priorities

The conventional approach to patient problems involves taking a careful history, performing a careful examination and obtaining laboratory, radiological and other diagnostic results to lead to proof of a specific diagnosis. This approach does not work well in the emergency department, because the immediate problem does not involve achieving a specific disease diagnosis but rather influencing a final common pathway of patho-physiological derangement that may be identical for many different diseases. For example, respiratory failure is no different if caused by pneumonia, or fatigue in a patient with asthma. The emergency physician should make a diagnosis if possible and if helpful, but the emergency team has more important priorities than establishing a precise diagnosis.

The first responsibility is to determine which emergency patient is most ill. Patients must be assessed by someone who is not only skilled in the recognition of serious but subtle illnesses, but who also has the capacity to avoid becoming involved with the details of care. This assessment has become known as TRIAGE.

The next step is to assign the patient to a physical location within the department. Emergency personnel must learn and relearn that placing the patient in a room usually assigned to trivial problems does not mean that the patient cannot harbour serious disease. Unfortunately, once a problem is labelled as trivial, re-thinking the case in a more serious fashion is difficult. However, each member of the emergency department must constantly reassess patients to acquire more than one point on the curve of their illness.

The following is an example of a Triage Scale:

CATEGORY               DESCRIPTION                TO BE SEEN BY DOCTOR WITHIN

        1                              Resuscitation                               Immediately

        2                              Emergency                                   10 minutes

        3                              Urgent                                          30 minutes

        4                              Semi-urgent                                  60 minutes

        5                               Non-Urgent                                  2 hours

Three components are necessary for triage and identification of the life-threatened patient.

a)           A chief complaint

b)           A complete set of vital signs in the field and in the emergency department

c)           An opportunity to visualize, touch, and auscultate the patient

The chief complaint, which sometimes cannot be obtained directly from the patient but must be obtained from family members and others, will help categorize the general type of problem (e.g. cardiac, traumatic, respiratory etc).

Vital signs are the most reliable, objective data that are immediately available to emergency department personnel. Vital signs and the chief complaint, when used as triage tools, will identify the majority of life threatened patients. It is essential to be totally familiar with normal vital signs for all age groups. Age, underlying physical condition, medical problems and current medications (e.g. beta blockers) are important considerations in determining normal vital signs for a patient. For example, a well conditioned young athlete who has just sustained major trauma and arrives with a resting, supine pulse of 80 must be presumed to have significant blood loss because his normal pulse is probably in the 40-50 range.

Most pre-hospital care systems with a level of care beyond basic transport also provide therapy to patients. Because this therapy usually makes positive changes to the patient's condition, the patient may look deceptively well on arrival in the emergency department. For example, a 20 year old female with acute onset of left lower quadrant abdominal pain, who is found to be cool and clammy, with a pule rate of 116 and a blood pressure of 78 palpable and who receives 1500 cc of fluid en route to the emergency department, may arrive with normal vital signs and no skin changes. If one does not read or pay attention to the paramedic's description of the patient and the initial vital signs, the presumption could be made that all is well.

Sometimes normal vital signs are not normal. For example, a 20 year old asthmatic patient has a respiratory rate of 14. An asthmatic patient who is dyspnoeic and wheezing should have a respiratory rate of at least 20-30/min. The "normal" respiratory rate of 14 in this setting indicates that the patient is in respiratory failure. This is a classic example of where normal is not normal.

Visualizing, touching and auscultating helps to identify the threat to life i.e. is it the upper airway, lower airway or circulation? Touching the skin is important to determine whether shock is associated with vasoconstriction (hypovolaemic or cardiogenic) or with vasodilatation (septic, neurogenic or anaphylactic). Auscultation will identify threats associated with lower airway (eg. bronchospasm, tension peumothorax).

In conclusion, obtain the vital signs on every patient without exception. It cannot be stressed enough the need for accurate temperature determination especially in young children. Doctors often overlook temperature determination in adults, resulting in delay in perceiving the magnitude of problems or in beginning appropriate interventions. It is difficult to understand why so many doctors pay little attention to vital signs and then face the unhappy task of trying to explain away abnormalities that should have provided clues to the seriousness of the patient's problems. Although a patient can be seriously ill with what appears to be normal vital signs and may not be seriously ill with abnormalities of the same, it is best to believe abnormal vital signs in patients who appear ill, because changes in vital signs may provide clues to worsening in a patient's condition.