Madhouse

Uncategorized

It’s Only Getting Crazier

Maybe it’s the change in the weather but our Emergency Department seems to have gone insane. It’s always been pretty busy but since the beginning of this month (and Spring temperatures) it seems like the patient population of our city has exploded as if there is some kind of Vague Abdominal Pain convention or the Grand Conclave of the Knights of Senility in town. We expect the usual increase in trauma, as befits the ability of people to stay out later now that it’s not below zero up here in the great American tundra states, but we’re also seeing an inexplicable increase in complaints of all kinds, from the serious to the futile to the sublimely ridiculous. It’s the usual stuff, you understand, just more of it. Even our attendings are puzzled.

I have been working the 9AM to 9PM shift this week which means that I’m actually working until about 11PM. I stop seeing new patients about half an hour before the official end of my shift but we have been so busy that I need another couple of hours to finish my charts. I get off to a good start at the beginning of my shift but no sooner have I seen one patient and written orders when somebody comes in who needs to be seen right away, say a trauma or a chest pain that turns out to be the real thing, and the chart just has to wait. At the end of the shift today I had about 20 charts to “lock” (or finalize on our electronic medical record system) and five of them had nothing on them but a chief complaint, lab results, diagnosis, disposition, and orders. All of that “History of Present Illness” stuff not to mention documentation of the physical exam was rapidly eroding in my memory because I didn’t have time to document after I saw the patient. This is not a good way to see patients. Ideally a running narrative should be kept of every decision and conversation with an admitting physician or consultant but sometimes all I remember is that I talked to cardiology but not who or when and the documentation can get kind of sketchy even though I try to document the big decisions.

We’re supposed to document rechecks of patients as well but seriously now, when the department is bursting at the seams and you’re constantly being called to do something at different ends of the multi-acre establishment, it’s hard to keep up with the stable ones let alone document it. And because we are so short-staffed for this current deluge, patients are sitting around for a long time waiting for disposition even after all of their lab work and studies are back. Today, for example, I had a whole slew of minor patients languishing while we took care of four traumas and a couple of critically ill patients almost one after another. I intubated two of these patients and you just can’t walk away from them to see how your chronic back pain patient is doing.

I enjoy the fast tempo but I also realize that this is not the best way to practice medicine. It can’t be safe this week to come to our department if you have something serious that presents as something minor. We are just a little more apt to throw a lot of tests at you to temporize, just to put you on the back burner so to speak, and your increased sitting-in-the room-time could be dangerous, not to mention the time you spend in the waiting room which can be hours and hours. Thank god that most of the complaints are still relatively minor. I am a decent guy at heart and I do feel bad about keeping my patients waiting but it’s an Emergency Department and we still have priorities despite the temptations of that Arch-Devil, Press Ganey.

And we still suffer, as a medical system (or whatever you want to call it) from a terrific lack of common sense. We have had the same drunk visit us every day, sometimes twice a day, for the last two weeks. The paramedics keep finding him laying in parks and alleys in an obvious alcohol induced stupor and they keep bringing him in whereupon he wakes up, becomes abusive, ties up a nurse dealing with his demands for some food, and then finally staggers out when he is ready to be discharged only to repeat the little charade twelve hours later. We don’t even bother drawing an alcohol level or any labs. What’s the point? More importantly, why do they keep bringing him to us to use up our finite manpower on a non-acute medical problem? They will have a salad bar in hell before he is cured of his affliction. It is just beyond out power. Better to make sure he has a pulse, prop him up against a wall somewhere, and leave him to sober up on his own. This would be no different conceptually from what we do for him in the department except he wouldn’t get a sandwich and he wouldn’t stink up the whole place.

Even the other patients complain so we’re not talking the usual bad smells of the indigent.

I also don’t quite understand what motivates some people to wait as long as they do with complaints that are amazingly trivial. Maybe American life has been so medicalized that nobody believes they should suffer any discomfort, no matter how minor. Look, I get sick sometimes but if it’s just a cold or a little diarrhea I just tough it out. I’m young, healthy, and camping out in a dirty, crowded Emergency Department waiting room with irate people, some of whom are indeed really sick, is not an appealing prospect. If I were on the public dole because of disability or polybabydadia and could sleep in or rest all day without having to worry about my job I’d be even less likely to come in.

