Hey everyone, welcome back to My Weird Prompts. I am Corn, and I am sitting here in our living room in Jerusalem with my brother, the man who probably knows more about emergency protocols than is strictly healthy for a civilian.
Herman Poppleberry, at your service. And you are right, Corn, I do find the mechanics of how we sort through chaos absolutely fascinating. I think it comes from that deep-seated need to find order in the universe, even when that order is literally a matter of life and death. It is about the architecture of decision-making under fire.
It is a heavy topic today, but it comes from a very personal place. Our housemate Daniel has been dealing with some asthma issues lately, what the doctors call an exacerbation, and he was telling us about his experiences at the local urgent care centers here in the city. He noticed something that I think most of us overlook because we are usually too busy being stressed out, gasping for air, or in pain. He was talking about the true frontline. Not the specialists in the back, but the people you see in those first sixty seconds. The receptionists and the triage nurses.
It is such a brilliant observation. When you walk into an emergency room or an urgent care center, you are not just entering a building; you are entering a highly calibrated machine that starts the second your foot hits the linoleum. Daniel was pointing out how these professionals, especially the veterans, have this almost eerie calm. You can walk up and say you think you are having a heart attack, and they will look at you with the same steady, unwavering gaze they use for someone with a minor skin rash. It can feel cold, like he said, but there is a profound, scientific reason for that professional distance.
Right, and Daniel wanted us to dig into what is actually happening behind that stone-faced exterior. What is the training? How do they spot a real emergency in a sea of people who all think their situation is the most urgent thing on the planet? And maybe most interestingly, what can those of us who do not work in medicine learn from their ability to prioritize and recognize patterns under extreme pressure?
I love this because it touches on the limits of technology too. We talk a lot about artificial intelligence in medicine, like we did back in episode three hundred fifty-three, but the human element in triage is incredibly difficult to replicate. But before we get into the modern tech, we have to look at where this all started. You cannot understand the triage nurse without understanding the battlefield.
You are talking about the history of the word itself, right? Triage. It sounds French.
It is French. It comes from the verb trier, which means to sort or to cull. And the man we have to thank for the modern system is Baron Dominique-Jean Larrey. He was the chief surgeon of Napoleon Bonaparte's Grande Armée. Before Larrey, if you were wounded on a Napoleonic battlefield, you were basically left where you fell until the fighting stopped. Sometimes that meant lying in the mud for twenty-four or even forty-eight hours before anyone came for you.
That sounds like a death sentence for anyone with a serious injury.
It usually was. But Larrey changed everything. He developed what he called the ambulance volante, or the flying ambulance. These were light, horse-drawn carriages with suspension systems that could gallop onto the active battlefield to collect the wounded. But the real revolution was his rule for sorting. Larrey insisted that soldiers be treated according to the severity of their injuries, not their military rank.
Wait, so a private with a gut wound would get treated before a general with a broken arm?
Exactly. It was a radical, egalitarian shift in medicine. He even treated enemy soldiers with the same priority. At the Battle of Waterloo, the Duke of Wellington actually ordered his men to stop firing in Larrey's direction because he saw the surgeon out there treating the fallen. Larrey's philosophy was simple: the most urgent need gets the first resource. That is the DNA of every emergency room you walk into today.
So, fast forward to twenty-six years into the twenty-first century. How has that Napoleonic sorting evolved? Because it is not just about who is bleeding the most anymore.
No, it is much more systematic now. In the United States and many other parts of the world, we use something called the Emergency Severity Index, or E-S-I. We are currently on the fifth edition of the E-S-I handbook, which was a major update released a couple of years ago. It is a five-level system that ninety-four percent of hospitals in the U.S. use to categorize patients.
Walk me through those five levels. If I am Daniel walking in with asthma, where do I land?
Well, level one is the highest acuity. This is a patient who requires immediate life-saving intervention. They are not breathing, they have no pulse, or they are in active cardiac arrest. You do not wait for a chart; you go straight to the trauma bay. Level two is high acuity. These are patients who are currently stable but have a high risk of deteriorating quickly. We are talking about chest pain that might be a heart attack, or symptoms of a stroke. The fifth edition of the handbook actually added more clarity here to help nurses identify these high-risk cases earlier.
And what about the lower levels? That is where most of us end up, right?
Exactly. Level three is the most common and the most difficult to manage. These patients are stable but need multiple resources. Maybe they need blood work, an X-ray, and intravenous fluids. Level four is someone who needs just one resource, like a simple stitch for a cut. And level five is the least urgent, like a prescription refill or a common cold. The magic, and the danger, happens in that transition between level two and level three.
Why is that the danger zone?
Because if a nurse misses a subtle sign and puts a level two patient into the level three bucket, that person might sit in the waiting room for four hours while their condition worsens. The fifth edition of the E-S-I specifically emphasizes checking vital signs for those lower-acuity patients to prevent what they call undertriage. They found that a lot of people who looked fine actually had dangerously high heart rates or low oxygen levels that were being missed.
