The No-Win Situation in the ER

November 10, 2010

“My doctor sent me in to be admitted. Is he here yet? I packed my bag and rushed right over, so I probably beat him in getting here. I hope he had time to finish his dinner.” I almost burst out laughing. The situation would almost be charming in a quaint 1950s television kind of way. This little old lady with her nonurgent problem had called her primary-care doctor’s office and had been instructed to hurry on over to the ER.

“My doctor sent me in to be admitted. Is he here yet? I packed my bag and rushed right over, so I probably beat him in getting here. I hope he had time to finish his dinner.”

I almost burst out laughing.

The situation would almost be charming in a quaint 1950s television kind of way. This little old lady with her nonurgent problem had called her primary-care doctor’s office and had been instructed to hurry on over to the ER. She even packed a little red overnight bag with flowers on it. She had no transportation, so she called a taxi, and the cab driver thought he’d be cute and dropped her off in the ambulance bay. So she walked right into the mayhem of a Saturday night in the ER, and in the confusion was brought right into an exam room instead of being sent out to the waiting room where she surely would have been triaged as “nonurgent” and told to wait for three or four hours.

Her actual medical problem was a chronic, nonlife-threatening but irritating issue that could easily have waited several days (or weeks) and was more appropriately managed in the office. But here she was at 8 p.m. in my ER and now she was my problem.

Except it’s not just her. The minute her son (who lives in Los Angeles) and daughter (who lives in Delaware but dropped everything and is hurrying into Philadelphia when she found out that her mother was in the ER) were contacted by my patient on her new cell phone (red with flowers to match the overnight bag) I began fielding phone calls from both coasts. The son seemed relieved and fairly reasonable when I told him that she seemed fine, but he became pretty irate when I told him that: 

A. The primary-care doctor never called to tell us that she was coming in.
B. I’ve never actually seen the primary-care doctor in the hospital, and barring the collapse of the building he was sleeping in, would be unlikely to see him in the ER that night.
C. I was pleased that his sister was coming in from Delaware because I planned to send his mother home and it would be nice if his sister could stay with her tonight, in the event that his mother needed any help.

I hadn’t even informed the patient that we were planning on discharging her home when the daughter called me from somewhere in Delaware to indignantly tell me that I was not to send her mother home under any condition, and that "Primary-care Doctor better be in that ER when I get there or else!”

I considered calling the primary-care doc and telling him about the crapstorm that his office staff has caused by following his CYA style management algorithm for phone calls from his patients (every single one ends with instructing the patient to go to the ER), but part of my job is to try to protect consultants from this kind of harassment.

I’m sure there was some miscommunication on the patient’s part or on the part of the office staff. Nobody expects their primary-care doctor to show up in the ER at 8 p.m. on a Saturday night anymore, do they?

The daughter finally arrived around 10:30 p.m. with a whole head of steam and demanded to speak with my supervisor. I told her that there were no supervisors around on the weekend and mine was the final answer. Her brother called as I was explaining to her that her mother didn’t need to be admitted to the hospital, would not be safe in the hospital, would probably contract some hospital-borne infection or suffer some adverse drug event in the hospital, and would probably be stuck with the bill from the hospital because there was no way that her insurance company would ever pay for this admission to the hospital. I might as well have been speaking to the television.

I instructed the nurses and the techs to stay out of the room and whenever I passed by I didn’t make eye contact or look in the room. Eventually, I noticed the daughter helping the old lady get dressed, at which point I instructed the nurses to help them and find a wheelchair to get her out to the car.

I know I did the right thing in blocking this admission and sending this woman home, but I know that I also upheld this old woman’s conviction that the world has become colder and more beaurocratic and less…nice. It would have been nice for her primary-care doctor to have answered her phone call himself or to have made a house call or to have met her in the ER or for me to have admitted her to a nice quiet room in the hospital for a day or two where her children could have visited her and brought her flowers to match the ones on her overnight bag and cell phone.

That would have been nice.

The old lady was quiet and sad as she left. The daughter was quiet and pissed off. We couldn’t even offer to validate her parking, because that only happens from 9 to 5 Monday through Friday.