I know we worry about how we would ever handle a mass casualty event but if we just got aggressive with triage and sent some people home to suffer and get better on their own we might be able to squeeze in a surprising number of injured or really sick patients.

My apologies for neglecting the blog this week. Hopefully things will slow down a bit as people come out of their sun shock and I will have some energy to write.

18 thoughts on “Madhouse”

  1. “Polybabydadia” made me laugh out loud.

    It would be neat if, when people presented with minor conditions (worried that they may be major conditions), a nurse or some other assistant could give them a printout that said something like “Your symptoms most likely match (insert common medical problem). Go home. Do this and that. If you have the following scary symptoms, come back. If you’re contagious, stay the heck home until you’re well. Have a nice day.”

    Keep in mind that a lot of us non-medical folks have been terrorized for years by “helpful” awareness organizations trying to get the word out about their special, horrible killer of people-in-their-prime. They want us to run to the ER “just in case” for the smallest things.

    What I’d like to see is a handy graph showing the probabilities of a collection of symptoms being something life-threatening. If you have A and B and C, then the chance is 5%. If you have A and B and C and D and E, then the chance is 50%. If your chance >= 50%, please go to an ER. If not, please call your PCP as soon as possible and keep a lookout for additional symptoms that might necessitate emergency treatment.

  3. Polybabydadia–awesome!!!!

    You nailed the cause–it’s the change in weather. Nobody has to worry about snowstorms, parking lot snowbanks, or even parking far from the door in the rain. So they come out in full force because it’s so EASY to get out now!

  4. It really is pretty dramatic. I often wonder if I’m just romanticizing the past, but it certainly seems that people were more apt to forgo medical care for the minor stuff in the past. Even the relatively recent past.

    I suppose in part some of the fault can be put on the physician. I have no doubt that physicians create their own demand and have done so at an increasing pace over the past couple of decades. Not inconceivable that individuals are becoming conditioned to seek care for everything in part because of physician efforts and the efforts of disease advocacy groups.

  5. Panda,
    I wonder sometimes if “Polybabydadia” oughtn’t to be “PolydaddyBABIA.” Are you referring to the perp having multiple inseminators, or to the fact that she has multiple kids by different men?

    Just a semantic point brought on by an a attack of dyslexia, though I love your original formulation.

  6. Dr. Kranky — “polybabydadia,” from the Greek “poly-” meaning “much,” and the modern “babydaddy,” meaning … well … sigh.

  7. I’ve worked EMS in the same area now for more then three years. Granted I’ve become more aware of the system and now work more hours in it. But within the last six or so months it seems our local trauma center hasn’t had but one or two slow days. They now keep five or so beds stacked around the hall in the subacute area and are on divert frequently throughout the week.

    Who’s to say if its any specific problem, a local hospital closed months past and demand shifted. Demand has generally increased or the facilites ability to process patients has changed. Regardless if the flu/peak season has ended it seems nobody told the public this bit of information.

  8. Kranky,

    I think PB is referring to polybabydadia, the condition which causes many of our urban youth to utter the phrase, “Yeah, I gets along with Moms, but my little sister’s dad…he real cool.”

    Multiple inseminators is the defining criteria for another common affliction, Polydaddybabia Maury Povichicus.

    PB,

    I’m a little disheartened by your vilification of the medics that bring in ol’ Stinky McDrunkerson. I am VERY fortunate to work as a Medic in an EMS system that allows us to refuse transport to non-critical patients, while other less progressive systems recoil in horror at the very thought of bucking the traditional “you call, we haul” edict.

    EMS systems are inundated with the same bureaucracy, documentation issues and oversight by ill-informed and out-of-touch supervisors that you write about so frequently. Medics in the field practice under the license of a physician, usually an EM attending at the largest hospital in the area. We play by their rules, as they have opened themselves up to litigation by allowing us to practice under their license. I’m sure this isn’t anything ground-shaking for the readers of this blog, but an EM attending at an academic medical center makes some pretty nice scratch and isn’t too keen on allowing a bunch of firefighters to jeopardize his livelihood, ergo the rigid transport protocol.