So, who is the person making these calls? You mentioned it is not a junior position.
Definitely not. To be the person in the triage chair, you usually need several years of experience in emergency or critical care. Many hospitals require a certification called a Certified Emergency Nurse, or C-E-N. To get that, you have to pass a rigorous exam covering everything from fluid resuscitation for burn victims to the pathophysiology of frostbite. You also see certifications like T-N-C-C for trauma and E-N-P-C for pediatric care. These nurses are experts in what researchers call gestalt perception.
Gestalt. That is another one of those fancy terms. What does it mean in a medical context?
It comes from Gestalt psychology, the idea that the whole is greater than the sum of its parts. A veteran triage nurse is not just looking at your blood pressure or your temperature. They are performing what is called thin-slicing. In the first thirty seconds, they are processing thousands of data points unconsciously. They are looking at your skin color, the way you are bracing your body, the rhythm of your speech, and even the smell of your breath.
It is like that Malcolm Gladwell idea. The expert who can look at a statue and know it is a fake without being able to explain why immediately.
Precisely. There was a fascinating study presented at the European Emergency Medicine Congress in Barcelona just last year, in late twenty-twenty-five. They compared the triage accuracy of experienced doctors and nurses against an A-I model using real-world case studies. The doctors had an accuracy rate of about seventy-one percent, and the nurses were at sixty-six percent. The A-I? It was only at fifty percent.
Only fifty percent? That is basically a coin flip. I thought A-I was supposed to be the future of diagnostics.
It is, but triage is not just about data; it is about context. The A-I was actually very good at identifying the absolute most critical cases, the level ones. But it struggled with the nuance. It tended to over-triage, meaning it thought everyone was an emergency. A human nurse can look at a patient and realize they are downplaying their pain because they are embarrassed, or they can sense that sense of impending doom that often precedes a major medical event. That human-to-human calibration is something an algorithm still cannot grasp in twenty-twenty-six.
That sense of impending doom sounds like something out of a horror movie, but I have heard doctors talk about it seriously.
It is a recognized clinical sign. If a patient tells a nurse, I feel like I am going to die, a veteran nurse takes that as seriously as a high fever. Their brain has seen ten thousand patients, and this specific patient is triggering a tiny alarm because their breathing rhythm is just slightly off, or their skin has a specific gray tint that indicates poor perfusion. It is top-down processing. They see the whole picture first, then they look for the details to confirm it.
Let us talk about the other person Daniel mentioned, the receptionist. They do not have the C-E-N certification or the nursing degree, but they are still part of that filter. What is their role in this pattern recognition?
They are the eyes and ears of the waiting room. While the nurse is focused on the patient in front of them, the receptionist is performing constant visual sweeps of the room. They are trained in crisis management and de-escalation. They are looking for the person who was sitting upright five minutes ago and is now slumped over. They are looking for the person who is suddenly sweating profusely or whose breathing has become audible from across the desk.
They also have to deal with the psychological side of the waiting room, which sounds like a nightmare. Everyone is stressed, everyone is in a hurry.
It is incredibly taxing. They often use a technique called radical transparency. If the wait is four hours, they do not tell you it will be twenty minutes to keep you happy. They tell you it is four hours and they explain why. They might say, we just had three ambulances arrive with major traumas. When people understand the why behind the delay, their cortisol levels actually drop. It is the ambiguity of the wait that causes the most aggression.
That leads perfectly into the transferable skills. Most of our listeners are not in the E-R. They are in offices, or they are parents, or they are running businesses. How do we take this triage mindset and apply it to a normal, non-medical life?
The first thing is the E-S-I framework itself. We all have days where we have twenty tasks and they all feel like level one emergencies. But if you are honest, most of them are level fours or fives. The skill is in identifying your personal red flags. In a hospital, a red flag is a heart rate over one hundred forty. In your work life, a red flag might be a specific type of feedback from a key client or a missed deadline on a foundational project. You have to decide in advance what constitutes a level one so that when the stress hits, you are not deciding on the fly.
Because when you are stressed, your brain's logic center starts to shut down. You want those protocols pre-loaded.
Exactly. Another huge tool is S-B-A-R. That stands for Situation, Background, Assessment, and Recommendation. It was originally a military communication tool that was adopted by healthcare to prevent errors during handoffs. Think about how much time we waste in meetings or long emails just getting to the point. If you use S-B-A-R, you strip away the fluff.
Give me an example of how that works in a regular job. Say, a software developer talking to a manager.
Okay. Situation: The login page is crashing for ten percent of users. Background: We pushed a minor update to the database last night at midnight. Assessment: I think the new encryption protocol is incompatible with older browsers. Recommendation: I need to roll back the update immediately and I need two hours of the senior engineer's time to debug.
That is so much better than a ten-minute rambling explanation about how tired everyone is and how the code was difficult to write.
