Rant (I have a feeling this is going to be a series!)

OK – here is something I have been meaning to get off my chest for a while now. Always remain true to your oath. Never forget, you are here – as part of a team – to help people at their most vulnerable. Do NOT become arrogant, or cocky. Do not think you know more, or enough even. It is always going to be a learning curve. You will always find something new, a different perspective, a different set of circumstances, a different allergy spectrum, a different way to treat and a different response. Always be open to suggestion, and NEVER assume the tone of ‘Me, Myself and I” – You are part of a team. Say it after me. T-E-A-M. TEAM. You can not and will not be able to see, treat, investigate, counsel, manage and completely sort out ANY patient thoroughly on your own. You will need to be part of a team, whether it is the nurses, the junior (or senior) doctors around you – in your specialty or in another specialty who you call upon to ask for advice, or whether its the janitor or the lovely lady who makes the tea and sandwiches for the patients. You can not do without any of them. We are all cogs in an intricate system, and should you feel the urge to think you are the most important cog or the biggest or the brightest – just remember, even the smallest nut can cause a whole plane to come down.

*OK. Deep breaths. You got this. Keep it together*

Where is this coming from? This is coming from an increasing number of experiences I have had interacting with colleagues from different specialties, whereby as soon as they answer the bleep or pick up the phone for a potential referral or even an opinion, you can almost hear the wheels turning in their heads in trying to pick out any reason to refuse the referral or bounce it on to someone else. But wait – I did not bring this patient from my home. I have assessed and tried to sort him out – and based on my assessment with the tools I have, I am obliged (in the interest of patient care and safety) to refer to your expertise in the matter. Not your expertise in how to NOT accept a patient into your services, but the actual expertise of your specialty, which you have signed a contract for and willingly and knowingly have signed up to provide!

Case in point: 80-something year old female, with some medical history which I now forget, admitted with non specific symptoms of progressively worsening mobility issues over the past few weeks, acutely deteriorating over the past week to become completely bed bound and unable to get out of bed – associated with a very poor oral intake of food as well as water. Husband called the paramedics that day because she was literally unable to lift up her head to have a drink of water. There were no other symptoms – no pain anywhere according to the patient, no recent fevers, no vomiting and normal bowels. Paramedics found her to be very tachypneic (higher than normal respiratory rate – hers was about 55) but the rest of her observations were all within normal parameters. She arrived into ED where I was the first one on scene along with the resus nurse. We quickly connected her to a monitor, and established an IV line, taking some baseline blood tests including a very quick blood gas, which gives us a very quick assessment of anything acutely going on. We found her lactate levels to be 11 (yes, ELEVEN – classified as sky-high in my dictionary!). I thought on examination her abdomen was slightly protuberant (?distended?) but not tender – thought she did appear slightly uncomfortable when I examined her. She was conscious, but drowsy – yet was able to answer all my questions. I got my registrar to come in and review her (sky-high lactate!) even though I basically knew my plan of action. He felt that the patient’s tummy was actually distended, with diffuse tenderness instead of discomfort. He advised I urgently get x-rays of the abdomen and an erect chest film, to rule out bowel obstruction/perforated bowel loops. As I was requesting said scans, the consultant was sat beside me on the next computer, she overheard the words ‘high lactate’ and ‘abdominal pain’ and immediately wanted me to drop everything, call the surgeons and get a ct scan of the abdomen to rule out bowel ischema. I requested the CT scan first, spoke to the radiology consultant, who (surprise surprise!) wanted the patient to first be seen by the surgical team and then be considered for the scan. I then bleeped the surgical team, this was a registrar, and our very pleasant conversation went thus:
Hello there, sorry to bother you – I am one of the ED SHOs, I would like to refer a patient to you please.
*give him the patient’s details*
after being interrupted 4 times during the whole history etc he asked me 3 things: Have you requested a CT scan? (yes) Have you discussed it with the medical team? (no, why would I do that? abdominal pain/tender abdomen with a high lactate, medics won’t touch her with a barge pole) and have you at least rung up ITU? (No, once again, why would I – patient is unwell I agree, but she is stable aside from a high resp rate, she may progress to needing ITU care but currently would really benefit from an opinion/referral to surgeons, and should you see fit to inform ITU you can let them know as part of a pre-op thing) No this patient does not sound surgical (excuse me? what part of abdominal-pain-high-lactate did you not understand? I hate using the ‘because my consultant wants you to see the patient’ card – and I rarely, if ever, use it. But I had to this time. He was not happy, but he came down to review the patient)

