I was admitting patients the other day, and it was another great day in the history of emergency medicine.
Case 1: 54 year old female with diabetes and hypertension who complains of chest pain and difficulty breathing with diaphoresis. Exam has reproducible pain. Cardiac enzymes are normal. EKG shows... it shows... wait. There is no EKG. The emergency department hadn't done the most basic assessment of a cardiac patient.
me: So, you want me to admit this patient for...
ER doc: For chest pain. She's here for chest pain rule out.
me: And her cardiac enzymes are...
ER doc: they're all normal. Why are you-
me: The EKG?
ER doc: It's fine.
me: Are you psychic?
ER doc: huh?
me: because you didn't do an EKG.
So I was kind of harsh, but really, what if the patient had ST elevation MI, and she was sitting in the ER for a couple hours while I was getting to her, and she should've been in the cath lab? The ER doc and I both knew that he'd dropped the ball big time, and was lucky that she had a negative EKG, because if it was positive, he'd be presenting at the next M & M conference.
And this was how I began my night of admissions. I wish I could say that it got better from here, but there's a reason I numbered that first case.
Case 2: 30 y/o with HTN presenting with chest pain with difficulty breathing, diaphoresis, nausea. ER doc wants to admit him for rule out MI. SIGH! Okay, well, at least tell me about it. I'm assuming the cardiac enzymes are normal and the EKG was okay. But the ER doc didn't do them. After all, he's a 30 y/o with chest pain and low risk. Why bother?
Case 3: ER doc calls and doesn't know the patient's name, age, room, what the vitals are, what labs were done, or if they were done. The reason for admission is difficulty in breathing. That's all I got.
Case 4: Called to admit patient that by the time I come down, he's intubated. So I ask, "So, this is going to the unit?" Dead silence. He still thought I was going to admit!
Y'know, to any ER docs or people involved in emergency medicine, this right here is why the medicine resident is always pissed when you call for admission. Because this is not okay. This ain't kosher. And it's sad when patient safety relies exclusively on me doing the ER doc's work.
The ER was pretty busy, so I decided against ramming a pole up ER doc's ass, because that waiting room full of people is more punishment than I could ever mete out.
back when I was an intern, my upper level got called about a "syncope" admit. however, when he got down there to talk with the patient, the patient said that he had tripped over a phone cord and fell. My resident grabbed the ED resident who had called, and dragged him into the patient room and asked the patient, "have you met this doctor?" Evidently, the ED resident had made the "call" based off the triage list for a "passing out episode" and had never seen the patient.
ReplyDeleteShit like that just makes my blood boil.
Once in my peds rotation the on-call team was called to the ER for a 2 year old with bronchiolitis. The consult read "R/O pneumonia/bacterial infection". But alas, there was no chest x-ray or even blood work asked by ER doctors-- this extremely intricate exercise in diagnostic medicine was carried out by the peds team, who were obviously the only doctors in the building able to R/O pneumonia/bacterial infection. By asking the appropriate obvious tests, no less.
ReplyDeleteI'm in the ER right now doing a required rotation. Let me just say that it has been educational to see these people at work. I could NEVER do ER in a million years. I find myself hoping for traumas to come in so that it will break up the endless succession of neuro exams for r/o stroke. This is painful.
ReplyDeleteObGyn Consult: 46 y.o. AAF with vaginal bleeding ...
ReplyDelete- Did you do speculum exam? no
- Did you look down there? no
- Did you check for other sources of blood? UA? GI workup? No, no, no
- Did you examine this patient or know anything about this patient?
Very frustrating!!!