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.

Stressful Jobs

I'm not going to post a preview so as not to spoil it. I'll just say that it is one of the best ER blog posts ever.

Stressful Jobs

Story of the Night

You can't make this stuff up. A young guy gets mad at another driver and words are exchanged, along with some honking and gesturing.


They decide to pull off the road and settle their argument old school style. As it turns out, one punch was enough, and my patient lost. His reasoning?

"I drive an Explorer and he was driving one of those boxy Scions, so I figured I could kick his ass."

A nod to my colleagues

I've been too busy working and commenting on other blogs lately to post much original material, but I hope to get back in the swing of things shortly. Meanwhile I would like to give a hat tip to my friends and fellow commenters over at Movin' Meat and Dr. Dork for their insightful posts and comments on the topics of medical insurance and universal healthcare. Thanks for allowing me to participate in these interesting discussions.

Access to Emergency Medical Services Act (H.R. 882)

This is an important bill, and I encourage all Americans to look it over. Reducing the waiting time in emergency departments and improving access to emergency medical care are goals that all of us should be willing to support. The links below make writing your Congressional representative as simple as can be. Somebody already wrote the letter for you, all you have to do is "sign" it.

Physicians:
Contact Your U.S. Representative to support this legislation

Concerned members of the public:
Contact Your U.S. Representative to support this legislation

___________________________________________________

Access to EMS Act Fact Sheet

From the ACEP website:

Every American expects emergency departments to provide expert medical care when they need it. Emergency departments are a vital part of every community - caring for critically ill or injured patients, as well as victims of epidemics, natural disasters and acts of terrorism. Emergency physicians also care for people who have nowhere else to turn and often are the only source of medical care available at night, on weekends and on holidays.

Recognizing the important role of emergency medicine and trauma care in this country and acknowledging the critical problems patients face when these services are not readily available, the "Access to Emergency Medical Services Act of 2007" (AEMSA) was introduced on February 7, 2007 by Reps. Bart Gordon (D-TN) and Pete Sessions (R-TX) in the U.S. House of Representatives.


* The legislation sets up a bi-partisan commission on access to emergency medical services that will make recommendations to Congress to rectify obstructions to patients receiving care. The commission would examine issues such as emergency department crowding, the availability of on-call specialists and medical liability issues that impede access to emergency medical services.

* The legislation addresses the practice of leaving or "boarding" admitted patients in emergency departments until an inpatient bed becomes available, which cause gridlock, long waits for treatment and ambulance diversion It requires hospitals to report to the Secretary of the Department of Health and Human Services (HHS) the amount of time admitted patients are being held or "boarded" in the emergency department while they wait for inpatient beds to become available. If the data collected justifies the development of a quality measure to ensure improved patient care, then HHS would work with all affected parties to develop a hospital boarding measure aimed at alleviating this problem.

* The continuing decline in payments for emergency medical care reduces resources to care for more patients, decreases access to on-call medical specialists who lack financial incentive to be on-call to emergency departments, and makes emergency medicine unattractive to medical students when choosing a specialty. For this reason, the bill calls for increases in Medicare payments to physicians who provide care in emergency departments.

Picture of the Weekend

After Shan Foster and his unranked Vanderbilt Commodores defeated the top-ranked Florida Gators today, he and an unidentified teammate celebrated by sharing a Snickers bar.

Quotes of the Day

You can tell what sort of interview it's going to be when the first thing your patient asks is:

"Do you give B-12 shots?"

The highlights were that she claimed to be a professional roller skater, she discussed at length (and demonstrated) how she learned to pick her nose without making it bleed, and I noticed that she was wearing unmatched tennis shoes.


And from the news:

"It happened so fast," mother Rebecca Johnson told the newspaper. "I didn't know what happened until he was in my pant leg."

Mason Matthew Parkinson, who weighed in at 5-pounds, 15-ounces, was delivered into his mother’s sweatpants, according to The Daily Courier.

Maternal Instinct

I love stories like this. Maybe we CAN all just get along.

Workers at the Meriden Humane Society are marveling at a short-haired mother cat that has adopted a 6-day-old Rottweiler puppy that was rejected by its mother.

The tiny pup, named Charlie by Humane Society volunteers, nurses alongside a jumble of black and gray kittens recently born to Satin, who was taken to the shelter by an owner unable to care for her. Charlie's mother was found by the side of the road in Meriden a couple of months ago. She gave birth to two puppies, but one was stillborn. As sometimes happens with a stillborn in the litter, the mother refused to accept Charlie.

