The accident that persuaded beginning motorcyclist John Rohm to abandon his new hobby reacquainted the 66-year-old with the inner workings of the emergency room.
On a recent Saturday, the Columbia, Md., man borrowed a motorcycle to ride around Fort Meade, but another driver abruptly stopped in front of him. He stopped, too, but without holding the forks of his motorcycle straight, causing the machine to tip over. He hit the ground with his left shoulder, and the motorcycle crashed onto his left foot.
Mr. Rohm, a retired lieutenant colonel with 26 years of U.S. Army service, thought the pain would go away, but two days later, he was in the 48-bed emergency services department at Howard County General Hospital, a Columbia-based hospital owned by Johns Hopkins Hospital.
After a short wait, Mr. Rohm was taken into one of the three triage booths where patient conditions are prioritized based on who is most ill or injured and needs treatment first.
“Our goal is get people in and out as quickly as possible,” says Dr. Mark King, chairman of the hospital’s Department of Emergency Medicine. “In the scope of the practice, you’re limited by your resources.”
The hospital implemented a five-tier triage system in mid-November to replace the conventional three-tier system. A nurse assesses patients such as Mr. Rohm by taking his vital signs, including temperature, pulse, blood pressure and respiratory rate, and asking questions about his injury or illness, checking to see if he is alert and able to respond to the questions.
The nurse uses the triage system to help determine if the patient’s condition is life-threatening, such as from a cardiac or respiratory arrest; high-risk that without intervention could become life-threatening; stable but requiring several resources, such as lab work or diagnostic tests; stable with few resources required; or stable with no need for resources. The three-tier system does not make any distinctions among stable patients.
“Nurse intuition plays a huge part,” says Diane Phillips, a registered nurse who is emergency department nurse manager at Sibley Memorial Hospital in Northwest. Sibley is considering implementing the five-tier triage system.
“The most important physicians in the emergency department are the triage nurses because they determine our priorities,” she says.
If Mr. Rohm’s injuries were life-threatening or if he had been the only patient in the emergency room, which at 10:30 on a Monday morning is unlikely, the nurse would have taken him directly to a treatment room. Because he was in stable condition, he was sent to the waiting area, where he says he waited a few minutes.
Dean Sutherby, 33, had come in about an hour earlier, when the hospital was not as busy, and within an hour had his diagnosis: a sprained ankle.
The hospital’s busiest times are from 11 a.m. to 11 p.m. and the slowest from 3 to 9 a.m. Monday is the busiest day of the week, says registered nurse Deborah Fleischmann, administrative director of emergency services for Howard County General.
“People have been home over the weekend. The doctor’s office is closed, then Monday morning comes, and they realize they can’t go back to work,” Mrs. Fleischmann says.
Mr. Sutherby, a professional golfer who lives in Ellicott City, originally planned to go to work that Monday at a Marriottsville, Md., golf club where he teaches golf. Ten days earlier, he had twisted his ankle playing basketball and thought it could heal on its own. The pain and his limp persisted, causing him to worry that he possibly could have broken something.
“I couldn’t stand it anymore,” says Mr. Sutherby, who has injured his ankles a few times in the past. “Most times, the pain goes away after a week. Not this one.”
Mr. Sutherby’s wife, Sheryl Sutherby, took him to the hospital greet desk, where he was asked to provide his name, date of birth and reason for coming. He was taken by wheelchair to the triage area, then on to evaluation in a patient room, where a physician or physician’s assistant determines the need for diagnostic tests, such as an X-ray in his case.
Cheryl Boehler, a physician’s assistant, examined the X-ray of Mr. Sutherby’s lower leg and told him he needs to wear an ankle brace. She referred him to an orthopedic physician, who she says likely will refer him to physical therapy.
“He does need to limit himself,” Mrs. Boehler says, adding that Mr. Sutherby likely will not be able to return to his normal activities for another month. “Sprains can take up to 12 weeks to heal,” she says.
Once a diagnosis is made and a treatment plan is determined, the patient may be admitted to the hospital, referred to a specialist or sent home with any needed prescriptions, referrals and follow-up treatments, Mrs. Fleischmann says. Eighty-two percent of the 72,000 patients seen annually in the emergency department at Howard County General, or about 59,000 patients, are sent home, she says.
“The emergency department is the start of care for the patient,” Mrs. Fleischmann says, adding that in-patient care in the main hospital is planned in advance and that in the emergency department, testing is done the same day. “Our goal is to accomplish [patient care] quickly, and we’re doing those tests right away.”
Staff in an emergency department have to be prepared for any kind of emergency and for unexpected busy times, says Dr. Martin Brown, chief of the department of emergency medicine at Inova Alexandria Hospital.
“We are an unscheduled environment,” Dr. Brown says. “We see all patients who come to our department. We don’t have any control over when they come.”
Dr. Brown considers the emergency department at Inova Alexandria Hospital to be the front door to the hospital.
“Our environment is such that patients come in without a label. … By the time they leave, we have a diagnosis and treatment plan for them,” he says. “We try to sort out the patients and get them on the right road to recovery.”
If the staff follows the ABCs — checking a patient’s airway, breathing and circulation — it will be on the road to providing the appropriate care, Dr. Brown says.