So: the last of the epic tales of my on call.
I knew I'd be late on the floor; 2 down and busy, no way was I getting off on time. Half two in the morning is close to my limit. If there are sick patients, well, strap on when it seems apt, but if its just busy...
As I was preparing to escape, I was introduced o one of my absolute favourite ED dilemmas. The 'problem' patient that no-one will admit, or discharge. Typically, this will be someone well known to one service, or more than one, with a chronic problem. They inevitably attend out of hours, with a flare of their problem, usually requiring strong painkillers.
In this case, the problem was abdominal pain. Surgical review diagnosed "not a surgical problem' with a plan of "refer medics'. But of course, the surgeon couldn't possible make that referral. Since the problem is "not surgical", the patient reverts to us.
Medical review resulted in a diagnosis of "not a medical problem", with a proposed plan of "have the surgeons admit, and we'll review"
This backing and forthing can go on for days.
It is a waste of everyone's time, especially my registrar's.
Usually, a polite call is enough. It makes sense for the two specialities to talk to each other, and agree a mutually acceptable plan, or discharge the patient.
Being a consultant, it has the added advantage that I can always suggest if they don't want to talk, I'll call their bosses in, and we three consultants can review the patient at the bedside, and agree a plan. After all, I'm still here at 3 a.m., I'm sure their bosses wouldn't mind coming in to join me?
Well, I left them talking, which doesn't guarantee resolution, of course.
But I'm hopeful.
There may be some follow up here.
Don't touch that dial.
Showing posts with label Awkward Colleagues. Show all posts
Showing posts with label Awkward Colleagues. Show all posts
Tuesday, March 29, 2011
Monday, March 28, 2011
Interlude: Referral Politics
Ah, the joy of the referral.
Times have changed. The all powerful target means less time for us, in the ED to reach a diagnosis; often the decision to refer for admission is based on a lack of a diagnosis, coupled with the fact that the hospital says I can't stop and think.
And so, the soft referral. I like to think that most of my referrals are kosher, and if I'm not sure, I'm honest about it. But sometimes, I just don't know what's wrong with a patient, but I'm pretty certain they need longer obs than I can offer in the ED, and maybe more tests. (More tests! The answer to everything!)
I had just a conundrum recently, and was given a hard time by the MedReg. Not necessarily inappropriately; I really couldn't figure out what was afoot, but I tried to be honest about that, and why I though the patient ought to come in.
Her SHO, one of our old trainees, told me a few days later, that she hadn't realised to whom she was speaking, and had been apologetic thereafter. (Apologetic, or worried that I might complain?)
This, of course, if bullshit. If she was rude, and I didn't think she was, especially, then who i am is irrelevant. No mater what some practitioners seem to think, there isn't a sliding scale of how rude you can be to someone, based on their job title.
If, on the other hand, she thought the referral was shit, who I am is equally irrelevant. Shit referrals transcend all boundaries.
Anyway. Last week, I'd seen a young girl, complaining of pleuritic, left sided chest pain, shortness of breath and cough. No temp, pulse 120 bpm, resps 30. Normal bloods, normal chest XR, normal gases. Despite her normal gas, I was still concerned about PE.
(The arterial blood gas measures oxygenation of the blood, and, in pulmonary embolus, should be abnormal.)
The MedReg was distinctly unimpressed, and wanted to know why I hadn't asked for a d-dimer.This is a blood test that, if positive, may indicate the presence of clot. It's more often used to rule the condition out, as it is more commonly negative when there is NO clot, than it is positive when there IS clot.
However, in certain circumstances, where risk is perceived to be high enough, even a negative d-dimer isn't really enough to rule out PE. This is, broadly, Bayesian probability, which deals with pre test probability, and how the result of a given test influences that figure to generate post test probability.
So for example if you have a 15% chance of having a PE, and negative d-dimer would allow me to reduce that below 1%, and I might say that's enough to rule it out. But if the pre test is higher, maybe 50%, then with a negative d-dimer, your post test is only maybe 5 or 6%. Enough to rule out?
I think not.
We backed and forthed on this for a while. Ultimately, it came down to, if she doesn't have a PE, why is she in pain, tachycardic and tachypnoeic. I CAN"T send her home. If she settles in 12 hours - brilliant. If she goes home and dies...
Not so good.
Now, I'm pretty boring, so I'm happy to talk Bayesian probability theory, and the evidence behind d-dimer all night. But it occurs to me that my juniors probably notsomuch, and this was all a bit hard work, for what may have been a soft referral, but was, at the end of it all, a patient with ongoing symptoms, and abnormal vitals.
I've seen cases like this before; not many. One or two, maybe, but that's all you need to know that sometimes what seems unlikely turns out to be real.
And I'm happy for a few uppity fellows to think me a por diagnostician, in exchange for avoiding the coroner's court.
Times have changed. The all powerful target means less time for us, in the ED to reach a diagnosis; often the decision to refer for admission is based on a lack of a diagnosis, coupled with the fact that the hospital says I can't stop and think.
And so, the soft referral. I like to think that most of my referrals are kosher, and if I'm not sure, I'm honest about it. But sometimes, I just don't know what's wrong with a patient, but I'm pretty certain they need longer obs than I can offer in the ED, and maybe more tests. (More tests! The answer to everything!)