Volunteers bottle-fed him every two hours, but the effort was exhausting for them and insufficient for the puppy, volunteer Chris Chorney said. Research indicated that a suitable substitute could be Satin, who had given birth to four kittens that have quickly warmed to Charlie.

"The kittens scrum up with him and treat him like one of their own," Chorney said. "There's a certain social benefit of small animals being with each other."

Happy Valentine's Day

To my readers of the female persuasion. Especially you, Mom.

Patient Dumping

It's a new blog, but already it's one of my favorites. Check out ERnursey and her take on the Los Angeles patient dumping scandal.

It's Flu Time in Texas

We've finally documented a few cases of influenza during the last couple of weeks. All of the cases I've seen so far have been in patients who have not gotten a flu shot.

It's not too late to get vaccinated, and if you haven't yet I recommend that you do so ASAP. It takes a couple of weeks for your immunity to the virus to develop, and by then I predict the flu is going to be widespread in these parts. And no, the shot will not give you the flu. So go get vaccinated.

Influenza is a serious condition that kills more than 36,000 Americans each year. Even if you survive it, you'll feel miserable for a week or two and certainly miss some work. Typical symptoms are:

* fever (usually high)
* headache
* extreme tiredness
* dry cough
* sore throat
* runny or stuffy nose
* muscle aches

Stomach symptoms, such as nausea, vomiting, and diarrhea, also can occur but are more common in children than adults. There are treatments available, but they work best if started within 12-24 hours of onset of fever. If you wait more than 2 days, you will just have to ride it out.

Here is a map of current influenza activity in the US:

Gross

It had been a pretty busy, fast paced night with the usual collection of head injuries, gallbladder attacks, fractures, psychos, chest painers, gastroenteritises (gastroenteriti?) and such. Finally we had cleared out the ER and settled down for a little break.

Ding! One more patient rang the bell.

No problem, a teenager with an upper respiratory infection.
In and out. It was late, or early (depending on your perspective) and we were all sort of spaced out in the 4 am daze. So I didn't immediately notice the wadded-up pile of sheets, blankets, and gown next to her. Or the wrinkled sheet sort of covering the stretcher, or the obviously used pillow. The patient didn't seem to notice either, nor did her parents. Finally, I did.

"Is this your pile of stuff, or was it already here?" I asked.

"It was there when we got here" she said.
She had just sat down next to the pile.

Nasty. I predict a scathing Press-Ganey.

Change of Shift

The weekly nursing carnival is up at Nurse Ratched's Place and is definitely worth a visit. Thanks to Mother Jones for including one of my posts. The virtual donuts are on me.

The Objective Pain Scale

As we have discussed previously, the pain scale commonly in use is practically worthless for triage, because almost every patient says their pain is a 10 on a scale of 1 to 10. Except for those jokesters who say their pain is "11" or "15" or some such nonsense, that is. Therefore I present my own pain assessment scale for the benefit (or amusement) of triage nurses everywhere.

I think the clinician's assessment of the patient's pain is more useful than the patient's assessment of their own pain, as far as triage is concerned. The currently used pain scale is only helpful in assessing response to treatment (the trend). Mine is more realistic:

Scalpel's Pain Assessment Scale

• 0 - No pain. Patient is asleep, respirations unlabored.
  
• 1 - No pain. Patient is awake and appears comfortable.
  
• 2 - Patient appears comfortable but says it "hurts a little."
  
• 3 - Patient appears comfortable, but says it "hurts."
• 4 - Patient appears comfortable, but says it "hurts a lot."
  
• 5 - Patient appears to be in pain and is wincing or limping.
• 6 - Patient appears to be in pain and is making painful noises (groaning).
  
• 7 - Patient appears to be in pain and has abnormal vital signs.
• 8 - Patient appears to be in distress and is writhing in agony, trembling, or crying.
  
• 9 - Patient appears to be in distress and is writhing/trembling/crying and vomiting
• 10 - Patient is in severe distress: writhing, trembling/crying/vomiting, and screaming.
  

