Entry 22

The other night a trauma was called in advance by EMS. All I knew was that an 80-something year old man was coming who fell for unknown reasons and had a head injury, but vitals stable.

EMS brought him into the trauma slot and he was talking and moving about (thus, quick ABCs were okay -- airway patent, breathing okay, circulation okay), but not making any sense, perseverating about his address. That was all he could say over and over: "I live at 100 spring street. I live at 100 spring street." Big bandage on his head put there by EMS. I unwrapped it to get a look at what was under there. It was bad, but I've seen worse -- a semicircular laceration about 10 centimeters in length, but the galea was exposed and you could see the bony white color of the skull underneath. A quick exam around the wound failed to show any depressed fracture that I could see. As protocol, I wrapped it back up with a compression dressing (someone will suture it later, first priority is stabilization, not cosmetic repair), he needed to go for his head and neck ct to make sure he didn't break anything. He had an altered mental status though, he couldn't tell me his name or where he was, only that he lived at 100 spring street for the last 50 years. I bet his rent control in soho now was, like, fifty bucks.

The trauma intern packed him up and escorted him to CT. The studies were all clean -- no intracranial bleeding, no skull fracture, no cervical spine fracture or dislocation, chest xray normal. His only apparent injury was the gash on his head. Good news for him.

It used to be the case that in our hospital, the protocol was that should any trauma case come in, no matter what injuries the patient does or does not have, it was an automatic admission to the trauma service and they were responsible for the ultimate disposition, treatment and discharge of the patient. I don't know how or when this next step started, but for some reason, within the last year or so, there's now an unwritten "policy" that was seemingly forced by the surgery team that if, after all radiology studies (CTs, xrays, etc) are negative, the patient is considered "de-trauma-slotted" and goes back to the ER as OUR patient for observation and discharge. "We're really busy," they said.

We're not?

I've been on the trauma service -- there are ten times as many active patients in the ED as there are on the trauma service. But whatever. I'm not that confrontational. I rather understand -- on a case-by-case basis, if it's very simple and requires no operative intervention, fine, I'm happy to have that patient babysat in the ER until they're ready to leave.

But I got pissed off in this case.

"Hey," said the surgery intern -- who's been a doctor for all of three months now -- "all his scans were totally clean, he's going to be de-slotted and coming back."

I felt a little affronted. "Is this your particular decision?"

"The whole team's." [Codespeak for "I don't want to tell you, but it has to be a united front so we can push this patient back to you."]

"I know this is way above you," I snapped back coldly at him. "I need to talk to your senior." But I thought ahead: "Can I see your patient list first?" Like I thought -- a total of seven patients on the trauma service, three under the "to discharge in a.m." column, no one slated for the O.R. Nice try.

So I paged the senior resident. "Jasmine," I said, "your intern is attempting to de-slot Mr. X."

"Yeah? His scans were negative."

"Have you talked to the patient yet?"

"I checked in on him."

"Was he alert and oriented to you?"

"I didn't specifically ask." She could tell I was trying to corner her -- appropriately so -- and before I could again speak, she said, in a not-too-friendly-tone, "LOOK, all his studies are negative, he just needs to be observed and then discharged, that's what happens in a de-slot."

"Are you kidding me? I know some cases are clear -- but he's not a 20 year old who fell down, and I know he's not going to the OR, BUT, he IS over EIGHTY years old, we don't know the mechanism of his injury -- did he trip and fall? Or did he syncopize or have a cardiac event and pass out and hit his head? He's on aspirin and coumadin, AND we all smelled alcohol on him, so he's got three really good reasons to have ineffective platelets, PLUS he has altered mental status and can only tell me his address, not even his name or date or where he is. What about any of that says this-is-okay-to-watch-and-discharge to YOU?"

"Well YOU can re-scan his head if you need to, we are VERY busy."

"About that -- your signout sheet has seven patients on it, three of whom are about to be discharged. We currently have 32 active patients in the ED with more in triage right now."

"His studies were all negative."

"And back we circle. He can't stay here in the ED. Have your intern babysit him."

"Why can't he sit in your ED with a monitor and you discharge him in the morning when he's better?"

Was I talking to a hole in the wall? Time for the trump card.

"Jasmine -- I don't know that he IS dischargeable. I think at this point I should bump it up to your attending and call him at 3am to see if he thinks this guy is stable to be discharged like YOU think he is."

"FORGET IT. WE'LL ACCEPT HIM." Click.

It's not her choice anyway since we have admitting privileges.


AAAARRRRGGGHHH. I just needed to vent about this one. I am no stranger to being on the losing side of a debate about the best thing for a patient, but this seemed totally obvious to me, and I just thought they were being lazy. I generally have a fine relationship with the surgeons but every once in awhile we have to have a spat like this. Incidentally, the patient continued to have altered mental status and had two more head CTs in the next 24 hours, both of which were negative for any pathology or slow bleed. For some reason, he became mentally "fine" and "with it" again later on and was discharged, but not until over 30 hours after presentation -- way too long to sit in the ER.