This is an intubated bulldog after a crisis.Photos courtesy Tami Lind Generally, most emergency cases in veterinary practices are unexpected. While most have heard the word “triage,” do we understand what it means? “Triage” is derived from the French word trier (or “to sort”). The word was generated around the 1790s during the French Revolutionary Wars/Napoleonic War when men had to care for the wounded on the battlefield. Battlefield triage is, of course, very different than hospital triage. The basis, however, is to identify which cases need immediate care to maximize the survival of patients presented to a hospital. One must identify which patients are stable enough to wait for care and which are critically ill. It is crucial to also identify patients that are stable but should not wait in the lobby. For example, a pet may have a small laceration, but it is dripping blood all over the lobby. Preparedness To triage effectively, walk around the clinic to ensure there is an area where critically ill patients can be taken to be tended to. Be prepared. When determining a space, one should consider: Where should you triage? The lobby? An exam room? Should you triage dogs and cats in the same space? Do you treat exotics? If not, do you know where to refer these cases? What supplies do you need? First and foremost, find a place that is best for both the clinic and the patient. Indeed, it is always beneficial if there is an area of the treatment floor designated for a critical/emergency patient. Have catheters, fluids, oxygen administration, a crash cart/tray, blood pressure supplies, warming devices, monitoring devices (e.g. ECG), and quick diagnostic tools (microhematocrit tubes, glucometer, lactometer, point-of-care devices, etc.) ready to go. Keeping this equipment at hand can help a clinician quickly diagnose a critical patient and create a better emergency experience for both the staff and the patient. A crash cart/box/tray is the most essential tool to have at a practice. It should include catheter supplies, emergency medications (lidocaine, epinephrine, atropine, vasopressin, etc.), syringes for drawing blood and emergency medications, endotracheal tubes, fluids, fluid lines, etc. Make sure the crash cart is fully stocked every day. Supplies are often borrowed, taken, or used for other situations, which can, in turn, make a critical situation more complicated. Nobody wants to be running to the surgery suite for endotracheal tubes when a patient has to be intubated. Mark the crash cart to indicate it is stocked. Finally, to prepare, make sure everyone practices. Practice, practice, practice. In an emergency situation, staff will make a more cohesive team if they all know where the supplies are kept, where the crash cart is, and how to stay calm. Starting the process Triage can be done in two ways: in person when multiple emergency patients come in at the same time, or over the phone. Receptionists are the “first eyes” when a patient walks through the door. It is strongly recommended these professionals are trained to see what is considered an emergency and what is not an emergency. They are the ones to determine when to call a technician for help. When a client calls the clinic for an emergency, however, it is best to have medical personnel on the phone to help ask the correct questions and assess if it is a true emergency. For example, a client calls and says her cat is in the litter box all the time and she thinks the pet is constipated. A veterinary professional may ask, “Has your cat been urinating in the box?” The client replies, “Well, now that you mention it, I don’t remember seeing urine in the box either.” If this cat is blocked, it would be considered a true emergency; a non-veterinary professional may have told the client to come in for an appointment the next day as a constipation case. That said, do not diagnose over the phone! Instead, state your concerns to the client: “I am worried your cat hasn’t urinated in a long time, and I would suggest you bring him in immediately.” If the client asks multiple questions over the phone or gets emotional, express concern for the patient. Let the pet owner know you will answer all their questions when they get in. Keep control of every conversation. Remember, too, if the client thinks they have an emergency, you should treat it as such. Additionally, know your clinic’s limits when it comes to emergencies. Can the hospital care for a patient for 24 hours? Are you open weekends? Is there an overnight technician who can care for patients? Can you handle wildlife/exotic emergencies? Can surgery be performed at any time? These are all questions to address to help ensure preparedness for an emergency you cannot handle. It is acceptable to send a client to a different clinic if your hospital does not have the capability to handle different types of emergencies. Assessments Always assess the most critical patient first. Remember your ABCs: airway, breathing, circulation. Infectious/dramatic cases can be brought into the treatment room and placed in a kennel while the technician is getting a more accurate history. If the patient is very critical and needs to be brought back right away, the next step is to have a triage estimate ready.1 This ensures the patient will be taken care of quickly and prepares the owner for what the cost may be. Have a cart ready to go. The estimate is usually a range, and can include radiographs, blood tests, intravenous catheter placement, and intravenous fluid administration. It does not include other tests or medications after the diagnosis is made. The form also includes a CPR code. It is better to be ready for CPR than to have to ask the owner when it needs to be performed. The receptionist can go over this form if necessary. Everything should be written clearly to ensure everyone understand what is included in the estimate. Communicate to clients this is a way for their pets to get the