2 weeks ago i shadowed an MD in the emergency dept. (formerly called the "ER") while he was working the night shift. I was always eager to do so, given that i've never experienced the ED outside of my 2-3 personal unfortunate encounters, of which i'm of course oblivious to observing how the place operates (least of your worries, right?!).
Expected observations-- the ED staff sees a LOT of random crap. And of that, a large chunk of ED-fed cases are not "ED-worthy". Over the course of the night, we confirmed one pregnancy and investigated another woman's pregnancy issues (abnormal discharge). We also saw 2 patients who are quote "regulars", coming in weekly for the same condition, which is nothing at all (more of a mental health issue). Then comes the good schtuff. One dude comes in on a stretcher sitting up at 90 degrees after crushing a vertebra in a bad car accident. The kicker? He absolutely refused to lay down on a straight board and strapped in, so the EMTs kept him upright, strapped against ~8-10 pillows between his back/head and the stretcher. What a knucklehead! In doing so, they explained that he did risk being paralyzed... and he was okay with that. This is when you empathize for the shcrap that clinicians have to put up with. Another guy thought he had a heart attack and turns out he just drank enough for 3 people and was still feeling the lingering effects. One lady had CHF and was unable to breathe, so we had to put her on a bi-pap. And another pt had what the Dr thought to be a classic seizure, as per the description by his wife. This was a great example of the importance of communication and the risk of misinterpretation, as one person's language often means something totally different to another. The Dr had to decipher the wife's story amidst her excitement and put the pieces together. Turned out to be a textbook seizure. Another textbook case was a cold, which expectedly is a frequent case that arrives to the ED that shouldn't. This is a prime example of when a triage nurse is necessary to sift out the non-critical cases.
Unexpected observations-- So that was the pretty textbook side of the observations. But with that came a lot of surprises. First and foremost, where's all the chaos that comes with "emergencies" just like on the TV shows?! There was not a single person running or stretcher flying through that joint! Nah, probably a good sign.. or at least best practices. In fact, the MD i observed was calmer than a golf tourney announcer. He calmly rounded, at random, to see how patients were doing. Something that I was very surprised by, and also concerned with, is how arbitrary the case review process is conducted. In fact, there is (at least at this ED on this night) no "best practice" protocol for how patients are triaged, notably the order, acuity, room placement, MD/nurse assigned, or treatment status tracking. They pretty much just arbitrarily circled the halls and checked on various cases.
Per the MD i shadowed, the case/EMR updates were usually made at the end of the shift; he said he has no problem remembering the facts and never confuses patient cases (so he says..). When we had downtime he would make updates accordingly, though. The ED also has an e-whiteboard tracking case status, including incoming cases. However, i think it's used incorrectly... so much info not referenced or even collected that the board is capable of and could be a huge time-saver (and CYAer). It was also very interesting to see the MD never request or confirm a patient's insurance status or ability to pay. He treated every patient equally, which is above the minimum requirement of EMTALA. I also found the MD's "BS report" to be really interesting. Because patients often come to the ED complaining of symptoms that are either unrealistic, not true, or severely exaggerated, he would commonly barrage a patient with questions and intertwine/follow up with specific condition questions. If the patient had inconsistent responses, he typically concluded that their condition was either not true or low priority. He said that patient pain level and/or description of condition is frequently exaggerated or even invalid, in hopes of seeing a MD faster.
This was probably the kicker of the night... a gradual observation. With the recent rise in patient safety and cleanliness, i really expected everyone to be extra careful with hand hygiene. FALSE. In fact, the MD i shadowed didn't wash his hands even once over 4.5 hours!!! After each patient observation, he flicked the hand sanitizer lever barely making contact and surely not getting any sanitizer on his hands. And while he had the whole "be consistent" part down pat, he consistently failed to actually clean his hands. This is quite scary and makes me want to squirt my physician's hands with cleaner at my next dr appt. I mean, if you mess around with someone else's open wounds, genitals, and bodily fluids, i would like a clean slate. Just sayin'. Joking aside, this is a HUGE risk, liability-wise and something that probably needs to be further evaluated. Note to self..
By 3:30am the flow had slowed and it was time for me to bounce. I'll be back for more, i just know it..
