Handling the Under-Triaged Patient

How often does this happen? We deliver a patient to the hospital who we believe is seriously ill, and a triage nurse assigns them to the waiting room or unattended hallway bed.

We should be advocates for our patients, but there is a fine line between being an advocate and a jerk.  The key is to know when it is appropriate to act, and how to do so with tact.

While in paramedic school, I worked as a ED tech at a busy urban hospital.   A nurse and tech were responsible for several patients at a time, which required daily MCI-type triage.  A lot of patients who I thought were really sick ended up sitting for a while and doing fine.  Many unconscious nursing home and overdose patients stayed unconscious for hours.   Stable patients in SVT or a 3rd degree heart block stayed in these rhythms until their cardiologist could see them.

The key is to identify the ones who appear to have gotten worse during your time with them.  Unfortunately I have cared for a few of these patients who fell through the cracks.  When this happens, we should tactfully advocate for them in the hospital.  Here are a few steps to do this:

First, take the patient where the nurse assigns them.   I’ve seen patients suffer because of arguments between EMS and the hospital staff.  Whomever made the assignment now has an emotional attachment to it, and is likely to become defensive if questioned.

Next, find a doctor.  Choose one you trust and that you thinks trusts you.  Of course this trust must be built before the incident.  Start by asking if they have a second to look at your patient. Usually they will, or direct you to another doctor who does.

Next, explain why you think this patient may be sick while walking over to them.  Try to use objective information, like an ECG, vital sign, or lung sound.  If the patient leaves something out that you picked up, gently remind the patient  about what they told you. Unlike us, the doctor can overrule a nurse’s decision, and the responsibility shifts to him or her.

You’re sticking your neck out, so make sure you know what you are talking about.  People also don’t like to be dazzled with big words when shorter ones will suffice.  You also need to be selective with the patients you advocate for.  Doing this too frequently is crying wolf and will not help any of them.

Even if the doctor does not order the patient to be moved to a room or have a test ordered, you’ve given the patient an identity.  The doctor will give them an extra look in the hallway when they walk by and hopefully be vigilant for any trends.

Our patients want us to be their advocate after we enter the emergency room, but we only have so much control over what happens there.  It starts with building good relationships with the ED staff, and using tact when questioning something.





  1. Really great post! The nuts and bolts about how to “work the system” to best advocate for your patients is one of the most valuable skills we learn, IMO.

  2. Excellent post Bob – Great details on how to walk the line, this is a skill we could all use a little help with. I always try to look at my “frequent fliers” with the mindset that I have the opportunity to “get it right” for them this time.

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