    The real issue here is the civilian “do-gooder”. Driving their Prius to the mall, they encounter one of the holy 47 million propped up against a bench in the local park. Overcome by white, middle-class guilt, they instinctively reach for their Blackberry and dial 911. They spew forth the usual tripe, which typically plays out as such:

    “911, What is your emergency?”
    “Yeah…There’s a guy in the park, he doesn’t look to good. He’s maybe on drugs or unconscious or something.”
    “Is he breathing?”
    “Oh, I don’t know, I’m way past him now, I’m running Jake out to soccer practice and I wasn’t about to pull over and give some residentially challenged person a nudge.”

    The dispatcher, following their own protocols, have to classify this particular exchange as “Unconscious/Unresponsive” or “Cardiac/Respiratory Arrest”, either of which will send a fire engine and ambulance racing lights and siren to the scene, only to give Stinky McDrunkerson a poke, listen to him mumble and (in most areas) load him up. Hobos have hemorrhagic strokes too, ya know, and putting up with their demands for the turkey sandwich avec oatmeal raisin special de jour is relatively more enjoyable that having your wallet pillaged by Jimbo Sokolove.

    Have a heart for us EMSers, Panda. We’re on the same team after all, and we don’t like transporting non-critical patients anymore than you like admitting your 30 yo CP with normal vitals, unremarkable EKG and negative enzymes to the telemetry floor.

    (I am not blaming the paramedics.  I mean that as a society we lack common sense. -PB) 

  9. PandaMD: I’ve really enjoyed reading your blog. You are doing a great thing for medical students in your writings lately! I can sympathize with so many things you’ve said. Please check out my blog and consider linking my site. I’m a family med resident.
    mdoncall.blogspot.com

  10. ghetto medic:

    “an EM attending at an academic medical center makes some pretty nice scratch”

    Not really true. Most of those folks are there for self sacrifice. The doc at the piddly widdly but busy community hospital might be making twice the scratch.

    Panda:

    Great description once again of what is going in virtually every ER in the country from the biggest academic Mecca to the smallest little band aid community hospital.

  11. I’m sure you’ve thought of this already, and/or dismissed it as laughable, but maybe a little voice recorder could be useful when you don’t have time to chart immediately–just dictate some notes into it for yourself as you’re heading from place to place and play it back later to help jog your memory.

  13. I’ll Have you know i just stole “polybabydadia”.

    And you know as well as I that the reason we can’t “triage aggressively” can be summed up in two words: tort lawyers.

  14. Quick question for you: how many 12-hour shifts do you have to work for a week as a senior er resident?

  15. How to aggressively triage:

    “If you have been categorised as Cat4, your estimated wait is over eight hours. Hospital X 10 miles away has an empty waiting room.”

    that cuts the numbers in half right there.

  16. Panda, we get bombarded all the time on going to the doctor for various things. I like what Sibyl said.

    I got annoyed over the years with having certain symptoms and my GYNs doing ultrasounds every three months and wanting scans. I quit trusting doctors when any problem that arose turned out to have a $500 – $2000 price tag not to mention being invasive as hell, finding no answers and not knowing anything. The nurses were pigs rolling their eyes at me while I spoke of my symptoms and I felt stupid for telling them– finally I met a doctor who educated his patients. “X is not usually a problem by itself, but we monitor it every year with an ultra sound because it could be a sign of ovarian cancer. If symptoms get worse [he defined worse] then I want to call and make an appointment and we can find out why this is happening.” We also had a talk about what was and wasn’t an emergency in general.

    I never wanted to be a difficult patient but for years I was, just because I didn’t know and was being told vague information.

  17. Hmm, I guess according to you, and the ER I visited based on the rudeness of the staff, I should not have gone to the ER after being hit in the head with the car door. I was not drunk or high, I’m just simply clutzy. I had a head wound, was dizzy & nauseous, and had a horrific headache. I’m not a frequent flyer (the last time I was at the ER was 3 years ago for a gall bladder attack that ended in emergency surgery- which I was treated exactly the same way until the surgery consult yelled at the attending for me being there 7 hours with no pain meds after looking at my ultrasound), and my concern regarding my condition was real. However, I was treated as an inconvenience and drug seeker. I was eventually given a head CT which I was made to walk to even though I couldn’t walk without support, could barely open my eyes my head hurt so bad, and had my wound cleaned with saline, though never bandaged with anything other than 1 strip of tape and a gauze pad. I saw a Dr. for 90 seconds and after barely glancing at the cut was told I didn’t need stitches. 6 hours later the nurse rudely told me I needed nothing stronger for my headache than Motrin and discharged with a dx of facial contusion with mild concussion. I was never offered to have the lights turned down, I was never offered pain medication (not even ibuprofen…), heck I wasn’t even offered a blanket. There was no compassion. I assume they felt I was wasting their time and a bed, or just drug seeking. The headache lasted 4 days, ibuprofen didn’t touch it. What else was I supposed to do at 11pm on a Sat with a head wound? Sleep it off? Being as I’m not a physician, I didn’t know that a puncture wound 3cm long in the middle of my forehead didn’t need stitches. I believe that’s why there are ER’s. Maybe more of ER staff need to check their disdain for what they view as irritating minor complaints at the door and treat patients with respect and compassion.

