More Reports from the ED

This past week was a busy one in the ED. We are seeing a lot more cases of COVID as of late. I was working in “fast track” one day, which is where our minor illnesses go. I saw six different patients who were positive for COVID. None of them were serious enough to be admitted, and were sent home with instructions to get lots of fluids, rest, and take OTC medications to control symptoms. So we are seeing lots of COVID patients, but none of them are seriously ill.

If you want to know more about how emergency medicine is done, read on. If that doesn’t interest you, then there will be other posts.

The ED is organized chaos. There is a lot that goes into a large emergency room that is seeing hundreds of patients a day. How this is accomplished is that the ED is divided up into zones, each color coded to indicate the acuity of the patients within it.

Gray Zone

Gray is not really a treatment zone. This is where patients are checked in and triaged. The gray nurses decide which treatment zone a patient will be sent to. It’s staffed with two technicians, two nurses, and a registration clerk. Security is also here, because this is where people decide to be assholes. If the ED is really busy, a doctor and an additional nurse (called the pit nurse) get assigned here and began treating the easiest cases out of two exam rooms (called the pit) in gray. The idea of the pit is for people with simple requests like toothaches, wound rechecks, and medication refill requests be treated and discharged within 30 minutes of arriving.

Green Zone

The “Green” zone, also called Fast track, is a subunit of the ED and is entirely made up of patients who the triage unit believes can be treated and discharged in less than two hours. Fast track itself contains three sections:

• Treatment. This area consists of 12 rooms staffed by two or three nurses. The nurses here are usually nurses who are still learning how the ED works. It’s a great area for nurses new to the ED to develop the skills and workflow that makes the ED more difficult and challenging than some other units. The idea of this area is to get the patient assessed, treated, and discharged in less than two hours. The team nursing concept is used in this section, so nurses see a lot of patients in a very fast paced environment. It isn’t unusual for a nurse to see 30 or 40 patients in a 12 hour shift.
• If the patient is not really ill, but we are waiting for some test like the results of a CT scan or some lab work that will take a bit of time, they are moved to RPZ (Results Pending Zone) to await a further clinical decision. RPZ is like purgatory, where a patient waits for the results of those tests to see if they will be discharged or admitted. The patients here have received medication and have been assessed and found to be stable. RPZ is staffed by a single nurse and can contain as many as 12 patients awaiting results, who sit in reclining chairs and watch TV while they wait. There are two rooms here that are used so that the providers can talk privately to patients to discuss lab results.
• Holding. This area is for those times when triage got it wrong, and the patient will be there for longer than two hours. Things like blood administration, medications than take awhile, or patients waiting for an inpatient room on one of the hospital floors. Holding is three rooms, staffed by a single nurse. When I am in fast track, I am usually (but not always) the holding nurse.

Fast track moves a lot of patients through it, over 150 patients a day. The cases are usually mild: toothaches, STI’s, lacerations requiring stitches, FLU like symptoms, and other mild illnesses go here. For that reason, this section sees more COVID cases than any other zone. If the pediatric patient load decreases to the point where they close pediatrics, the children go here for treatment. If patient load drops further, fast track gets closed at either 11pm or 1am. There is one charge nurse that is assigned to both green and purple together.

Purple Zone

Across the hall from green is the purple zone, or pediatrics. It is exactly what it sounds like. It consists of 8 rooms and a pediatric triage room. This zone is staffed by 3 nurses. This is a secure unit that is located behind locked doors. When the ED is especially busy with pediatrics, the gray nurses will send pediatric patients to a separate waiting room so they don’t have to be seated next to the druggies and other people in the gray zone waiting room.

If there aren’t enough pediatric patients, this zone gets closed at 9pm, and pediatric patients go either to the red, orange, or green zone. It’s rare for them to go anywhere other than green, as kids usually aren’t all that ill.

Yellow/Blue Zone

This zone is called “subacute” but it usually is anything but that. With a name like subacute, you would think that this area has patients with complaints that aren’t that serious, but you would be wrong. Some nasty stuff happens in here, and I swear that some of the rooms in this area are located on top of an Indian burial ground or something, because they seem to be cursed. If Red/Orange is full, then any other high acuity patients who come in wind up in Yellow or blue. This area contains 36 rooms that are staffed by 9 to 12 nurses, a charge nurse, and 1 or 2 technicians.

Red/Orange Zone

This zone is called acute care. The patients who are deemed to be the sickest come here. If EMS brings in a patient in cardiac arrest, they come here. Severe respiratory distress comes here. This unit contains 36 rooms that are staffed by 14 nurses, a charge nurse, 3 paramedics, a respiratory therapist, 3 patient care technicians, a clerk, and a lab technician. Three of the rooms are called trauma rooms and are kept empty as much as possible. The most unstable patients are initially put in them, stabilized, and then moved to other treatment rooms as soon as possible. Additionally, there is a room that can be accessed through a decon shower room, and a psychiatric room that is the classic “rubber room,” but thanks to a court case from another hospital deeming that to be inhumane, that room is no longer used for that purpose.

Other staff

Staffing for providers varies, but there can be as many as 6 doctors, a pharmacist, and 2 midlevel providers (Nurse Practitioner or Physician Assistant) in this ED. Also included here are 2 pharmacy technicians, some transporters to move patients around, and two janitors for cleaning rooms. There is also Xray and CT, which are staffed by another 6 technicians, and the lab which is staffed with 4 more technicians, as well as the radiologist who is offsite, but interprets all of the imaging that is done.

So there you have it- a 100 room Emergency Department that, when fully staffed, contains 10 providers, 40 nurses, 20 or so technicians, and 8 to 10 other personnel.

And yeah, this is a filler post, with most of the content written for the day when I needed a post but didn’t feel like writing that morning. (To be honest, it’s because I am out mowing the lawn and doing other honeydew chores this morning.)