Please, Leave YOUR Doctor at Home

This is something of a rant, so forgive me if there's a lot of jumping around.

"The other day" I walked into a room to find a 60's something female. She was brought in by ambulance, and the nurse was still finishing up reviewing her medications and getting her vital signs, so I walked into the room "cold". The only thing that I knew before walking in was that the word "Dizzy" was written on the whiteboard. Fine.

So, after walking into the room I begin interviewing the patient. I am a few questions in when a well-dressed woman in the room interrupts and asks me if the patient will be getting an EKG. I haven't decided this yet, but to get her off my back, I just say "Yes" because basically just about everyone over 40 gets an EKG... for just about anything.

So, I go back to the patient. The other woman then introduces herself as an internist and says that she works with my patient. She then proceeds to answer for my patient and gives me what details about the episode of dizzyness, only including what she thinks is important. She then adds that "I'm really anxious to see what my friend's 12-lead EKG looks like."

Finally, I get through my interview. As it turns out, the patient didn't just get light-headed, she has numbness and tingling in her left hand, foot, and although I don't observe any slurred speech, the patient is reporting that she just "isn't talking like her normal self."

So, I run through a quick physical exam, being sure to complete a full neuro exam. Now I'm thinking this isn't just a near-fainting dehydration/cardiac problem, it could be a stroke.

I duck out of the room. The attending is busy, so I quickly order an EKG and some meds to make the patient feel better. I give the attending a brief synopsis, and we decide to activate the stroke pager, which means that this patient basically gets pushed in front of everyone else in the hospital with respect to lab results, and imaging studies.

At this point, the internist grabs me in the hallway, and says, "Look, I don't mean to tell you how to do your job, but we still don't have an EKG." As she says this, the neuro resident is stepping into the room behind her back and the patient's nurse is putting her on a portable monitor to get her ready for the head CT.

I calmly tell the internist that the patient is not only getting an EKG, but she's getting evaluated for a possible stroke. Silly me, I had thought this would make her happy. She then asks me if I'm getting cardiac enzymes. I respond that they have already been ordered. At this point, I'm already daydreaming about punching this internist in the face.

I check up on one of my other patients, and see the internist pounce on my attending. By this point, the neuro resident is stepping out of the room, and she then proceeds to pounce on him, too. The patient is starting to improve, so it looks like more of a TIA or mini-stroke picture, rather than a full-blown stroke. Finally, to placade the internist, an EKG is done before the CT scan, and it is completely normal.

The CT scan doesn't show any hemorrhages and all of our labs come back normal. However, the neurology team is convinced enought that this is a neurological problem that they want to admit the patient and start her on a medication to help prevent any future events.

I walk into the room to make sure that the patient understands what is going on, and the internist is sitting there telling her who she'll need to see as an outpatient and blah, blah, blah. Finally, the internist leaves. At this point, the patient starts saying that she just wants to go home. Today, when I did my dictation I saw that she did actually get admitted.

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I have several issues with the way this patient was taken care of. First off, if someone wants to accompany a patient, fine, but this woman was nothing but a hindrance from interfering with me speaking with the patient directly all the way through her workup. If she wanted to be in control of how this patient's workup went, she could have easily admitted the patient directly to the hospital herself.

There's nothing more annoying than patients that show up in our department with prescriptions for MRI's and other studies. I'm not running a lab. I'm there to actually evaluate patients and do some of my own independent thinking. If bloodwork or imaging needs to be done, then just send your patients to a place that does that crap and sends the results back to you without ever looking at it.

My other least favorite thing is when patient show up expecting their doctor (who usually is not even the one on-call for their group) to meet them at the door. When your doctor tells you to go to the ER, that means check in, get evaluated, and if the ER finds something we'll let him/her know. If they really want you admitted, then they do it directly, and you can just bypass our infernal lobby of misery.

I'm Rubber, You're Glue...

I sat there this morning and kept my mouth shut. Around me there was smirking. I took a long swig of my coffee. It was too hot, and the liquid burned as it went down my throat, through my esophagus, and right into my stomach. Tonight my tongue still has the angry, sensitive sensation from the scalding. However, sipping at my coffee was the only way I could keep quiet.

I hate morning report. Morning report involves sitting around a large conference table and discussing a case that was admitted overnight. Typically much bashing of the Emergency Department ensues. Today's case was a four-day old infant with bloody vomit who also had a fever. A full septic workup was started looking for a source of the fever by checking the blood, urine, and CSF. The baby was started on antibiotics and admitted to the floor.

The head pediatrician started in on how the cause for blood streaks in the vomit wasn't worked up very thoroughly, and how he thought that the antibiotics weren't really necessary as the infant was being monitored in the hospital. Then he made some snide comment about the ER starting antibiotics as we just wanted to avoid lawsuits in the event of a bad outcome.

Does he consider the unnecessary death of an infant a "bad outcome"? Why is it ok to take chances with someone's child? Our job in the emergency department is to look for life-threatening conditions. Yes, most of the time we see people who don't have a doctor or can't get an appointment. However, in the event that we do find or suspect something serious, we act on it. Otherwise, it would be called the Let's-Just-Order-A-Shitload-Of-Tests-And-See-What-Your-Dumbass-
Doctor-Wants-To-Do-In-The-Morning Department.

Granted, there could have been a little bit more of a workup done for the vomiting. However, the kid was already being admitted to the hospital, and the mother gave a history that her nipples were chapped and sore from breastfeeding. The blood could have been swallowed or it could have been coming from the baby. There's a test that can distinguish maternal blood from the baby's blood that could have helped with this, but it takes awhile to get those results. Is it asking too much for their department to do something more than just sitting back, observing the patient, and waiting for our results to come back? Does it pain them to have to do some work?

This is a problem that I will continue to face. When patients are passed between departments, either side often has issues with the other. However, I think it's rude for them to be so critical when they know that I'm sitting right there. It also didn't help to improve my mood when it turned out that many of their residents were clueless as to when to start the workup, or how to even do it.

Sometimes it's hard to keep a poker face when you really just want to tear someone apart.