"The humans are dead..."

I haven't been in EMS that long, so the fact that I have observed changes in the way things are done at all is a testament to the rapid nature of progression in the medical field.  

Recently, at a major area hospital, the triage system was made paperless.  Nurses enter patient information, history, medications, and allergies into one computer, while CNAs take vitals and enter them into another.  Registration clerks put billing and address information into yet another computer.

One of my first experiences with the new system came on a Sunday morning.  We had responded for a nosebleed.  My previous experiences with nosebleeds had mostly been pediatric calls, nervous mothers who were concerned about a relatively small amount of blood loss.  This would be different.  Walking into the apartment, we found a deaf man who lived alone.  Blood had soaked through a towel he pressed to his face, the pajamas he still wore, and left a trail throughout the dwelling.  My lieutenant, leading the patient care, asks me to find out what medications the patient takes while she applies a trauma dressing to his face.  I write the message down on a piece of paper and hold it in front of one of the patient's friends–also deaf– so that he can relay the question to the patient.  He signs something to her.  I intercept his reply with the limited sign language my girlfriend had taught me.  D-E-P-A-K-O-T-E.  C-O-U--oh, great.  Coumadin.  "He takes Coumadin, LT."  

"Okay, we need to get out of here."  Releasing pressure on the trauma dressing for an instant unleashes a stream of blood from the patient's nose.  We put him on the stairchair, but "getting out of there" would prove harder than we thought.  Overwhelmed, frightened of being out of control, the patient didn't want to leave without all of his articles, keys, motorola sidekick, cards, wallet, overnight bag.  Things we just didn't have time to collect.  My lieutenant scribbles on the notepad: "He may be bleeding to death, we need to go now," and showed it to the friend.  He frantically signed to his friend, presumably urging to let go of the door frame, and let us take him to the hospital.  ("I hate using scare tactics," she told me later, "but I knew we wouldn't be able to stop the bleeding.")

In the truck, I overcame my timidness about using sign language, which I'm not very comfortable with, in order to calm the patient down.  I told him that we had to start an IV to replace lost fluid,  and that it would hurt.  We raise his legs on the stretcher.  I asked if he had pain, and he pointed to the nose.  I tried for an IV with an 18 in the left AC, but missed.  The lieutenant got the line in a vein close-by.  We spiked another bag, and I placed another 18 in the other arm.  Blood soaks through dressing after dressing.  The patient signed "mom," and gave me his mother's phone number.  I told him we would call as soon as we could.  The small exchanges we have take forever–they're sent back and forth one letter at a time–still, I can see the patient is less frantic for having been able to communicate with someone.  We call the hospital, advise them that we're bringing in a patient with uncontrolled hemorrhaging, and that we'll need an ASL interpreter.

We get to the hospital, wheeling the patient into the ambulance triage area.  We expected to be waved into a trauma room immediately.  "What do you have?" a hidden voice asks us.  I look around.  The voice came from behind the desk where the triage nurses usually stand, but I can't see anybody behind the 22 inch computer monitors that are mounted on rolling carts at eye level.  I walk up and give a report.  Each time I use words that should be red flags for the nurse–"hemhorrage, coumadin, large blood loss before our arrival, bleeding uncontrolled by pressure, two large bore IVs"–I expect her eyes to snap up, for her to just look at the patient and recognize the gravity of the situation and assemble a team in a critical care room.  Instead, she clicks through the fields on the computer program, entering information as she goes.  

Under the old system, a triage nurse standing at the waist-high desk would have given the patient a once-over glance that would generally tell them more about the patient than the rescue report itself.  If the patient were critical, he or she would have time stamped the triage form at the desk and accompanied the rescue into the trauma room to gather information.  

My partners and I exchange wide-eyed "WTF" looks as we stand there in triage, our patient still bleeding.  Eventually, the nurse walks out from behind the computer stand and lifts the trauma pad off of the patient's face, revealing a very-actively bleeding nose.  We are finally sent to a trauma room, where I stay to help interpret as long as I can before we have to leave.  The ASL interpreter is still half an hour away.  

I believe that kinks in the new system will be worked out.  As nurses become proficient in working the machines, data entry will become automatic, much like the scribbling of notes on the intake form, and hopefully won't prevent eye contact between the nurse and provider or patient.  Computerized triage conceptually sounds like something that would break down delays in patient care, but until the system is optimized it may cause undue delays.