Monday, October 24, 2005

In the ER we routinely "work-up" patients, even after we have determined that they need to be admitted. Often the admitting physician won't see the patient until the next morning and the ER doc bears some liability for what happens in the intervening time.

So, if a 60 year-old man comes in acutely short of breath and febrile, the CXR shows bilateral infiltrates and the pulse ox is 85% on room air and he is showing increased work of breathing, he needs to be admitted, right? Who cares what the WBC is, or the results of the CMP?

Well, certainly the doc taking care of the patient in the hospital would be interested. But from the view of the ER doc, once the decision to admit is made and you have made the ICU vs med floor decision, you are done.

The other day I had a 49 year old woman present with acute onset of urticaria. As I was talking to her, she became increasingly SOB and stated that she was having trouble swallowing. I looked in her mouth and her soft palate and oropharynx were markedly edematous. Unfortunately, she had eaten about 15 minutes earlier.

I told her and her husband that I need to intubate her immediately. I needed to get an airway in while there was still an opening to put the tube through.

As we were getting ready to do the RSI I told the nurse to call the hospitalist and tell him to come down. While I was busy threading the eye of the needle (easily the most difficult intubation I have ever done) the hospitalist came down, looked at the chart and left the ER.

When I called him and asked him to come down and take care of her, he asked if any labs were back. I said no, but that some blood had been sent off. He refused to come down until I had "worked her up." I asked him what he wanted done. He replied, "It's not my job to teach you how to work up anaphylaxis. Look in any book. Just do your job!"

I said that I had done my job. She was intubated and ready to go to the ICU. I didn't particularly care at that point why she had the reaction she had, only that she was going to require ongoing critical care and I didn't have the time to do that with the other 20 something patients I had in the ER.

He hung up on me. I called him back and he again refused to come see her. He was angry that he didn't see any labs ordered when he came down and looked at the chart. Maybe he didn't understand the process of taking care of an actual sphincter tone inducing emergency. Orders are shouted out and documented later.

Anyway, I asked him what labs he would think might affect his decision to admit. Of the labs I would reasonably have access to through the ER, what possible abnormality would conceivably change my decision making? He couldn't answer.

None, of course.

As I have written before, I also work as a hospitalist. I know that the ER sometimes calls without the info necessary to make critical decisions such as ICU vs floor, admit to our hospital vs transfer to a higher level of care, etc.

This obviously wasn't one of those situations. I think we need to establish a better system of getting patients admitted. When it is obvious that the patient needs to come in, even if the database is incomplete, put them in. Complete the work-up in house.

Our hospital was recently bought out by a for-profit corporation. I suspect the desire to decrease ER waits will prompt some changes. We should not be holding patients in the ER to do work-ups that could easily be done as inpatients.