quickest, best care possible. Client communication is key in an emergency situation. Explain to them where you are taking their pets and why. These scenarios can be distressing to pet owners because they are separated from their four-legged “family members.” Keep control of a resistant client. Focus on the patient and assure them the staff is doing what is best for their pets. Update the client frequently and consult them on any medical or financial decisions. (Additionally, receptionists can remind other clients waiting the in the lobby that it is better to not be first in the emergency room.) A history should be taken quickly once the emergency patient walks in. This includes the presenting complaint, when the patient was normal last, what has been done/given already, whether there have there been any previous medical issues, and if the patient is receiving any medications or has any allergies. A more thorough history can be taken after the patient is stabilized. This should take less than five minutes. Next steps Triaging should be prioritized in order of respiratory compromise, cardiovascular compromise, neurologic compromise, and then other emergencies. Again, assess each patient’s ABCs: Airway Breathing Circulation Disability/neuro External After the ABCs, temperature, pulse, and respiratory rate must be taken to complete the primary assessment. Do not forget about pain management! Assess the airway first. Keep the patient calm and cool, and supplement oxygen if needed. Supplementing oxygen is never the wrong thing to do. Intubate the patient if it is warranted. A tracheostomy tube may be needed if an endotracheal tube is impossible. A tracheostomy tube can be made out of an endotracheal tube if the hospital does not have tracheostomy tubes available. Next, assess the breathing. Ascultate the patient’s lungs. Are there any crackles, wheezes, harsh lung sounds, or no sounds at all? A pulse oximeter can tell you the oxygen status of a patient. It is never good if a patient is cyanotic. Place the patient on oxygen and minimize stress. Pink gums do not necessarily mean the patient is stable. A patient can still have low oxygen saturation with pink gums. There are many ways oxygen can be supplemented (e.g. oxygen cage, incubator, E-collar with plastic wrap on it, a cat carrier with a plastic bag over it, a mask, nasal cannulas, etc.). As a next step, assess the patient’s circulation. Start by assessing the mucous membrane color, capillary refill time, pulse quality, level of consciousness, heart rate, and extremity temperature. If the blood pressure is normal, this does not mean the patient is stable; however, if the blood pressure is low, this is an indicator of shock. Shock is a physical exam diagnosis. If the patient is externally hemorrhaging, make sure to stop the bleeding. Place an intravenous catheter to give fluids to replace the volume lost. If the patient is in cardiogenic shock, fluids may be contraindicated. ECG, blood pressure, bloodwork, stat chemistry values, and “Big 4” (PCV/TP, BG, Lactate) should be assessed. If imaging is deemed necessary, the patient must be stable. Use sedation if needed; the patient should stay calm. If a neurology emergency comes into the clinic, assess the patient’s level of consciousness. This can determine if you bring the pet to the treatment room, or to place the patient in the room to be assessed by the clinician as the next step. Is the patient able to walk? Did they have some sort of trauma? Are they seizing? Lastly, perform an external assessment. Look over the entire patient and check every side. Attend to wounds, lacerations, punctures, or abrasions. Assess for any crepitus, fractures, or pain in the abdomen. Are there any skin issues? Infectious diseases are always something to keep in mind while triaging patients. Ask yourself, where would you triage an urgent infectious patient? Is the patient going to transfer that infectious disease to you or to other patients? When working with a patient, the pet’s owner should be on the mind of every attending staff member. Indeed, staff should be triaging the owner as much as they are triaging the patient. Keep the owner calm, cool, and informed. The more informed they are, the more they will feel comfortable knowing the staff and veterinarian are in control of their pet’s health. Wrapping up A secondary assessment should be done after the patient is stable. A full physical exam, bloodwork results, imaging interpretation, and repeated ABC assessments are performed. Repeating and reassessing the ABCs is crucial, as these levels may change quickly in any patient. Shock may reoccur, pain may surface, or other symptoms may come up. Keep the patient clean, dry, and comfortable. Change bandages and splints as needed. Always keep an eye on the patient’s neuro status, pain, anxiety level, urine output, and hydration status. Triaging is important in any hospital setting. If prepared, emergency situations can run smoother with the hospital staff. Remember to assess the ABCs and communicate effectively with the client. This can save your patients’ lives. Tami Lind, BS, RVT, VTS (ECC), is the current ICU and ER supervisor at Purdue University Veterinary Teaching Hospital. Lind has been at the university for 10 years. She went to veterinary technology school at Purdue and graduated in 2010 with her bachelor’s degree in veterinary technology and has never left. She started as a veterinary technician in the ICU and has been the supervisor at Purdue since 2012. References Battaglia A, Steele A. Small Animal Emergency and Critical Care for Veterinary Technicians. 3rd Ed. St. Louis: Elsevier 2016, Chapter 12: p. 209-222. Silverstein D., Hopper K. Small Animal Critical Care Medicine. 2nd Ed. St. Louis: Elsevier, 2015, Chapter 1: p. 1-5. Creedon J., Davis H. Advanced Monitoring and Procedures for Small Animal Emergency and Critical Care. West Sussex: Wiley-Blackwell, 2012, Chapter 1: p. 5-10.
