Case Presentation
One evening a man in his 50's arrived by private vehicle to an emergency department with complaints of shortness of breath and abdominal pain. He arrived "moaning loudly" that his "stomach hurt" and a pulse oximeter at that time revealed a reading of 79% on room air. Because another patient presented at nearly the same time and was perceived to be more critical than this patient, he was sent, along with the friend who accompanied him, to the waiting room with a non-rebreather mask. It is unknown and undocumented what time he actually arrived to the emergency department and is unclear who decided that the patient should go to the waiting room. The triage staff was notified by the friend who accompanied him to the emergency department that the patient looked bad and was changing colors.

Case Progression
The patient was found in the waiting room unresponsive, cool to touch, ashen with peripheral cyanosis, and absence of palpable pulses. He was taken to a treatment room, ACLS was initiated and he was intubated. The patient remained unstable in the emergency department with repeated episodes of PEA and oxygen desaturation in spite of being ventilated with 100% oxygen. His EKG revealed atrial fibrillation with a rapid ventricular response ranging from 120-170 beats per minute. Following various interventions, the patient did recover palpable pulses and a blood pressure that ranged from 76/37 to 144/74. Previous records revealed a history of acute MI, atrial fibrillation, hypertension, and CVA. He also had a history of drug addiction and was apparently noncompliant with medications. He was admitted to critical care 1 hour and 42 minutes after being placed in a treatment bed with a diagnosis of multiple bilateral pulmonary emboli, atrial fibrillation with rapid ventricular response, and metabolic acidosis.

What Went Wrong
There are several issues identified by the circumstances surrounding this patient's presentation. As most ED nurses are well aware, patients often arrive simultaneously and it is not impossible (or even unlikely) that more than one unstable patient can present to triage at the same time.

Emergency departments must have a process in place to assure that patients experiencing a life-threatening condition are not sent to the waiting room. All patients should receive a rapid triage assessment performed by a registered nurse to determine whether the mandatory immediate bedding criteria can be met. This criteria includes: (1) a patient presents who is obviously ill or you can rapidly and accurately determine acuity and disposition, (2) there is an open bed, and (3) there is an available care provider. If these criteria are met, get the patient in a bed. In this particular case, it would also have been appropriate to initiate a team response to the room.

Additionally, there was no mechanism in place for capturing the actual arrival time when more than one patient was presenting. No one knew what time this patient actually arrived, only what time he was placed in the treatment room in full cardiopulmonary arrest. Lastly, there was a clinical decision made that this patient could be sent to the waiting room after arriving to the emergency department with a room air saturation of 79%. It is incumbent upon us to imagine worst-case scenarios and prepare for those inevitable times when more than one critical patient arrives simultaneously. Failure to have these mechanisms in place can clearly result in an unsafe delay between presentation and triage.