Madhouse

April 21, 2008 | Leave a Comment

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.


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