I think I made a booboo. Took a pt home that prolly wasn't ready

[HERBIE1]

Gosh I wish we had your medical system, here you only get a Consultant Physician if you are really crook; rest of the time it's the Reg or if they have died from fatigue then a dangerously underfed, overworked and chronically burnt out House Surgeon.

Dear Jeebus, let me get into medical school so I can work in said system and earn enough money to buy a boat ...

In many instances around here, each attending MD (with admitting priveleges to the hospital) of a patient has a different set of requirements/standing orders for their patients. Some require a consult from the ER only when one of their patients is admitted to the hospital, some want notification on every one of their patients who are brought to the ER. In the case of nursing homes, some attendings literally may have a hundred or more nursing home patients(that is their entire practice) and have very specific rules about what to do when their patients present to the ER.

This of course is for comprehensive ER's, and some of the smaller hospitals have a different set of rules, or none at all.

[nypamedic43]

According to her physicians necessity (gotta love medicare and their ring circus) She is bed bound, has dementia (which was not stated in her half assed version of a H&P.) Requires medical supervision (though it does not state why). She cannot sit or support herself in a wheelchair due to L sided weakness caused by a CVA (age of CVA not stated in H&P)

Unfortunately thats what Medicare wants...a reason WHY she has to go be stretcher. Here in NY, the dementia is enough to warrent it and being unable to ambulate because of past CVA seals the deal. The need for supervision comes from the hx of dementia. You have to stop and remember, other than essential medical information, the ED doesnt have to give you any paperwork. While you may think it was a half-assed H&P, at least you got something to help write your chart. The age of the past CVA is irrelevant, she has a deficit from it and that is enough. We also dont know if the ER Doc, talked to her primary before discharge. He probably did but that wont be in any paperwork that we are concerned with. We just dont know the dynamics of what transpired while she was being treated.

If you are second guessing yourself, and thinking that she shouldnt have gone home, then maybe she shouldnt have. Listen to your gut. Learn from it, move on and next time, do it better. ED staff may get a little pissy with you for second guessing them...but if you have the patients best interests at heart, they can't fault you for that.

[Kiwiology]

In many instances around here, each attending MD (with admitting priveleges to the hospital) of a patient has a different set of requirements/standing orders for their patients. Some require a consult from the ER only when one of their patients is admitted to the hospital, some want notification on every one of their patients who are brought to the ER. In the case of nursing homes, some attendings literally may have a hundred or more nursing home patients(that is their entire practice) and have very specific rules about what to do when their patients present to the ER.

Ah yes you are talking about a General Practitioner, they're Consultant Physicians, I thought you were referring to the Doctors at the emergency department.

Interestingly, no Physician has admitting rights except the particular service who is accepting the patient - if a GP wants their patient admitted they must call the hospital and speak with the particular service e.g. internal medicine or cardiology; and then it's usually the Registrar or more frequently, the House Surgeon attached to the particular tream.

[chbare]

Yeah Kiwi, it's different here. However, many hospitals are transitioning to a model where patients are admitted to what is known as a hospitalist or an intensivist in some cases. Many of the ICU's will have pulmonologists taking care of the intubated patients. There is no standard format however. This is especially true in many rural facilities that may have a paediatrician running the ER who has to call a different physician for each patient who has a different primary care physician.

[runswithneedles]

ED staff may get a little pissy with you for second guessing them...but if you have the patients best interests at heart, they can't fault you for that.

Im more worried about the eternal fire Im going to get from the big kahuna in the office when he gets an earful from the nurse when I "questioned her sound judgement".

"Honestly bro go scoff down some concrete pills and harden the fuck up"

That is an awesome quote

[chbare]

How did you question, what did you ask, what were your concerns and what answers did you receive? You've been incredibly vague when answering questions thus far.

[DwayneEMTP]

Kiwi, you're so full of shit, you know damn good and well what he meant by a narrative. Perhaps you use a different term, but you've been here more than long enough to know that...friggin' witch doctor....

And it's not uncommon in rural areas for an ambulance to take patients home when other means of transport aren't available. I've several times asked the doc to create a statement of need on elderly patients that we'd taken from their homes a few hours before and were now being released without any reasonable way for them to get home. I would have been happy to sneak them home on the sly but we needed his note for liability and billing.

And the hell you'll burn in will only happen Brother if you approach the staff in a confrontational manner. If you get your vitals, and yeah, sometimes that alone will piss them off, (But won't end you in hell) and don't understand something, track down a decent nurse, or the doc and tell them, "Man, this blood pressure seems high compared to what I was taught/am used to, do you have a second to explain what's going on here? Any idea what caused her headache?" etc...

With very, very few exceptions it's been my experience that if they have the time ER docs love to teach. Anyone, anytime (almost), if it appears that there is learning happening.

+1 for hanging in on this thread Mike...I have a lot of respect for that. I'd ask that you go back, start at the beginning, and reread all of your posts, including the topic heading, and see if there is anything that you would do differently next time. Different questions, presentation, etc....I'm not saying that anything at all is wrong, but I do this constantly with my posts, particularly when I'm blessed to have a thread full of heavy hitters like this one, and I never, ever fail to find several things that I wish that I could change, or take back, or present with a different energy.

One thing I'd like you to consider is this, you, and many here have questioned whether or not you should have taken the patient back inside, but maybe you should have taken the time in your assessment in the ER to have had those questions indoors first?

Just a thought.

You have a ton to learn, but man, this is such a terribly good start. You've been here long enough to know that despite our best, though often clumbsy efforts, most won't stay with a thread long enough to present, re present, and possibly even change their ideas...

There may be hope for you yet...I mean, look how awesome I turned out!! (Gag...)

Dwayne

[Kiwiology]

Kiwi, you're so full of shit, you know damn good and well what he meant by a narrative. Perhaps you use a different term, but you've been here more than long enough to know that...friggin' witch doctor....

Love you too Dwayne now where the fuck is my Mongolian BBQ?

One thing I'd like you to consider is this, you, and many here have questioned whether or not you should have taken the patient back inside, but maybe you should have taken the time in your assessment in the ER to have had those questions indoors first?

I agree

There may be hope for you yet...I mean, look how awesome I turned out!! (Gag...)

You know the people at the centre for the developmentally disabled tell everybody they turned out awesome right?

[DFIB]

I possibly have a simplistic view of this situation.

If your patients condition deteriorates in rout to her destination in a way that changes her priority, I take her back to the hospital.

Second, If I am not sure about the significance of the S/S that I am observing I will contact online medical direction and receive orders as how to proceed.

When I pick up the patient I would have made my own assessment and asked questions according to my findings. Is her hemiplegia old are recent? What was her chief complaint on admission? What labs/test did she have and what were the results? Armed with this information I will understand the S/S of a changing condition a lot better. Some hospitals will let you see their chart or records on a computer screen.

The hospital should have a translator available to help complete the transfer of care. They may not like requesting one but this patient is fixing to be yours and you need to know the details.

So instead of assuming that the ED were negligent in their assessment, diagnostic and treatment I would simply procure more information before I accept the patient.

I also have to echo Dwayne about rural public transportation. It simply does not exists in many areas because most americans drive their own cars. This puts the "non driving' population at a huge disadvantage. Of course if they lived in a commune they would always have a ride and a friend to drive them.

Edited January 24, 2012 by DFIB

[Asysin2leads]

I was going to make a comment about asymptomatic hypertension and medical stability, but ERDoc will just tell me how wrong I am. I defer to him. I just brings 'em.

(I don't think asymptomatic hypertension makes you too unstable to discharge from the ER). *hides*.