25 July 2009

Drawing a line

It was a busy Saturday afternoon today, and the charge nurse came by to let me know about a "heads-up" we got from the rehab center across the street.  The nurses there are pretty good about letting us know when one of their patients needs to come over, which is nice because their patients tend to be chronically ill and kind of complex (otherwise, they wouldn't be in an acute rehab center!).  This one was a little weird, though.

Says she: "The rehab nurse says they have a patient with an upper extremity DVT they are going to send over for evaluation."
I said: "That's odd, how do they know it's a DVT?"
"The patient already had an outpatient ultrasound."
"Oh." [pause to think] "It sounds like they've already got the diagnosis, don't they?"
"And they can give lovenox over at rehab, right?"
"So why are they sending the patient to us?"
"The patient's attending said to send him over."
"I have no idea."

So she calls back to rehab and verifies that we have the story straight.  We find out who the attending is, a Dr. Jones who I have not met before, and I have him paged.  This was an interesting chat, summarized so:

"So, Dr. Jones, I gather you wanted to send us Mr. Anderson for assessment.  I just wanted to touch base with you and get a sense of what it was you wanted us to do for him?"
"I don't know the patient; his doctor's off this weekend and I'm just covering.  The nurses say he has swelling of his arm, and they say there's a clot there, and I thought someone ought to take a look at it."
"OK, but if we know it's a clot, why don't you just anticoagulate him?"
"Well, the nurses said it's looking kind of red, and no physician has laid eyes on the patient. He really should be examined by a doctor before he's anticoagulated.  Don't you agree?"
"Riiiight.  Look, I'm not trying to make trouble, but the ER's really busy and the waiting room's full.  I'm not sure that this is an appropriate use of the ER.  This is something that his attending can look at and treat if it's appropriate."
"But he doesn't have an attending. His doctor is out of town."
"He does have a doctor.  That's you."
[long pause]
[the pause is now getting uncomfortably long]
[he still doesn't say anything]
"I'm letting you dangle."
"Yes.  I see your point."
"I'm not trying to be obstructive.  Ordinarily, I'd be happy to take $150 of the taxpayers' dollars..."
"No, no, you've made yourself clear.  I'll come in and take a look at him."
"Very well, and if you find something unexpected, by all means send him over and I'll eat humble pie."
"Right, thanks." [click]

I hung up the phone to a round of applause and a standing ovation from the nursing staff, who had been listening avidly to the conversation.  I actually felt kind of bad, that I was too tough on him, but the nurses really rallied around me.   One of the nurses said to me, "I can't believe you got Dr. Jones to come in!  He never comes in for anything!" 

I was just annoyed that it was clearly a dump on the ER for the doc's convenience.  This is the problem with the ER -- we're always there, and we're always open and we can't say "no."  When some doc in any outpatient setting doesn't want to deal with some problem, they can just turf it to the ER.  The doc was clearly astonished that he got pushback, that there was an expectation that he would have made some effort to see the patient he was covering for before sending him into me. 

This is to some degree an unintended consequence of EMTALA.  Because we cannot say "no" to transfers, the ER becomes the default option, and the path of least resistance.  We are the resource of last resort, and before long, that becomes the resource of first resort.  It's standard operating procedure to "just send it to the ER."  The only reason I had a chance to block it was because the nurses gave us the courtesy call in advance.  More often they don't call at all, or wait until the patient is en route before calling.  I didn't even "block" the patient, per se; it was only because I shamed him that the doc relented and took care of it himself.

The patient never did come in.  So I'll chalk it up as a victory, but I'm more sure it won't turn out to be a pyrrhic victory.   Next time, they just won't call, and it's gonna be way awkward the next time I have to talk to Dr Jones, especially if I need something from him.


  1. It still amazes me that a conversation like that has to exist. How can anyone get away with the 'turf-effect'.
    Better yet, how does a physician swallow that pill? Instead of treating the patient, you shove them aside.
    I understand, we all have busy lives and we all have responsibilities, but isn't this shirking your duty.
    From a fellow nurse that 'gets it', I thank you for that phone call.

  2. He may have second thoughts next time he wants to send a patient over as a dump.

  3. If its dead and you don't know what to do with it, send it to pathology.
    If its alive and you don't know what to do with it, send it to the emergency department.
    Ties go to the ED.

  4. Great post. The only thing wrong is the idea that you saved the taxpayer $150.00. I've never seen an ED visit for less than $1500 and it would probably be higher after doing some "tests" and administering the Lovenox.

    Unfortunately, Dr. Jones probably doesn't get paid anything to see the patient in the SNF on a weekend. It is the lack of compensation for the community doc that drives patients to the ED.

  5. This is so interesting to me, because as a ED resident in a public hospital, other services are the ones who feel "dumped on" by the ED, and it's always them trying to block. Especially, as we all know, surgery.
    Sometimes it's outright amusing to watch surgery residents having temper tantrums in the ED about admitting patients. I wonder if karma will bite me in the ass one day for laughing at them.


Note: Only a member of this blog may post a comment.