How a Resident Views Nurses at Triage

Some amusing toing-and-froing in the comments of this post at Movin’ Meat, which originally dealt with media coverage of a triage miss and the death of child as a result. NurseK, Cartoon Character and others have some fun taking their resident-beating stick to a PGY1 for ill-advisedly smacking down triage nurses. The relevant excerpt:

PGY1 said…
“A febrile child with petechiae or purpura is a medical emergency, and this is clearly one of those cases where the triage nurse missed it.” 

At the risk of drawing some hate, why are nurses responsible for determining what constitutes a medical emergency? The clinical acumen of triage nurses depends on a combination of intelligence and clinical experience, both of which vary widely among ED nurses.

Same goes for doctors, you say? Compared to medical education & residency training, nursing school is brief. Nurses don’t do residencies and are taught by other nurses. How can we expect even an excellent nurse to have clinical judgment on par with a that of a physician who has trained for years prior to entering practice?

1/14/2011 4:47 PM
[Cue beatdown music — ed.]

I won’t rehash the rebuttals for this particular piece of wisdom. NurseK et al. do a better job than I could, but I have to add that PYG1’s observation that  “nurses . . . are taught by other nurses” (O, the horror of it all!) is pretty funny too. Old nurses like me have heard physician criticism of nurses performing triage for a very long time — usually in the form of “how can they — nurses don’t have the 27 years of education that make me a great physician!” or “how can they — they’re doing what physicians are supposed to do!” or “Look at how the stupid triage nurse missed this exceedingly esoteric complaint!” In the hospital where I first practised, the Chief of Emergency Medicine* was adamant nurses could not triage because triage was tantamount to diagnosis — and nurses don’t diagnose. In any case, he said, nurses didn’t have the critical thinking skills to do it properly. This attitude reflected then, as does PGY1 comment does now, a fundamental misunderstanding of role of the triage process and underscores the archaic notion of the role of nurses as uneducated and passive tools of physician knowledge and experience. Well, plus ça change, plus c’est la même chose.

Yet I have to say, in my experience, the attitude that MDs must micromanage every element of patient care is slowly disappearing  among physicians. Occasionally you get one who appears to have slept through the lectures on collaborative practice and the critical role of nursing on the health care team, but this is increasingly rare. I actually hope PGY1 isn’t one of these and does take something away from the reaction to her comment — namely, that her view of nursing is skewered. She seems to indicate she will. She’ll be a better physician, and ultimately, her patients will be better for it as well.

[UPDATE 26/01/11: Minor word changes for clarity.]


*Fortunately, the Ministry of Health was pretty insistent nurses fill the triage chair. This physician was also the sort who if a nurse said “renal colic”, would say “aortic aneurysm” and proceed to treat on that basis — sometimes with unfortunate results.


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  1. #1 by Lurkette on Monday 17 January 2011 - 1157

    Harrumph. When i was a student nurse, every member of my class was given a little book called The Physician’s Handmaiden or some such. Our teachers encouraged and taught us to hint at a mistake the MD might be making with elaborate circumlocution. God forbid we should clearly express our clinical judgment! And I’m not all that old.

    I am so glad that things are changing, this PGY1 not withstanding. She’d better get a clue pretty quickly or that attitude will gain her some sleepless on-call nights pretty fast. We trained-by-other-nurses nurses can get pretty passive aggressive. Doesn’t help us be treated professionally, but my! it feels good sometimes…

    • #2 by torontoemerg on Monday 17 January 2011 - 1220

      I was thinking somewhat snarkily afterwards, wait till she finds out all our advanced certifications, ACLS, PALS, etc. etc. are taught by other nurses!

      Also, before, it was, “Doctor, I think, I mean I’m almost sure the patient sounds congested. . .”

      Now, it’s “Are you going to order the Lasix or what?” :)

      One of my instructors told me when she was a young nurse she was advised never to contradict or nag a physician, because he didn’t want to be reminded of his home life!

      • #3 by Lurkette on Monday 17 January 2011 - 1231


        We’ve come a long way, baby!

  2. #4 by Cartoon Characters on Monday 17 January 2011 - 1322

    Geez. Didn’t know i was taking the “beating stick” to PGY1, never mind having “fun” doing it… :)
    All I was doing was stating the facts…that in our triage, the purpura and petechiae are high up there on the list of questions we ask….. ;) – and interestingly enough, we DO have a computerized system complete with checklist. It’s very thorough.
    Today was the first day coming back to Moving Meat since I made the comment, and was surprised at the ensuing discussion. Nurse K did a great rebuttal and I have to admit, came back softer when PGY1 backpedaled.
    I guess I took it for granted that everyone knew that RNs have training to triage and can recognize emergencies – and I had no idea of the controversy involved. =^@

    • #5 by torontoemerg on Monday 17 January 2011 - 1325

      Colourful figures of speech.

      I guess I find it’s odd that it is a point of controversy. Still.

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