    (What on Earth are you talking about?  My chiromancer patient literally just bumped his head with no Loss of Consciousness, was dazed for a few seconds, and had no injuries at all.  As for your experience, well, I can’t imagine treating a patient like you describe.  We just don’t operate like that.   In fact, the way we tend to over-react your injury would have been paged out as a Level One trauma and you would have gotten the works, the whole nine yards, the big enchilada.    But why you need anything stronger than Motrin is debatable.  What does “stronger” mean.  Motrin is “strong.”  It was once hailed as a wonder-drug. 

    I’m calling BS on the your Gallbladder story.  If there’s one thing that we want to do is to get patients out of the department.  Acute gallbladder pain is almost a no-brainer and any self-respecting EM physician would be all over that like a cheap date.-PB)

  18. What I’m talking about is a struggle for respectful patient care. You are overworked, no doubt. You get dumps, and probably more drug seekers than you care to count, and minor irritating illnesses. However, in my most recent ER experiences, I have been treated as nothing more than one of those irritating stupid patients who is just wasting time and resources. What I’m saying, is although it might seem minor and irritating to you, it isn’t to the patient. Maybe it’s just where I live. Maybe the doctors here are not the norm. Call BS all you want on the gallbladder situation, it’s the truth. I was told I couldn’t possibly be in as much pain as I said because I drove myself to the hospital in a blizzard, so I was getting no pain meds. Never mind the fact I had 2 small children at home, and my husband stayed with them so I could go the the ER. I was in the ER 7 hours total before being admitted by the general surgeon. Further, he was the one who ordered something for the vomiting and pain after obtaining my ultrasound results and doing an exam. The same exam the ER doc did when I first came in. Until the surgeon came to see me, I was balled in the fetal position on the bed, I hurt so bad. Gangrene had set in to the gallbladder, and I was on IV antibiotics for 4 days after surgery. But I was just making up how bad it hurt, right? It didn’t change the fact I was treated like I was making up the pain story just to score, not just by the Dr. but the nurses too. Sorry if that story sounds like BS to you, but that’s how our local ER treats patients- at least it’s how I’ve been treated twice now. I’m not a frequent flyer, I’m not constantly claiming I lost my script, or accidentally dropped my pills down the drain, but when I obviously present with something that (in my case once every 3 or 4 years) is worthy of appropriate treatment, I would appreciate the respect of receiving it. As far as “strong” and “stronger” goes, it’s pretty obvious what I meant. Although after suffering with a debilitating headache (even with the Motrin) for 4 days, it did subside. So, I suppose I shouldn’t have expected anything prescription. Should I have been made to suffer with it when there are pain relieving medications (Tylenol 3 or 4, Darvocet, Percocet, Vicodin- to name a few) that I could have been given a small amount of to ease the pain during that short time span? Figure 1 or 2 pills every 4-6 hours for 3-4 days. At most we’re talking 30 pills. Obviously, since I was only there to score drugs, and I was only inconveniencing them to begin with, I didn’t deserve a prescription pain medication for a head injury. They couldn’t even be bothered to durmabond the cut together to keep it from separating, which it did since I obtained no closure of the wound, not even a steri strip. What I’m talking about is not assuming the worst in every patient, taking a step outside, looking at every patient’s individual situation, and treating them accordingly.

    (I am not overworked nor am I down in the dumps and an inflamed gallbladder is such an obvious presentation and so much of a perfect Emergency Medicine case (real physical exam findings, classical history, and ridiculously easy disposition) that I’m calling bullshit on your little story. A patient actively vomiting in my department complaining of abdominal pain? That’s a no-brainer. -PB)

Comments are closed.