in a few minutes.
- But my wife needs help now!
- Your wife is fine. I will be there in a short while. I have nine people waiting to be triaged. As soon as I have finished, I'll come and look."
Mr. K. threw up his hands in frustration and went back to his wife. She was still arousable but stuporous. He waited another twenty minutes and no one came. He went back to the triage nurse and told her he was very concerned and demanded immediate medical attention. The nurse gave him the same reply as if it were prerecorded. This back-and-forth continued every ten minutes for another hour until Mr. K. found a different nurse and asked:
"What happened to the other woman?
- She went on her dinner break," was the reply.
"Please come and look at my wife. I am having a hard time keeping her awake, and she has been in the hallway on a stretcher for almost two hours. Please!"
The relief nurse became alarmed at what she heard. She immediately went over to Mrs. K. and found her completely unresponsive. She sounded the alarm, and suddenly an array of doctors, nurses, and medical students appeared and rolled Mrs. K. into one of the code rooms (space designed for life support). Within a few minutes, Mrs. K. had an intravenous line and an endotracheal (breathing) tube. A transporter brought her to radiology, where a CAT (computerized axial tomography) scan revealed a large hematoma (blood clot) on the brain. Apparently, the head trauma on the subway train three days earlier had caused a slow hemorrhage in the back of her head that ultimately produced continuously increasing pressure within the skull. In less than thirty minutes, Mrs. K. was in the operating room undergoing neurosurgery for removal of the clot and cauterization of the bleeding vessels. She remained in a coma for eight months and died without ever regaining consciousness. Too much time had passed, causing irreversible brain damage.
In this case, there was no problem with the skill and efficiency of the emergency department staff in general. The quandary was one triage nurse with a bad attitude. When Mr. K. left his wife to take care of her paperwork, he, in effect, put the life of the mother of his children in that nurse's hands. When she said, "As soon as I have finished, I'll come and look," Mr. K. had to believe that once his wife was on a stretcher, she would get prompt medical attention. If he had not had that typical mistaken confidence in the health-care system, he might have been alarmed at the nurse's initial low-priority assignment, refused to leave his wife's presence, and vociferously demanded immediate medical attention from hospital management.