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Triage: More than just a history (Proceedings)
In every practice, general or emergency, triage is encountered and should be understood.
In every practice, general or emergency, triage is encountered and should be understood. Triage, by definition, means to sort. It is the process of prioritizing patients based on clinical signs to determine severity. When a patient presents for illness or abnormalities, they must be triaged. Triage includes a brief exam, history, obtaining a set of vitals, and assessing the patient by “watching”. Mistakes can occur during triage, and can be avoided through “triage by committee”. By understanding how to triage, patients can receive more timely emergent care when necessary.
When a patient first presents, it is important to determine how critical they are through a quick visual assessment and brief verbal communication with the owner. Is the animal pale? Are they having difficulty breathing? Are they currently seizing? Is the owner describing a potentially serious medical problem? If through a brief visual and verbal assessment it is determined that the patient is stable, proceed with further triage. If there is any question about the stability of the patient, the next step should be to “triage by committee”. Taking the pet to the treatment area to obtain further vitals with the assistance of another LVT or DVM to determine stability allows “triage by committee” to take place. The veterinary team can then determine the medical standing of the animal.
When the presenting animal can withstand further triage, it is important to first “watch” the patient. Determine how the animal is acting prior to obtaining vitals and performing a physical exam. Assess the patients breathing. Note breathing posture, effort, rate, ventilation pattern, and sound. A high pitched honk, for example, may suggest tracheal collapse. Be aware of attitude, mentation, and level of consciousness. Be sure to note sedation, depression, anxiety, anxiousness, hypersensitivity to light and sound, temperament, apprehension, abnormal neurologic signs, and agitation. Noting attitude and awareness may prevent animal bites as well as lead to potential diagnosis. If the animal seems sedated, we may need to consider potential toxicities. Head pressing signs may point us to a neurological condition for example. Be aware of any vomit, stool, or urine the animal may have eliminated in the exam room, and any abnormalities. Bloody or black stools may warrant certain medication questions, i.e. is the animal on NSAIDs or has the owner given any human NSAIDs at home? Be aware of any sneezing or coughing which could potentially be infectious or cardiac in nature. Note any nasal discharge and color. If there is any question regarding the potential for infection while “watching” the animal and through talking to the owner, appropriate isolation protocols should be practiced. Observe patient posture and note any “hunching”, straining to urinate, or abnormal gait. These observations may indicate abdominal pain, urinary obstruction, or potential neurological disease. The list of potential diagnoses begins with the observation of the patient. It can help direct the technician to ask certain questions, regarding the history, that may not have otherwise been asked.
The period the triage tech uses to “watch” the animal should be brief, lasting no longer than 1-2 minutes. After the technician has ascertained further triage will not compromise the animal, the next step should be to obtain a set of vitals. Obtaining vital signs includes temperature, heart rate, pulse rate and quality, respiration rate and level of effort, mucus membrane color, capillary refill time, body weight and body condition score. An abnormal temperature may require immediate heat/cooling support. Body temperature can cue the technician to such problems as potential sepsis, heat stroke, shock, hypotension, or thromboembolism (ATE). When obtaining a heart rate, it is important to auscult the patient. Determine if heart sounds are muffled or if there is a murmur or arrhythmia present. Abnormal heart sounds can point to potentially fatal medical problems. A heart rate should be followed by a pulse rate. Obtain pulse rate while ausculting the heart. Note any pulse deficits. Determine pulse quality as well. “Snappy” pulses, for example, may indicate anemia and warrant further diagnostic testing. Absence of pulse in a limb should direct the technician to assess paw pad and nail bed color to rule out the possibility of a clot. Once temperature and heart/pulse rate have been analyzed, respiration rate should be noted. Be aware of increased or decreased respiration rate. In addition to rate, ventilation quality should be noted. Watch for shallow breathing or short, quick breaths. It is necessary to auscult the lungs and upper airway as well. Diminished lung sounds on one side of the chest may indicate lung disease or pneumothorax. Other concerns include hernia, trauma, and airway disease. Note any crackles, wheezing, and upper vs. lower airway noise. Mucus membrane color may be beneficial in determining breathing abnormalities as well. Abnormal mucus membrane colors such as pale, grey, lavender, or blue/cyanotic may tell the triage tech the patient is anemic or has airway disease and requires oxygen. This alerts the technician to the need for immediate medical intervention. If mucus membranes are bright red or brick red in color, it may lead the triage tech to consider infection, sepsis, or polycythemia warranting certain diagnostics be performed. Icteric mucus membranes may indicate hemolytic anemia, liver or gall bladder disease. Capillary refill time should be noted. Delays in refill time may indicate fluid therapy intervention. Body weight should be taken, and body score decided. If the animal is emaciated in appearance, despite a normal or voracious appetite, neoplasia or protein losing disease may be put on the list of rule outs. An overweight cat that has not eaten may be a concern for hepatic lipidosis. These observations can help direct our questioning during the history and form our list of rule outs.