I had just a conundrum recently, and was given a hard time by the MedReg. Not necessarily inappropriately; I really couldn't figure out what was afoot, but I tried to be honest about that, and why I though the patient ought to come in.
Her SHO, one of our old trainees, told me a few days later, that she hadn't realised to whom she was speaking, and had been apologetic thereafter. (Apologetic, or worried that I might complain?)
This, of course, if bullshit. If she was rude, and I didn't think she was, especially, then who i am is irrelevant. No mater what some practitioners seem to think, there isn't a sliding scale of how rude you can be to someone, based on their job title.
If, on the other hand, she thought the referral was shit, who I am is equally irrelevant. Shit referrals transcend all boundaries.
Anyway. Last week, I'd seen a young girl, complaining of pleuritic, left sided chest pain, shortness of breath and cough. No temp, pulse 120 bpm, resps 30. Normal bloods, normal chest XR, normal gases. Despite her normal gas, I was still concerned about PE.
(The arterial blood gas measures oxygenation of the blood, and, in pulmonary embolus, should be abnormal.)
The MedReg was distinctly unimpressed, and wanted to know why I hadn't asked for a d-dimer.This is a blood test that, if positive, may indicate the presence of clot. It's more often used to rule the condition out, as it is more commonly negative when there is NO clot, than it is positive when there IS clot.
However, in certain circumstances, where risk is perceived to be high enough, even a negative d-dimer isn't really enough to rule out PE. This is, broadly, Bayesian probability, which deals with pre test probability, and how the result of a given test influences that figure to generate post test probability.
So for example if you have a 15% chance of having a PE, and negative d-dimer would allow me to reduce that below 1%, and I might say that's enough to rule it out. But if the pre test is higher, maybe 50%, then with a negative d-dimer, your post test is only maybe 5 or 6%. Enough to rule out?
I think not.
We backed and forthed on this for a while. Ultimately, it came down to, if she doesn't have a PE, why is she in pain, tachycardic and tachypnoeic. I CAN"T send her home. If she settles in 12 hours - brilliant. If she goes home and dies...
Not so good.
Now, I'm pretty boring, so I'm happy to talk Bayesian probability theory, and the evidence behind d-dimer all night. But it occurs to me that my juniors probably notsomuch, and this was all a bit hard work, for what may have been a soft referral, but was, at the end of it all, a patient with ongoing symptoms, and abnormal vitals.
I've seen cases like this before; not many. One or two, maybe, but that's all you need to know that sometimes what seems unlikely turns out to be real.
And I'm happy for a few uppity fellows to think me a por diagnostician, in exchange for avoiding the coroner's court.
Thursday, November 12, 2009
Management Flail
I hate being stuck in the middle.
It happens a lot, mostly because many of my colleagues still regard the ED docs as non-specialist, and think we will be their scut-monkeys. Old habits die hard, an all that.
Recently, I was presented with a challenging patient. A young woman, with a non-specific history of headaches, who had suddenly gone bananas. I apologise for the use of technical jargon. She had rapidly become delirious, with a fluctuating conscious level, and was spouting mostly gibberish.
Part of the work up was to include a CT scan, and we doubted our ability both to transfer her safely, and to convince her to lie still. ITU helped out with both of these things, but then pretty much washed their hands.
Her scan was normal, but bloodwork suggested and infective process and acute renal failure. Obs showed her persistently hypotensive, with diminished urine output. Getting near her, necessitated recurrent chemical restraint, physical restraint not being an option.
My medical colleagues were reluctant to admit her to the floor, concerned as they were that she was a) pretty sick, and b) difficult to manage safely.
ITU flat out refused to take her.
A 3 way argument between my boss, the medical and the ITU consultant ensued, with the end result being she stayed in my Resus room for 7 hours and then went to the medical floor. I can't help but feel that this once again paints us as the bitches in this piece, especially as less than an hour after arriving on the medical ward, she was transferred to ITU and tubed...
It happens a lot, mostly because many of my colleagues still regard the ED docs as non-specialist, and think we will be their scut-monkeys. Old habits die hard, an all that.
Recently, I was presented with a challenging patient. A young woman, with a non-specific history of headaches, who had suddenly gone bananas. I apologise for the use of technical jargon. She had rapidly become delirious, with a fluctuating conscious level, and was spouting mostly gibberish.
Part of the work up was to include a CT scan, and we doubted our ability both to transfer her safely, and to convince her to lie still. ITU helped out with both of these things, but then pretty much washed their hands.
Her scan was normal, but bloodwork suggested and infective process and acute renal failure. Obs showed her persistently hypotensive, with diminished urine output. Getting near her, necessitated recurrent chemical restraint, physical restraint not being an option.
My medical colleagues were reluctant to admit her to the floor, concerned as they were that she was a) pretty sick, and b) difficult to manage safely.
ITU flat out refused to take her.
A 3 way argument between my boss, the medical and the ITU consultant ensued, with the end result being she stayed in my Resus room for 7 hours and then went to the medical floor. I can't help but feel that this once again paints us as the bitches in this piece, especially as less than an hour after arriving on the medical ward, she was transferred to ITU and tubed...
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