3 patient scenarios show triage doesn’t need to be traumatic

November 27, 2018

Article

Working in an eye clinic can be fraught with scenarios that occur suddenly; they drop without warning.

You are fitting a patient with contact lenses, and she passes out. You are dilating a patient’s eyes, and he tries to bite you. Someone walks into the clinic asking for an evaluation of her foreign body, and when you look up from the front desk you see she has a nail sticking out of her eye.

When these situations occur, most clinic staff goes into emergency mode and addresses these scenarios efficiently and professionally.

But there is one scenario that occurs every time the phone rings, or a patient arrives in the clinic, that sends waves of fear throughout technicians.

It’s triage.

FYI patients
Triaging a patient for his presumed eye problem is difficult at best. You are asking a non-medical person (the patient) that is in a state of distress to help you make a decision on the potential care, and timing of that care, of his ocular condition. The patient’s agenda is often not yours. He is describing a potential diabetic third nerve occurrence-you want him seen today, but he wants to come in three or four days when work is not so busy.

I call these “FYI” patients. All clinics have received calls from FYI patients.

“I am calling to say I have those floating thingies back in my right eye. Oh, no, I don’t need to come in. The doctor told me when I have them again to just call the office and let you know.”

The challenge begins. The patient does not understand that the doctor says, “Call and let me know” because the doctor wants the patient to call so technicians schedule the patient to return to the clinic, not simply note it in the chart.

The patient’s “floating thingies” could be telling you she may be experiencing a posterior vitreous detachment or a retinal detachment. All the patient knows is that the technician’s insistence to come into the clinic is an annoyance, and soon you are an annoyance as well!

Know what to ask
Technicians need a game plan to focus patients on the important needed information, and they need to know how to ask patients questions to obtain that information. It’s best to avoid getting mired in the details of the situation.

It boils down to the who, what, where, when, and how of the problem. If you follow this line of thought, you should have a good idea of what is occurring.

Working at a county level I trauma/burn/pediatric hospital, I learned quickly to stay focused and firm and how to avoid distraction with ancillary information. Throughout my time there, I had three “hated” phone calls:
• “My eye is red.”
• “I see double.” (This is also associated with blurry or “bleary” (which I later learned meant blurry and teary)
• “I suddenly went blind in my eye.”

Let’s talk about these types of calls and how to triage them. The examples I am using are actual calls that came into the clinic. I will highlight the key points to the important parts of the triaging process.

1. My eye is red
This is an unclear complaint, and the technician must probe to find out what the patient really means. Very often patients will say they have bumps on their eyes when they mean their eyelids or they have swelling of their eyes when they arrive with a black eye, so it is important to ask:
• Is the white part of the eye red, or is your eyelid red?
• Is it one eye or both?
• When you went to bed last night, was your eye/eyelid red? Did you hurt your eye or have recent eye surgery?
• Does your eye/eyelid hurt right now?
• Has your vision changed in that eye since your eye got red?

Scenario 1
“My right eye is red. I woke up like this. No, I don’t have any pain. My vision is fine. There is no drainage, and it doesn’t itch. I can’t come in because I work for myself, and I can’t afford to lose the day. I don’t remember getting anything in there. What do I do for work? I am a roofer.”

After much discussion, the patient finally agreed to come in that day.

When he arrived, he had a 360-degree subconjunctival hemorrhage, hyphema, peaked pupil pointing to 5 o’clock, and, after examination by the doctor, retinal metallic foreign body.

What on the phone sounded like a simple potential foreign body ended up in the OR for a ruptured globe and removal of the intraocular foreign body.

2. I see double
Technicians need to ascertain if the patient’s vision is actually doubled or simply so blurry that the vision appears to be doubled.

Plus, is the diplopia horizontal or vertical?

Some additional questions:
• Are you diabetic? (This is the number-one question I ask with diplopia presentation.)
• When did you notice you were seeing double?
• Do you have any pain when you move the eye side by side or up and down?
• Is your eyelid drooping on either side?
• Have you injured your eye recently?
• If you close one eye, do you still see double?
• Is the double vision vertical or horizontal (side by side)?

