A Comedy of Errors...

...only none of them were funny. I was on Friday-Sunday call this weekend. So I went into the hospital on Friday morning, didn't leave until Saturday noon, went back on Sunday morning and didn't leave until Monday noon. Not the nicest way to spend my long weekend, but at least I get a "lieu" day for working on the stat holiday.

Last night was busy for internal medicine. We got flooded with referrals from emerg, nearly all of which required admission into hospital. There were many of the usual suspects-- MI's, COPD exacerbations, CHF exacerbations, and the parade of confused eldery people usually found to be suffering from pneumonia or urosepsis. There were a few more interesting cases, too-- and a few that should have been routine but became more interested through gross mismanagement.

In our hospital it's not unusual for patients to spend a day or more in the emergency room after being "admitted" (on paper, anyway) waiting for a bed. The emergency room is a busy place, and it isn't the nicest place to be hanging around all night. Plus, the nurses are busy and the care that our patients get isn't the same as if they were on the floor. Usually, this is just inconvenient. This night, however, it became downright ridiculous.

At around 11pm I saw an 18-year-old kid with diabetic ketoacidosis. This is a serious complication of (usually) Type I diabetes that has a 5% fatality rate. So it's taken pretty seriously. I had actually asked to see this referral as I had never managed a DKA before and wanted the experience. I had admit orders (instructions to the nurses on how to manage the patient) within 30 minutes of seeing him. They included close monitoring, an insulin drip, correction of his hypokalemia (low blood potassium, can cause heart arrhythmias if not treated), blood sugars measured every hour, electrolytes measured every two hours... the usual. By 5am, not only had the orders not been implemented, but the night nurse had allowed the patient to take his usual dose of long-acting insulin. You don't have to necessarily understand the medical management of acid-base disorders to appreciate the bottom line-- this delay in treatment could have killed this kid. Luckily, he wasn't all that acidotic (it's the acidosis that kills, not the blood sugar per se) and was fine the next morning. But things could have easily turned out much worse.

One of the other residents saw a young (early 40's) healthy guy who had a spell of atrial fibrillation (a heart arrhythmia) after finishing a 5k run that afternoon. First of all, it didn't need to be referred to internal medicine-- he was stable, and could have easily been started on medication and followed up as an outpatient. But he got referred, so we saw him. The other resident ordered some anti-arrhythmic medications and decided to keep him overnight on telemetry (constant vital sign monitoring). Good thing. Her orders weren't carried out either-- he never got his meds, and ended up going into atrial flutter (a worse arrthymia) in the middle of the night.

At midnight, already snowed by admissions and referrals (including a very rare blood disease, the management of which was a mystery to everyone including the thrombo attending on call) the R5 (emergency medicine resident in his fifth and final year of residency training) dumped three referrals on us that hadn't even been worked up. His explanation?

"Well, they're three old ladies that are confused and short of breath, so whatever the cause they'll end up going to your service anyway."

Um, thanks. This is the kind of bullshit that gives emergency medicine a bad name with other services. I took one of them-- an 88-year-old woman with severe Alzheimer's dementia who was non-verbal. All I knew was that the nursing home had thought her to have a decreased level of consciousness that afternoon and sent her in by ambulance. The resident hadn't even ordered a CBC (the most basic of blood tests).

To add to the confusion, the computer system went down inexplicably sometime after 1am. So we had no access to lab values, x-rays... and perhaps most importantly when dealing with demented elderly patients who can't tell you about their medical history, their old notes and files. Information was passed by phone calls from the lab and the stressed radiology resident, and was then relayed through a twisted game of broken telephone until it reached us and could be translated into a diagnosis and treatment plan. In many cases, it was easier to give up on nailing a diagnosis and just start everyone with nonspecific fever on broad-spectrum antibiotics and delay the more formal workup until the morning.

I guess that night was the perfect storm of problems-- some of them, like the computer problems, being nobody's fault. Others, like the mass referral of patients without workup, the resident's fault. But the delay in receiving treatment that some of our patients experienced last night was downright dangerous. If it had been my family member, you can be damn sure I'd be demanding answers. Not enough nurses? Not enough beds on the floor? Complete incompetence of the health care team in general? Maybe a little of each. But it's definitely not a night I'd like to repeat.

But maybe I'm naive in thinking that this was an unusual scenario.