Wednesday, November 07, 2007
Many Emergency Medicine doctors would probably agree that one of the main times where mistakes happen with patient care is at sign-out. At the end of a shift, care of any remaining patients left in the department is transferred over to the incoming physician. The goal is to get as many of one's patients dispositioned (discharged home or admitted with orders by the admitting service) prior to sign-out. As one may imagine, with "emergencies" continuously filtering in throughout the shift, it is sometimes difficult to know exactly what is going on with Mrs. Smith or her catscan. Patients are re-assessed by the incoming physician, but is generally a much more brief process than the initial history and physical exam, and often patients that are signed out as "stable" may not be checked up on until other, larger fires are put out first.
The other morning, I took over a patient with a rectal bleed. However, this was not your typical rectal bleed. This patient had intentionally shoved a paring knife up her rectum. This story of course set off all sorts of bells and whistles in my head regarding psychiatric issues. The overnight team left, saying that she had some blood products ordered and the surgery team was taking over. Fortunately, it was slow enough, and her story was bizarre enough that I went in to see her right way. The woman was pretty quiet, and seemed rather hesitant to talk about it. At first she just said that she cut herself so that she could get admitted to the hospital. However, after a few minutes of talking, it turns out that she thought that she had "telepathic" powers with her dead boyfriend, and that by killing herself she thought that she would be able to see him. At that point, I had the patient put on a psych watch as she had been left unattended before that. She ended up staying all morning in our department though as her blood was too-thinned with coumadin and had to be reversed with transfusion before surgery would take her for exploration under anesthesia and repair the damage. She ended up doing fine, but she definitely required more time and attention than what was discussed at sign-out.
On the overnight last night it was pretty much a one-woman show. There was a medicine intern there, but she can only handle about two patients at once. This meant that I took all of the patients at sign-out, plus saw my own new patients, and supervised patients picked up by the med student. The shift started off with a very minor gunshot wound in the trauma bay, and several transfer patients from other hospitals that had multiple injuries. Much of my night was unfortunately spent on the phone with consultants. It took hours just to wade through the sign-out patients that I had assumed care of at midnight. Our nursing staff is pretty awesome, and I get along with them. I think that what saved me was having the patient's nurses let me know when studies had been completed or the patient was essentially wanting to go home, because there were just too many people to check up on.
I think that we did a pretty good job, and by sign-out at 8 am, there was no evidence that we'd had a messy night. However, the shift was such a blur that I can't help but worry about things that may have been missed here and there. There were definitely people who could have been sent home sooner if it weren't for the volume of patients.
I watch the attendings in our department, and their styles range from very conservative with workups to relying almost entirely on clinical assessment. At the end of the day, this is a specialty where one definitely has to be able to rely on their colleagues. Sometimes there simply isn't enough time or resources to check and re-check someone else's work. It is becoming obvious to me that you have to like the people in your workplace, but I don't know how to assess whether a place will be a good fit when it comes time for interviews.