Sunday, July 29, 2007

Whose patient is that??

University Hospitals are often battle grounds; each service trying to duck, dodge and weave their way around direct responsibility for any patients. It's in the name of the patient census, the numbers, the 'teaching', the fairness of the situation. It's in the name of all sorts of nonsense, but rarely (rare as in the limit of x as x approaches zero) is it in the name of patient care. Much of my training took place in just such a place where endless debates about whether a particular patient with pneumonia and diabetes belonged on respirology, or if the patient actually had diabetes and pneumonia and therefore should be admitted to the general medicine service took place.

One night, while a junior resident on a general surgery rotation, I was asked by the doc in emerg to see a patient with abdominal pain. The exam, the labs and the imaging all added up to a diagnosis of choledocholithiasis. For those not initiated in the nuances of the multi-layered complexity of a university hospital it may seem to make sense that general surgeons, the surgeons who deal with the abdomen specifically, would be a good choice to take care of such a patient. The uninitiated might not know that an obstructing gallstone is a battleground, in fact the battleground, where general surgeons and gastroenterologists of the academic variety wage an ongoing war: A patient with a stuck gallstone needs 2 procedures, an ERCP to remove the offending stone, and a cholecystectomy to remove the offending gallbladder. The surgeons believe that since the ERCP needs to take place first the gastroenterologists should admit the patient (and therefore take primary responsibility for them), do their procedure and then consult the surgeons to remove the gallbladder. The gastroenterologists, on the other hand, believe that the surgery, being the bigger of the 2 procedures, should mean that the surgeons admit the patient (taking primary responsibility) and consult them to do ERCP prior to the surgery.

The battle is waged daily (and nightly) in the emergency department, and although direct engagement between the primary adversaries (the two attending doctors) is rare, they freely dispatch their underlings to wage a war through proxy. When things look grim and a patient might actually be admitted one of these great generals might even phone down to the emerg to chew out the emerg doc in an effort to restore a more favourable balance to the conflict.

The causes of the ongoing conflict are many. People are overworked, overstretched, tired, angry and hungry. The residents, foot soldiers in the conflict, are indoctrinated in the importance of being a wall, protecting the service from admissions and keeping the census low.

After seeing the patient I prepared for the buff and turf. I arranged my arguments and evidence like a row of grenades and called my general for the final battle orders. I've got a patient down here in emerg., consulted for abdo pain but turns out to have an obstructing gallstone. I'm going to call GI and try to get them to do the admit. I'd been through the battle before, I knew this was how it was all supposed to go. On the other end of the phone I heard only a moment of silence, and then a slightly confused Why? ... I'll come down in a couple of minutes and see the patient with you.

The general surgeon working that night happened to be a particular human and humane man. He saw the patient, agreed with the diagnosis, agreed with the treatment, but disagreed with the disposition. Why would we get someone else to do the admission? The emerg asked us to see the person, to help them. How does it help the patient to see a whole other team of people and to sit here in emerg for another 3 or 4 hours all just so we can have one less person on our service? His point was well taken, the real question was more about the patient in front of us than with the politics of the place she was in. In actual fact it typically took less time and effort for both us and the patient to simply do the admission than to wage the ongoing war.

In rural medicine I don't have to deal with these issues in my own hospital. If I'm working in the emerg and want to admit to someone I just do it, admitting them to myself and caring for them in hospital. Occasionally I face these roadblocks when I'm trying to get assistance over the phone, or to transfer a patient. Should a trauma patient with altered level of consciousness go to neurosurgery, emergency or ICU, when they're transfered to the University Hospital? The reality is that what the patient really need is to get to the next level of care, under whom they are admitted is likely of limited importance (since all these players will be involved in their care regardless). I find the human approach (an appeal on alternate grounds) is best, since the politics run too deep for an outsider to get embroiled in. The patient is sick, I say, I'm in the middle of nowhere and I don't have a CT scanner, a neurosurgeon, or an actual ICU. I need to transfer this patient to you because I've done everything I can here and it's not enough, so I'm asking for your help.

It's beyond the petty politics of hospitals, the bad feelings about division of labour and the history of the various players. It's outside of politics and speaks a language that is common to most doctors, worry about a patient, stretched to the limit of what you are able to do. It usually works...


Bostonian in NY said...

Well written, it's inspiring to see someone pulling the humane card instead of jumping into the multi-service pissing match.

The Lone Coyote said...

Nice post. It beings us back to the reality--the patient needs care and not to sit for hours while the services battle.

MedStudentGod (MSG) said...

You know, being a medical student who is forced into these kinds of battles, I've seen the transformation wherein I find myself disliking a service I liked just a month or so before simply because they weren't "our team" anymore. I understand why it happens, but I'm often puzzled as to why it must occur. For some reason or another it's rather common for professionals to argue about admits, treatment, and to cast down-ward glances on those outside of their respective field. I imagine it's human nature, but it's still not cool.