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Too Many Chefs

I am now in Los Angeles visiting my sister and her newly born daughter. Immediately after work I drove straight for San Jose and Southwest Airlines to see the first new member in our small family. The stark transition of my last two hours in the emergency room to the joy and hope I immediately encountered in the delivery room has left my head spinning. The ER blog about boarding brings me back to those last two hours and keeps me thinking of how I can improve my care.

Stanford Hospital is currently modernizing and expanding components of its residencies because of the surge in its daily census that often reaches capacity. For us, in the the emergency department, this means patients that require an internal medicine team and hospital bed instead wait in the ED.

In my recent case I was signed out a "boarding" patient, awaiting a hospital bed, and followed by an internal medicine team. This 76 year old woman presented with dizziness, abdominal pain, and one episode of bloody stool. She had some abnormal laboratory values which included elevated markers of infection, but otherwise looked "good." By that I mean she seemed very safe for a floor bed and medical management without any emergent interventions such as colonoscopy or invasive procedures.

Now I see the danger of her ED stay being that though she is under our care the major thrust of her treatment is being managed by the admitting medicine team. This sets up a situation where we know less about her direction because communication is difficult to constantly update between the two groups. Also, each of us may feel a little too comfortable because there is someone else taking on responsibility for her care, and being too comfortable is alway dangerous.

Needless to say, her pressures dropped near the end of my shift and after 14 hours in the ED. We called the ICU, started central intravenous lines, and transfused her with blood and saline. Soon the surgeons also showed up concerned about ischemic bowel and took her to the operating room. Though I think we all worked well together to arrive at her best possible plan, it was at times difficult to determine who should be directing her care and who had the most current information about her.

There are certainly other problems with having patients managed long term in the ED related to work load and nursing but as a resident this issue looms the largest. Next time in the ED I will try to help these patients as if I am not only responsible for them in the ED but also as a de facto member of the medicine team, pushing them on issues of care and staying in the loop.

This patient did go to the operating room with the surgeons who looked inside her abdomen and did not find ischemic bowel and then did a colonoscopy that did not show any evidence of bleeding. Her low blood pressure was most likely due to an unknown infection progressing to sepsis.
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About the Author

The Stanford Emergency Room is the center of emergency care at Stanford University.