» Does it really need to be this hard?

Does it really need to be this hard?

Posted on March 24th, 2009 by Jessica

I saw a patient today who has become a semi-frequent flyer. She has been in for chest pain, had MI’s ruled out, received, narcotics, reassurance, the run around, etc on several occasions. When I first saw her come in I was planning to do more of the same. After-all, we have tons of patients who complain of pain all over and no matter how big of a work-up they get, it usually turns out to be a fruitless waste of time and money. None-the-less, whenever a patient mentions back pain, chest pain, and abdominal pain during the same visit I still wonder if it is being caused by an aortic dissection (or aneurysm). I typically ask a few key questions, and the answers don’t often raise more red flags, which I feel lets me off the hook.

Sometimes I ask these questions grudgingly because I’m not sure I really want to know the answer, especially if I am nearing the end of my shift and trying to wrap up, get out on time, and not leave too many loose ends. I ask anyway because I simply must if I want to put the idea of an aneurysm or dissection out of my head and sleep well at night. This habit has made some colleagues and co-workers roll their eyes at the big and time consuming work-ups occasionally prompted by this practice habit, but when the tests do reveal potentially catastrophic conditions it seems to justify all the negative scans. The problem is what happens next.

Today my patient turned out to have a major dissection of her aorta, which is potentially catastrophic. It was fortunate that we caught it, but it was unfortunate that almost every hospital in the state of California was unavailable to help her. Our hospital has no thoracic surgeon to manage this condition. No hospital with a thoracic surgeon had an ICU bed where she could be admitted. After 4 hours and 30+ phone calls, I realized why many doctors don’t bother looking very hard for these things. While there is some gratification in catching a life threatening diagnosis, before it is too late, there is also tremendous negative reinforcement for this particular job well done.

For hours after my shift was over I found myself pleading with hospitals up and down the state, and wondering how full these ICU’s actually were. Were there really no beds, or simply not enough nurses. Had nurses been sent home (or not called in) to save money and as an added benefit the ICU could legally decline any transfer. Who knows. At the end of the day we did find a hospital with both an ICU bed and a thoracic surgeon. After I invested so much, and went above and beyond on my own time I hope those surgeons do the same for her. I also wonder what obstacles they may encounter attempting to do so.

Filed under: Emergency Medicine, General Medicine, Story, story

221 Responses to “Does it really need to be this hard?”

ERGuy in tulare Ca, on March 27th, 2009 at 5:39 am Said:

You know…. for starters, i must say, that is is really easy to get caught up in the frame of find that the frequent flyers are just full of bull. But then when common sence kicks in and we think, i really need to use the education that i worked so hard for and really work up this patient. I am sure that anyone that in your shoes will agree.

I know this for a fact because I also have this mind set form time to time, and when you least exspect it… BAMM… its that patient that ends up as a train wreak and holds us up for hours on end trying to provide the quality medical care they deserve.

I have tried to explain this to every student i get in the er and as they are training as a lvn or rn and here i am a tech, giving them this skill set that i can on the level of education that i have.

let me tell you a little story i told one of my students recently…

I had a medical clearence patient… treating the r.n. like crap… responded to me well and apperently there was a personality conflict with the patient and the nurse. to make a long story short, i had to finally ask the nurse to step out of the room and turn over the care to another nurse. Because in the end , regardless of the fact that the patient was a medical clearence, on his way to jail because he broke the law, he was still a patient, a human being, and had rights and deserved the best care we could give…..

I say to you… great job… way to go and good work for doing the proper work up that was suppose to be done and pat yourself on the back..

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