Scenario 1
“I think something is wrong. I am having double vision in my eyes. I feel OK, but I am scared. No, I am not diabetic. When I look in the mirror, I look OK. It’s very hard to drive-I just came back from the grocery store and I was scared to death. Maybe I had a stroke. It runs in my family. But I feel OK. Should I come in?”

We had this patient come in immediately.

She arrived to the clinic very nervous and upset. She was convinced she had a stroke. When she was checking in, the receptionist casually told her that after she had her exam, the optician would be happy to replace the lens back in her glasses if she brought them along.

Everything the patient had said pointed to a potential major problem. We were glad she came in and even happier that she didn’t have a medical emergency.

Scenario 2
“I woke up this morning with a pounding headache. Then I noticed that I was seeing double. I feel shaky. When I move my eyes, I have pain. I have had diabetes for 18 years. I probably have the start of the flu. We had the grandchildren this weekend, and they all had it. Look in the mirror? Yes, my eyelid is droopy today. Why would you ask me that? It was droopy yesterday, too. I am 73 you know-everything droops! Maybe I’ll wait until I feel better to come in.”

She arrived to clinic that morning with a diabetic third nerve problem. On intake, her lid was not droopy-it was fully closed and could be opened only by physically lifting her eyelid. Looking under the now-opened lid, we noticed that she had an exotropia in that eye as well. She was evaluated by the ophthalmologist, then sent to her primary-care physician for further evaluation of her diabetes.

3. I suddenly went blind today
This statement is a massive red herring because instead of suddenly going blind, perhaps the patient just realized it.

Let’s use the same scenario for two separate cases to see what happened with two different patients.

Scenario 1: Ted
“I was watching TV last night, and all of a sudden I went blind in my right eye for 20 minutes. Just like that. I covered one eye, then the other, and yup, it’s my right eye. Black as night. Didn’t hurt a bit. Well, no, I haven’t had an eye exam in about five years…no need. I have always seen great. I was a fighter pilot in World War II, you know. The wife said I had to call. I’m the family chauffeur. Yeah, I have a little high cholesterol. I’m a meat and potatoes guy.”

When Ted came into the clinic, his vision was tested as 5/200 pinhole no improvement in his right eye. His left eye was 20/40.

His retinoscopy was poor in his right eye, and his left eye was fair. Upon dilation, the doctor diagnosed him with cataracts OD ≥≥OS and scheduled him for cataract surgery.

Ted didn’t suddenly go blind. When he was rubbing his eyes, he covered his left eye and “noticed” his right was “blind” suddenly. It certainly seemed sudden to the patient.

Scenario 2: Millie
Using the same details, Millie comes to clinic after suddenly going blind. But in her case, Millie lost her vision for 16 minutes, then it returned. Vision was slightly diminished upon its return.

On exam, her vision was 20/30 OD and 20/30-2 OS. Her pupils were equal, round, and reactive to light. There was no afferent pupillary defect. Pressures were 14 mm HG OD and 20 Hg mm OS. The technician dilated the patient in preparation for the exam.

The doctor found a Hollenhorst plaque (cholesterol emboli) in her right eye. The patient stated that she had been having blood pressure problems, and it was noted she was taking five medications for blood pressure.

She was referred to her primary-care physician for further care of her blood pressure.

Right now counts
Working with the patient to find the “who, what, where, how” of his concern can yield a number of different instances-and interpretations of those instances.

Be mindful of the patient’s “interpretation” of the problem and keep him focused on the facts of the story.

It doesn’t matter if his problem happened today or two weeks ago. The clock starts ticking when he calls the clinic. Once he tells the technician his story, the technician needs to do what is appropriate right now for the problem.

Sudden loss of vision three weeks ago? Today, the tech is hearing the story, and today the patient should come in.

Remember the golden rule: When in doubt, check it out. If you’re not sure, bring the patient in to be seen by the doctor.