Sunday, January 10, 2016

An Emergency Room Story that Makes me Think

"Birdstrike" is an emergency room physician who blogs at Dr. Whitecoat. Her/his blog came to my attention on MedPage Today recently. She/he is somewhat anonymous and so the musings have to be taken with that context. 

Last July, Birdstrikpublished a post regarding an emergency room (ER) visit. It provides some interesting perspective. 

First she/he describes a long 12 hour shift in the ER. At the end of that effort, Birdstrike finds the ER with 25 patients still to be seen. Who works 12 hour shifts? Any of us likely can. Just because we can, does that mean we should? Are any of us at our best after 12 hours spent on any activity?

In sympathy with the physician on the next shift, Birdstrike remains and takes another patient, a complaint of ruptured eardrum. The patient is a minor, presenting with both parents. She complains of a head trauma, and expresses fear of a ruptured eardrum. 

The patient, who has a history of prior eardrum rupture, notes that her last experience put her on the injured reserve, and conjectures that she will be unable to play at this time. The exam reveals a "perfect" ear drum, and discharge/blood that looks and smells like "raspberry jelly." At the end of the exam, Birdstrike concludes "her ear is completely normal."

Birdstrike inquires further and when confronted the patient admits to putting jelly in her ear. She explains that an upcoming basketball tournament is not her priority and instead desires to attend a friend's party coincidentally scheduled. 

She is discharged. One parent returns to the exam room to ask about the encounter. The parent is suspicious, and with merely a nod, Birdstrike confirms the parent's suspicion "she faked it?"

Days later, Birdstrike learns that the patient subsequently attempted suicide. The parents are blaming Birdstrike. They have submitted a satisfaction survey rating Birdstrike with "the lowest scores possible" and they have filed a complaint with the hospital administration that Birdstrike violated HIPPA with the head nod. The family is consulting an attorney with the intent of suing for malpractice; the claim is that Birdstrike missed the diagnosis. Not the jelly-in-the-ear diagnosis, the suicidal depression diagnosis. 

Birdstrike now faces the patient, the family, the hospital and the litigation. And while she/he faces and deals with this, I suspect, she/he continues with the stress of 12 hour shifts in the ER and the parade of maladies and injuries that entails. See, we might all agree on some things that are emergencies. We might also disagree whether all the complaints that end up in that venue are emergencies, despite being completely legitimate. Some people apparently use the ER as their primary care. 

Birdstrike's story resonated in a couple of ways. 

First, there are patients that are using our medical system for purposes other than receiving medical care for legitimate maladies and complaints. Some may be malingering in hopes of attending a party. Some may be exaggerating in hopes of obtaining some pain medication. Some may legitimately perceive complaints that simply have no sound foundation in physiology or science. Some may have conditions that should be presented to a family phsician during normal business hours, but are not for whatever reason. They are consuming resources that could be devoted to people that need emergent care.

Second, it illustrates the varying perspectives we may have on ERs. I was recently in a conversation with a mother that had taken a child to a local ER. This was one of those ERs that has billboards all over town with a digital portion promoting their current "wait time" in minutes. The implication is that a visit to this ER will entail a very short wait time. This mother's experience was that the advertised 10 minutes was actually more like 3 hours. Oh, she was greeted within 10 minutes. She was given papers to complete within 10 minutes. But she was two hours getting her child to an exam room and another hour after that being seen.  After the exam, there were papers to complete, orders to explain, and in all about four hours was reportedly consumed by this ER visit. 

She related that during her hour-long wait in the exam room she periodically stepped out the door to view the hallway. The clerical area in the center of the ER was consistently well-populated by men and women in hospital scrubs. Conversations were ongoing, animated, and she noted periodic eruptions of laughter and frivolity. She repeatedly wondered why one of this cadre of souls could not be bothered to come provide care and treatment in her examination room. She became angy. She concluded, her own opinion, that much or all of the delay that day was avoidable. She did not come away from the ER experience (1) impressed, (2) satisfied, or (3) happy. 