It saves mental energy for everyone involved. And then there is the emotional side, which is where the B-A-T-H-E technique comes in. This is used for quick emotional support without getting bogged down. B-A-T-H-E stands for Background, Affect, Trouble, Handling, and Empathy.
How does that look in practice? If I am a manager and an employee is melting down?
You ask: What is going on? That is the Background. How does that make you feel? That is the Affect. What bothers you the most about this? That is the Trouble. How are you handling it? That is the Handling. And then you finish with: That sounds incredibly frustrating, I can see why you are stressed. That is the Empathy. You can do the whole thing in sixty seconds. It validates the person's feelings so they can move back into a logical state, but it prevents the conversation from turning into a two-hour vent session that kills your afternoon.
It is efficient empathy. It sounds a bit clinical, but it is actually more compassionate because it allows you to help the person and then get back to the work that needs to be done.
Precisely. And we have to mention the local flavor here in Jerusalem. Daniel mentioned that the staff here can seem particularly stone-faced. There is a cultural element to this called dugri. It is a Hebrew word that means direct or straight-talk. In Israel, social niceties often take a backseat to efficiency, especially in high-stress environments.
It can be jarring if you are used to the very polished, customer-service-oriented bedside manner in the States. But here, if you are not dying, they are going to tell you that you are not dying, and they are going to move on to the person who is.
It is a culture of resilience. People here have a very high baseline for what constitutes a crisis. That translates to the medical staff. It takes a lot to rattle a nurse in Jerusalem. They have seen everything. That professional equanimity we talked about? It is reinforced by a society that is very comfortable with pivoting in the face of chaos.
So, looking at the future, where does this go? We are in twenty-twenty-six. We have smart inhalers, we have wearable tech that tracks our heart rate variability. Does the triage nurse just become a data-entry clerk?
I think it is the opposite. The role is evolving from data-gatherer to data-synthesizer. Instead of the nurse asking you what your symptoms are, they might already have a week's worth of oxygen data from your watch. Their job will be to look at that data and provide the context. The machine says your heart rate spiked, but the human nurse sees that you are also grieving a loss or that you have a specific type of anxiety. The human provides the judgment, and you cannot automate judgment. Judgment is the application of rules to a messy, unpredictable reality.
That is a powerful way to put it. They are the gatekeepers of the system. Next time I am in an urgent care, I am going to look at that receptionist and that nurse with a lot more respect. They are performing a high-level cognitive dance while most of us are just trying to remember our insurance numbers.
And if you are listening to this and you work on that frontline, thank you. You are the reason the system stays upright when the chaos hits.
Truly. Well, I think we have covered a lot of ground here. We talked about Baron Larrey and the Napoleonic roots of triage, the five levels of the E-S-I, the power of gestalt perception, and those actionable tools like S-B-A-R and B-A-T-H-E.
It is a lot to chew on. I hope our listeners find ways to apply that triage mindset. Whether it is using a thirty-second reset between tasks or just being more direct in your communication, there is a lot of wisdom in the emergency room.
Definitely. And hey, if you found this episode helpful, we would really appreciate it if you could leave us a review on your favorite podcast app. It really does help other curious people find the show.
It makes a huge difference. We love seeing this community grow.
You can find us on Spotify and at our website, myweirdprompts.com. We have the full archive there, and if you have a question or a topic you want us to dive into, there is a contact form right on the site.
Or you can be like Daniel and just shout it at us while we are making coffee. That works too.
It helps if you live with us, but the contact form is a close second. Thanks again to Daniel for this prompt. I hope your asthma settles down soon, man.
Yeah, breathe easy, Daniel. And thanks to all of you for listening. This has been My Weird Prompts.
We will see you next week. Stay curious.
And stay calm. Bye everyone.
So, Herman, I have to ask. If you were a triage nurse, what would be your biggest challenge?
Oh, definitely the talkative patients. You know I love a good deep dive. I would probably get stuck in level five with someone explaining the history of their hangnail for forty-five minutes while a level two is waiting in the hall.
See, that is why they have the checklists. To save you from yourself.
Exactly. The system is there for a reason. It protects the patients and the practitioners.
Well, I think I would struggle with the stone-cold face. I am a natural smiler. I would probably look way too happy to be checking in someone with a broken leg.
You would be the most confusing nurse in the hospital. They would think you were some kind of cheerful villain.
Alright, on that note, let us wrap this up.
Deal. See you later.
Take care, everyone.
One last thing, Corn. Did you know that in some hospitals, they actually use the smell of vanilla in the waiting room to lower patient heart rates?
Really? Does it work?
Some studies say it lowers the heart rate by a few beats per minute. It is a subtle way to manage the room's energy.
Maybe we should get a vanilla candle for the house. Might help with the next podcast deadline.
Not a bad idea. I will put it on the grocery list.
Perfect. Alright, now we are really done.
Bye!
Bye!
