“I waited three hours in that ER before they brought me to my room,” some say.
“You were in the fast lane,” I inform them.
Oftimes I have to see a patient in the ER in order to admit them to the hospital upstairs, and yet, as hospital doctors, we don’t get passwords into the ER computer system. The ER considers themselves separate from the hospital. They have their own systems. Their own allegiances. To get a report of a patient’s stay in Emergency, we’re forced to pry the ER clerk’s attention from her Lockbox of Loathing as she ignores us for five minutes. It gets really old. My shortcut is to stalk the various ER stations and jump on the first computer that someone forgot to log off of. I then stealth print my own copy of the patient record. Saves four minutes and an exasperated clerk from rolling her eyes at me. This is modern medicine and technology at its finest, folks.
As I’m going over my purloined report, I hear the ER nurses talking about the patient I’m about to see.
“I can’t believe they’re admitting a PE (pulmonary embolus, a lung clot) patient to a regular bed.”
“Maybe the doc thinks he just has a DVT (deep venous thrombosis, a leg clot).”
I look at the papers and the reports I just ninja-printed off the computer and I have to agree with the nurse. I make a phone call to the operator who assigns beds and upgrade the status to a monitored bed.
Five minutes later, Dr. Honcho, comes over to where I’m sitting. I can tell he’s the guy in charge because (1) most of the time, I never actually see him working, and (2) he’s the only ER doc with a belly out to here.
“Why are you changing the bed status on this patient?” he asks calmly but squarely in front of where I’m seated. His hair is so closely cropped to his head, it looks glued on. It gives me a little gastrointestinal upset.
“He’s got a pulmonary embolus in both lungs and a leg clot. He needs close monitoring,” I answer, just barely leaving out the “DUH!”
“He’s asymptomatic. His vitals are completely stable in there. He’s fine,” Turfhoss snaps quickly.
“But he’s got … moderate clot burden… in BOTH lungs AND right ventricular heart strain on the cat scan,” I say it more clearly as if he didn’t hear me the first time.
“The radiologist said the RV strain was exaggerated.”
“That’s not what the report says,” I correct him.
“Well per the guidelines, if his vitals are stable, there’s no reason he needs special monitoring. Do you know the guidelines?”
“I don’t know the guidelines, but this guy has not one, but several PEs, in both lungs. And another clot in his leg waiting to finish what it started. He is high risk and he needs more attention and more monitoring.”
Dr. Honcho leans over the counter I’m sitting at. His expression is unmoving and passive but his posture is clear aggression.
“Look. They’ve got a general bed for him right now and no monitored beds. I’ve got people in the waiting room, in the halls. He needs to get out of here.”
The Truth comes out. He doesn’t care about guidelines any more than he cares what’s best for this patient. He just wants another open room in his ER. More turnaround. Better efficiency. Better numbers. Better record.
“Are you taking care of him when he gets upstairs then?” I ask. It’s rhetorical.
“No I’m not. But we need that room. This is an irresponsible use of resources.”
There’s two opposing alignments in medicine; what’s best for the greater good and what’s best for the individual. (Lawful versus Chaotic in D&D terms.) Improving efficiency and speed in the ER for example allows a greater number of people to be seen and cared for faster. But if you lean too far that way, then the individuals suffer. Like in this case.
That said, while I understood the perspective of Dr. Honcho and his strive for efficiency, I still found him to be an intolerable douche of hot flatulence. People like him use the whole “resources” and “guidelines” angle to deflect whatever they don’t agree with. The thicker the documents, the more padding you have to cover your ass. Too many times this is the fast track to becoming an administrator. (To be fair, most ER docs aren’t like this. They’re usually colorfully funny but cynical people, who will actually respect a hospitalist’s recommendations on any given patient.)
“If you want to, you can send him to the regular floor,” I offer, “But as soon as he gets there – I’m transferring him to my monitored bed.” Sucka!
He just didn’t want to let it go. At this point, it wasn’t about clearing the bed in his emergency room, he just wanted to be right. These fat boss types just aren’t accustomed to being told they’re wrong in their own domain. I guess that’s one of the bonuses of me just being a stranger in his strange land.
“I’m calling the uh … that one guy …” he stammers trying to remember someone important who isn’t himself.
“Dr. Momm?” I helpfully suggest the medicine program director, one of the bosses of my domain.
“Yeah.”
I page him too, in fact. Just to balance the politics with actual concern for a human being.
The ER clerk gets Dr. Momm on the line before I can. Of course. As I watch Dr. Honcho desperately plead his case to Momm, I briefly wonder if I’m wrong here. Maybe I’m being alarmist about the risk. Maybe modern medicine really is about the numbers. A hospital is a business at heart. Maybe I’m still thinking like a wide-eyed resident who’s never done his own billing codes.
Then I hear Dr. Honcho say to the phone, “But … don’t you need criteria for that?”
Dr. Momm answers my page next. He says the real answer in this case is subjective. Every case is different. Numbers don’t mean as much as judgment. Then he hangs up, he’s a busy man.
I am vindicated. Thanks, Momm.
When I turn to see what Dr. Honcho is doing, he’s gone already.
I go to see my patient in the ER room and – it’s empty!
They had moved my patient right under my nose to the general floor like Dr. Honcho had wanted all along. He was stalling me.
A half hour later…
“Any more questions?” I ask the clotty patient and his wife in the hospital room upstairs.
“No, thank you, really, for taking the time to explain everything.”
Well, I didn’t exactly tell them everything. I didn’t tell him about the whole clusterfuck with that prick in the ER.
After I walk out, the nurse informs me that the monitored bed I’d fought Dr. Honcho for was available now.
“Good. Let’s move him,” I order. The nurse breathes a sigh of relief in agreement and the clerk promptly facilitates the transfer. It was nice to be on my own turf again.