There are multiple perspectives on things. A patients' parent see a "coffee-clutch" in the clerical area and feels no one in the ER is working. Possibly those people are working, completing the plethora of documents, forms, referrals, and prescriptions that modern medicine requires? Perhaps they become jaded regarding urgency when they see enough raspberry jelly or similar complaints? Perhaps those people, who inexplicably are scheduled for 12 hour shifts periodically, and naturally, reach a point where laughter is their only medicine?

Third, Does any patient know everything else going on the ER? Likely not. Can the medical personnel explain to the waiting patients why the wait was what it was? Again, not likely. HIPPA precludes them from explaining what they were doing in the room next door for the last minutes or hours, which delayed their entry to this exam room. They may apologize and share that "it has been one of those days," but that is likely as far as it goes.

Though they cannot explain in that detail, the advertisement of a "10 minute wait" on a public billboard is not so simple to explain. That raises expectations. Anyone seeing that the "wait" is 10 minutes will perceive that to be the "wait" before help, not the "wait" before paperwork is provided for completion. Do hospitals create satisfaction by raising expectations of service after a 10 minute wait, only to fail to deliver what people reasonably expect from the advertisement? No. If you create an expectation, you are responsible for failure to live up to it. 

Many people have related similar expectation stories to me: when they scheduled a doctor's appointment for 9:45, and the doctor does not see them until 10:30; when the repair person is to visit between 8:00 and noon, and does not show up until 1:00; when the hearing notice says trial will be at 9:00 and the judge does not show up until 9:30 and then spends another 30 minutes obtaining coffee and getting situated; when the shop promises the vehicle will be ready at 3:00 and presenting at that time the customer gets the keys an hour later; when the judge promises an order will be "issued later today" and then days pass before this occurs. If you create an expectation, you are responsible for failure to live up to it. If you fail to live up to an expectation you specifically created, the disapointment and anger are your responsibility. Justified perhaps by circumstance, but still your responsibility. 

Fourth, The ER physician perspective is interesting. The patient in this story presented with a frank misrepresentation. The medical system was inappropriately engaged for a purpose other than medical care. This may have contributed to the delay in the ER for others that evening. This may have contributed to a cultural malaise or frustration or jading of ER personnel. It may be difficult to rush to the next emergency when your last emergency was raspberry jelly.

The ER physician is expected to take people at their word, address the presenting complaint, make a diagnosis, and provide care that stabilizes the patient. But is the ER doctor supposed to diagnose conditions or anticipate diagnoses of which there is no complaint? Perhaps the answer is "yes" in some circumstances. 

What if a trauma victim presents with a broken arm and emphatically denies other symptoms and complaints? If the patient's pupils are unequal, should this be investigated despite denial of head trauma and any symptoms? I suspect most would agree that the physician should do a reasonable exam and should pursue visual or other clues and signs. But, Birdstrike identified no such signs of depression. Was the teenager suicidal or depressed in that ER when seeking a spot on the injured reserve, or did that teenager become suicidal later after failing to obtain the excuse from the tournament that would facilitate attendance at a party?

That dichotomy will be examined in retrospect in the malpractice action. What was said, and what was not? What signs or symptoms were there? It will not likely be a brief process. 

What lessons can be gleaned? Does every ER physician need to do an in-depth depression inventory, complete with documentation, for each patient that presents? Perhaps this effort and documentation would identify and memorialize the presence or absence of signs or symptoms. But, how much additional time would that require? What would it mean in terms of delay for the next patient(s)? 

I think we can glean a few lessons, however. If we create expectations, we should live up to them. When we do not, to the extent we can, we should explain why. In any event we should deliver a sincere apology. When others do not live up to our expectations, we should understand that perhaps they could not, and for whatever reason they cannot explain this fully to us.  We should be willing to forgive when we can. We have to realize that people may perceive us differently, as we show up late and obtain our morning coffee, or stand about and seemingly joke while they wait? We cannot change them or their perceptions, but we can strive to understand them.

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