And still did not think they had a significant surgical problem. So my consultant had a word with him, and he still insisted the patient needed to go to medics. To which he was reminded that we have referred tot he specialty we think is appropriate for patient care in this patient’s current condition, so if he felt that the patient required to come in under a different specialty, he would have to convince that specialty himself. There was a bit of an argument – and he conceded. He saw the patient in detail, and informed us he had referred to the medical specialty who had accepted the patient, and that he had booked a contrast scan for the patient to rule out bowel ischemia – but unless something horrible showed up on CT, this patient was not to come under surgery. It seemed like the case was sorted, I made sure the patient had adequate analgesia on board, antibiotics and fluids ongoing and then went for my break.
I came back after half an hour, and picked up the next card – but my consultant reminded me that the medical team still hadn’t come down to see the patient, could I give them a call and find out what the situation was. THE MEDICAL REGISTRAR WAS NOT AWARE OF THE PATIENT! I could have almost cried. I had worked with her, though, so she very kindly listened to the story, but understandably (well, maybe not) asked that I get that CT done before she gets moved from ED on to the medical ward. I felt like banging my head against the wall. My shift was about to end in 45 minutes, but we got a CT scan requested, vetted by the radiology consultant who finally agreed because the surgeons had touched the patient and given me their blessing (so to speak) – and the last thing I did before my shift ended was confirm that the patient had had the scan, she had come back from it, I said good bye to her and told her and her husband that the results were still awaited, but since my shift was ending, it was over to the surgical team then.

Questions –
-Was the event survivable from the beginning when she first came in? Unlikely, based on how acidotic she was, and her lactate and kidney functions were through the roof.
-Could I have done anything more? There is always something that can be done to improve outcome – but I was hitting roadblocks left right and centre. In the event of each one, I escalated to the appropriate seniors, but all that did was save my back. It did nothing for the patient, and that is something that I had (and am still having) a hard time accepting.
-Was this case mis-managed? Not at all. The patient was treated adequately as and when we were finding things, thoroughly investigated, and seen/reviewed by 2 different specialties aside from ED – ITU and surgeons. She was at the ceiling of care when she passed away. The reason I am ranting here is that sometimes, or more often than not, it is a multistep process to achieving optimum care for each patient, and at every step of the way there are potential hurdles, things that are the rate-limiting factors that if the pieces do not fall into place in a timely manner, everything gets delayed. And the reason I am ranting is also – please be humble. If someone asks for your opinion or an assessment of a patient based on a skill set you have, then you should be honoured, and also honour the ethics behind the title. It is a huge responsibility, and you need to make sure that every step of the way, every day, you are discharging that obligation with humility and respect. Your patients, unaware of your moral standards and ethical beliefs, rely on you bringing your A-game. They are usually already fighting a battle, and they need you to fight for them, because they won’t be aware of the minutiae of the battle. That is where your responsibility comes in. And your A-game. Bring it. Or don’t come at all.

(Edit: I came in to work the next day, and due to force of habit I check up on the online patient database of admitted patients what had come of the case. The patient’s CT Abdomen/pelvis with contrast had been reported: “Intra-abdominal air, likely due to perforation in the sigmoid colon, secondary to probable diverticular disease. ”

My patient had passed away about 45 minutes after my shift ended.)


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