Who Cares?

Here is a scenario I see all too often. An elderly gentleman is brought to the ER by his wife. They came straight from the specialist's office, reportedly to be admitted to the hospital. Unfortunately, as is usually the case, no such arrangements were made by either the specialist or the primary physician. A room was not reserved, orders were not given, the ER was not notified.

So late on a Friday afternoon, the couple arrives to find a crowded department. "We're here to check in," she tells the triage nurse. Somewhat miffed at the dropped ball, they still consider the ER visit to be only a formality. A brief stop, if you will, on their way up to "their room" in the hospital.

So they wait, and they wait, and they wait....and finally they get placed in a room. A room in the ER, that is. I can't see them immediately, however, because we have a packed house of really sick folks. But I move quickly, and perhaps in an hour or so I make it around to evaluate them. By this time, the patient's labs have been drawn and their overnight bags are stowed unassumingly in the corner. It's now almost midnight, and they have been in the ER over 6 hours. He's sleepy, and although she is exceedingly polite the strain of the experience is evident in her voice.

"When do we go up to our room?" she asks.

"Well, I need to talk to you a bit to see what I can do for you. What brings you into the ER tonight?" Because she was brought up well, she stifles the eye roll and sigh. But I can read her mind.

Unfortunately, after my interview and examination it is not at all clear that he NEEDS to be admitted to the hospital. I have no previous records to review, and the problems I can identify seem to be chronic and self-limited. There is no obvious indication for admission. Perhaps I can discuss the situation with either his primary care physician or one of the specialists he sees. So I proceed to make a series of calls.

Of course none of his physicians are on call, and none of the cross-covering MDs know anything about the patient at all. What's worse, they aren't inclined to accept a soft admission late on a Friday night. And often they are noticeably grumpy that I am bothering them after midnight. Cross-covering MDs are the bane of my existence.

"But Dr. Specialist reportedly talked about this with Dr. Primary, and he sent this gentleman here to be admitted," I protest. Unfortunately, they didn't pass the word along to their partners or make the necessary arrangements. So I'm stuck in the middle, hoping for some laboratory or imaging test that will justify an admission.

We in the ER are going to be considered the bad guys either way. If he is admitted, they will complain about the wait. If I am forced to send him home, I am a big meanie. Meanwhile, the waiting room gets even more crowded as I have to spend a significant amount of time dealing with this inappropriate situation.

UPDATE: Hallway Four feels my pain.