A brief physical exam should be performed during the obtaining of vitals. This process should take 2-3 minutes to complete. In addition to auscultation of the heart and lungs, auscultation of the abdomen for gut sounds is recommended. This can direct us to ask questions about potential foreign body ingestion, in the absence of gut sounds, for example. Palpate the abdomen for obvious masses, pain, or distension. Distension may point the technician to ask questions regarding potential bloat, ascites, or hemoabdomen. A painful abdomen may indicate foreign body or pancreatitis. This should spark questions about diet and dietary indiscretion. Assess the bladder during belly palpation. A large, firm bladder in a sick cat may indicate to the triage technician to ask the owner about urine elimination. Assess hydration status and skin turgor to determine if immediate fluid intervention is required. These assessments can indicate to us the animals' prior food/water consumption, as well as fluid losses. Look for bruising on the patient. The pinnae, mucus membranes, abdomen and sclera should be checked thoroughly. If bruising or petechie are noted, questions regarding potential rat poison toxicity should be asked, as well as considering thrombocytopenia for the list of rule outs. It is important to use the findings during the brief physical exam to help direct questioning when taking a history from the owner. From the examples above, it is evident that small findings can help the veterinary team when pursuing a diagnosis and course of treatment.
Now that the patient has been fully assessed and does not immediately require medical intervention, the history should be taken. The history should be thoroughly performed in a timely manner. Though some histories are longer than others, a full history should take roughly 5 minutes. It is important as the triage tech to be calm, and keep the owner calm, especially during emergent situations. Often keeping the owner “on track” regarding the patient is necessary. As time is of the essence in emergent situations, unnecessary information from the owner can delay necessary treatment. It is imperative to listen carefully when taking the history from the owner. Often owners will use their own terms to explain what the animal is doing at home. For example, instead of using the term “vomiting” the owner may say “Fluffy gave up his food”. This could easily be misinterpreted to mean the animal did not eat, not that the animal vomited. Repeating the history to the owner as you interpreted it, is highly recommended. This can prevent an inappropriate treatment plan based on an incorrect history. Obtain an appropriate timeline form the owner regarding the patients' current illness, as well as previous illnesses. In addition to the timeline, obtain a current list of medications, dosages, frequency, and the last time the medication was given. It is important to note recent medications the animal was given, but is not currently taking (i.e. steroids, NSAIDs, antibiotics). The owner should also be asked if the pet was given any medications that had not been prescribed, as often times owners may choose to give medications on their own (i.e. Imodium, aspirin, Benadryl, Tylenol, etc..). In addition to medications given, vaccinations given and the date administered should be recorded to rule out potential disease processes. Ask about the pets' normal diet, current diet, and any table scraps or treats they may be given. Be sure to note amount and frequency of the diet that is fed. Typically when a pet has been sick at home and not eating, the owner may try various table scraps to encourage appetite. This may be pertinent information in a pancreatitis suspect, or potential garbage ingestion case. Inquire about vomiting, diarrhea, coughing, sneezing, activity level, appetite and water consumption, as well as attitude and weight change. When recording the history, ask about the amount, color, and frequency of vomiting and diarrhea. These answers can guide us when forming treatment plans and diagnoses. Inquire about the frequency and sound of a coughing patient, as this can help decipher potential cardiac disease vs. airway disease. Sneezing should inspire questions about discharge and color of the discharge, or if ocular discharge is associated. Be sure to document any previous medication allergies or reactions. Note patient signalment including if the animal has been altered. Breed and age can also add certain disease processes to the list of rule outs based on presenting symptoms and physical exam.
Many mistakes can occur during the triage process. Typically they occur during the history taking process. The owner may not be forthcoming with information, which can hinder a diagnosis. This is when pointed questions to the owner based on symptoms and physical exam become important. For example, a young, healthy animal presents seemingly sedated for sudden onset of lethargy, hypersensitivity to stimulus, and urine leakage. Toxicity should be on the top of the rule out list for the triage technician, including marijuana toxicity. If the owner insists the pet did not get into anything, the owner should be asked about potential marijuana toxicity. It is important to be compassionate, calm and professional during questions of this nature. Tactful and pointed questioning will allow the owner to be more liberal with information. It is important not to judge the client, and allow them to feel comfortable enough to be honest. Other mistakes occur during the physical exam. When an abnormal vital sign is obtained, or found on the physical exam it should not be understated. It is important to bring the abnormality to the attention of the attending clinician as soon as possible. Oxygen therapy, blood transfusion, pericardiocentesis, thoracocentesis, gastric decompression, or emesis induction are just some examples of required emergent medical intervention that could be postponed due to incorrect triage of a patient.
Triage should be managed by a skilled, knowledgeable, and compassionate LVT. Triage should be performed in less than 10 minutes if the patient does not require immediate medical intervention. When there is any doubt regarding the stability of a patient, “triage by committee” should be initiated. Through skill, thorough history taking, and a team approach, the patient can receive adequate care without unnecessary diagnostics.