The Place Where They Have To Take You In

Days and nights on the front line at Minnesota's busiest emergency room.

The entrance to the Hennepin County Medical Center Emergency Room is a set of double glass doors under a wide concrete canopy. They're routinely locked; only patients get through, some arriving with lights and sirens, more under their own steam. "Can I help you?" the security guard inquires as someone walks up. "Yes," comes the password. "I need to see a doctor."

Facing the double doors is a big, glass-walled counter where a nurse sits 24 hours a day. The word triage originated in the battlefield to describe the practice of separating the wounded into three groups: those who will live regardless of what you do, those who will die anyway, and those for whom treatment is crucial. Here it means something similar, with one difference. No one is refused care.

Triage has its well-worn rhythm. The morning nurse takes over from the night shift at 7 a.m. and little happens for the first couple of hours. Things pick up as people get up and decide they're sick. Three p.m., when the kids come home from school, marks the beginning of rush hour, which runs through about bar-closing time. Then it slows down again until morning--except for the obligatory cardiac arrest who will come in from a nursing home, like clockwork, at 5 or 6 a.m.

Today's early risers aren't so bad. A lady with a raspy voice fell on the ice in her yard, thinks she hurt her back. "Feels like someone slammed on my crazy bone, or whatever it is," she explains jovially while the nursing assistant takes her blood pressure. "Like knives down your spine. Do you know how terrifying that is?" She carries on, then wants to know if she can have a cigarette. An aide wheels her out; it's early yet, time for small favors. Next comes a man with his arm in a sling, who needs a doctor to write him a slip explaining why he missed work last Friday. Then an eight-year-old who has a high fever that came on fast. "The clinic said it sounded like he was shutting down," his mother says. "They told me to get him down here right away."

The triage nurse types each name into the computer, adding a line to the multicolored spreadsheet that fills some 60 monitors around the department. It's a state-of-the-art, touch-screen system, and Hennepin County was only the second in the country to get it. Each patient is assigned an acuity level, one through five, shown in vivid colors on the screen. The lowest acuities, yellow and green, are for minor complaints--toothaches, head lice, or just feeling out of sorts. Pink is for level 3, Compromised, like the woman with the sprained ankle. The kid with the fever is a Level 4, Serious, which shows up in red. Level 5--Critical--patients are coded black.

By 10 a.m. the screen is mostly pink. "Dizzy," begins the column that shows a shorthand version of each patient's complaint. "Vag Bleeding. Cough. Fatigue with SOB [shortness of breath]. Fell Shoulder Pain. Vomiting Diarrhea. Chest Pain. Abd Pain. Back Pain. Stiff Neck. Chest Congestion. Fatigue. Cat Bite." Next to the complaint column is the patient's time in the department; the wait depends on your acuity and can range from zero to several hours.

A girl walks up, carrying a toddler. "Yes?" "I brought my baby here today. He's got problems--his arms are out of place." The kid lets out a scream when the nursing assistant touches his elbow. "She says she picked him up last night, was swinging him around," Carol, the triage nurse this morning, says softly as she types up the complaint. "But we always have to wonder, was it on purpose?" She peeks furtively at the young mother, who's cooing over the baby and smiling at us from the waiting area. "When they X-ray him, they'll be looking for old fractures."

There's a lot of guesswork in triage, and the ER as a whole. People can't or won't always tell you what's bothering them. Some complain of a cold, and hours later allow how they've been having chest pains for days. Others have learned, with a precision that could get them into med school, just how to work the system; teenagers are especially good at this, delivering a great abdominal-pain impression so they'll get a pregnancy test. It's one reason why only experienced staffers get to work out here.

Carol is the undisputed triage queen. A real estate agent in her spare time, she has the ageless face of a mother, and the cool needed to make split-second decisions. "What's hard," she says, "is when it's real full and you have a 60-year-old with chest pains, a 20-year-old with chest pains, and maybe a renal patient vomiting. Then you have to make some quick decisions, and they're not always what you'd think. The 20-year-old with chest pains doesn't look like too much trouble. But if he's been doing cocaine, that's a whole other story.

"When I train triage nurses now, I tell them: You may place a lot of people who really don't need to be placed, but the worst thing you can do is not to place someone who should be."

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