Note that if a patient appears comfortable in no apparent distress, it doesn't matter how they rate their pain; they are still ranked below those with obvious evidence of pain. I don't expect any bigwigs to endorse or utilize these recommendations, of course, but it should give you an idea how I personally triage patients who are in pain. I don't like to have patients who are screaming or vomiting, so I'm going to expedite their care.

Of course, other factors are important in the official triage assessment such as age, chief complaint, comorbidities, and vital signs (which are the most important feature of triage but perhaps underrepresented by this scale). Often it's the quiet patients we have to worry about. But if you have a screaming kid in the ER, you can rest assured that I won't keep you waiting long.

Ipecac Contest

Don't try this at home. Pee-in-pants funny.

Super Sunday

I was so looking forward to the Super Bowl this year. Not because I really cared who won; I couldn't name more than three players from either team. I don't watch football much anymore, being more of a baseball and basketball fan the last few years. But I'd worked each of the last seven nights with a nagging upper respiratory infection sucking the life out of me for the last three, and so I was ready for a day off. Barbeque, beer, and football: just a typical day in heaven, I suppose, but to a nightshift ER doc a day off that coincides with something actually happening in the world is precious indeed.


So I tiptoed into the house after my brutal slog of shifts only to find my wife was already awake. And crying. When I am faced with the prospect of diagnosing and treating a family member's medical condition, I feel like Superman when he is weakened by Kryptonite. My medical powers disappear, and I am just another mere mortal.


Well, that's not exactly true. I think my ability remains intact, but the physician-patient relationship is altered. As I have mentioned before, the interaction seems to work better when there is a little emotional disconnect. Besides, she was hurting and she probably needed some narcotics, but the Bizarro Medical Board frowns on physicians prescribing the good stuff to spouses. So after I had exhausted all of the nonnarcotic arrows in my quiver (and taken a short nap), off to the ER we went. Yes, the last place I wanted to spend my day off.

It was interesting seeing the process from the "concerned husband" perspective. After the doctor interviewed and examined her and discussed the tests he was going to do, he asked her if she wanted something for pain.

"No, I'm OK right now" she said. And so he left.

"Umm, honey? The whole reason we came here is to get you some pain relief. Remember?"

"Well, I'll just ask him when he comes back."

"He's not coming back until all of your tests are done and he's ready to discharge you," I said knowingly. If then, I thought.

"Then I'll just ask the nurse when she comes back in."

Yes, I think you'd better.

Fortunately everything turned out OK, her pain was relieved, and I only missed the first quarter of the game.

Who You Callin' Fat?

You go, girl. Rantilicious.

The Sad Truth About Miscarriages

KANSAS CITY, Mo. (Wednesday, January 31, 2007)— A woman whose premature baby died the day after she was arrested has sued the Kansas City Police Department and two officers who repeatedly ignored her pleas for medical help while they were arresting her.

A police videotape released Tuesday shows Sofia Salva telling police officers numerous times on Feb. 5, 2006, that she was (three months) pregnant, bleeding and needed to go to a hospital.

After the ninth request, a female officer asked: "How is that my problem?"

Salva, a Sudanese native, was held overnight on traffic violations and outstanding city warrants. After being released the next morning, she delivered a premature baby boy who died after one minute, according to a lawsuit Salva filed Friday in Jackson County Circuit Court.

Salva sued officers Melody Spencer and Kevin Schnell and the Police Department for wrongful death, personal injuries and failure to provide medical assistance. Salva is seeking actual damages exceeding $25,000 and punitive damages to punish and deter such conduct in the future.

"The officers went into this with a preconceived idea of who and what they were dealing with, and they were wrong," said Salva's attorney, Andrew Protzman. "It's tragic."

---

Well, the bottom line is that medical attention would not have affected this outcome at all. If someone is having a miscarriage, we are powerless to stop it. As long as we are pretty sure a patient does not have an ectopic pregnancy and is not suffering a life-threatening (to the mother) amount of bleeding, then all we can do is pat them on the shoulder and wish them well. Maybe we administer the occasional shot of Rhogam, for whatever that's worth.

"Wrongful death?" ...ridiculous.
"Personal injuries?" ...apparently not.
"Failure to provide medical assistance?" ...that all-important pat on the shoulder, I guess.

Should the officers have taken the woman to a hospital?
Probably. She might have had an ectopic pregnancy and died.

Did they cause harm to the mother or fetus by not doing so?
Not this time.

Does she deserve any financial compensation?
I say no.