Night Shift
Print
E-mail
Reprint

It was my first night at a new emergency department, so I was just getting used to the system and the people. Everything seemed to be going along smoothly. The staff was great and very welcoming. The patients were pleasant and generally not so sick as to create a stressful first shift. The PA, who functioned completely independent of me, seemed competent and knowledgeable. There was just one thing in my orientation shift that caused me a little concern.

“I assume the PAs run this part of the ED,” I said as the doc who was orienting me pointed to the fast track rooms.

“No,” he said bluntly. “The patients are all mixed up. You’ll see fast track just like the PAs.” It wasn’t that I was ‘too good’ to see fast track patients. Rather, I was concerned about the more complicated patients being seen by the PAs.

“That’s OK,” I thought. “I’ll just have to keep visibility on all the patients in the ED, whether I see them or not.” I was in the habit of doing that anyway, but I knew that I’d have to be careful not to insult the abilities of the PAs. I’d need their cooperation when things got busy. The last thing I needed was to paralyze them with the impression that I didn’t trust them.

Despite my best intentions, half way through my first shift the PA sat down and presented me with a stack of charts, mostly for patients of whom I was unaware. It was clear by the way she simply slid the stack of charts over to me – physician signature box on the back page facing up – that she expected me to simply sign them and get on with things.

“I can read through each of the charts or you can summarize each case,” I said. “Either way, I need to become thoroughly comfortable with the care on each chart before I sign it. I don’t want to insult your intelligence, but I need to know what you know before I’ll feel comfortable blindly signing your charts.”

Rather than appearing insulted or challenged, the PA seemed genuinely pleased to be given the opportunity to present her work. I knew that it could have been much different with a different PA, so I took her response with a lot of gratitude, hopeful for a good working relationship.

The cases were pretty simple and we got through them without many questions. But before we could get back to work, a young woman with a lab coat that read ‘Laboratory’ over the pocket walked up to address the PA. “I have a critical lab for you,” she said, completely ignoring me. “And I couldn’t give you a diff because all the white cells are so immature that I can’t really tell what they are.”

This case was completely new to me and had not been presented by the PA since the patient was still in the ED. “What’s the critical lab?” I interrupted.

“The platelets are only 16,000.”

“What IS the white count?” I asked with a growing alarm.

“18,000.”

I took a deep breath of concern. “Do you want to tell me about this case?” I said to the PA, trying not to sound irritated.

“Well,” she said, turning to me with an expression I couldn’t read as confusion, irritation, or mild embarrassment. “This is a 30-year-old male who presents with a high fever and a sore throat . . . which is positive for strep.”

There was a slight pause that briefly led me to think that she was going to stop there. “His past medical history is that he had leukemia five years ago, but went into remission after several rounds of chemotherapy.”

After a long silence, I launched into a long string of questions about the history and physical exam. She knew some of the answers, showing that she had simply shortened the presentation to its essence. But other questions were met with a simple, yet eager, “I don’t know. I’ll go find out.”

“He did complain that his neck was a little stiff and painful. And he has a headache,” she added as if throwing in a last bit of detail as we headed toward his room. I quickened my pace.

Upon pulling back the curtains to enter the room I was relieved to find a healthy-appearing young man. However, with the room only steps from the spot where I had been quizzing the PA, it was clear that the patient and his young wife had both overheard our conversation and were preparing for the worst news. The patient was muscular and strongly built, but his face was clouded by a stiff expression of fear and impending doom. His wife was weeping and talking on the phone to a relative.  

I breathed a deep sigh of relief as I went through my own history and physical. His fever was already under control. His neck was not stiff and the headache was minor. I had envisioned entering the room of a patient in septic shock or a hemorrhagic CVA. It was clear that this patient was in a lot more trouble than just a sore throat, but at least he wasn’t going to crash on my shift.

Somewhat relieved that a disaster was not imminent, I was tempted to step back and let the PA proceed with the treatment and disposition. It turned out to be a great teaching case, and the PA was an eager learner. However, it was clear that the patient and his wife needed the emotional reassurance of my personal involvement. No one could tell them what to expect from this, but they needed to know that we were doing everything possible to have the very best outcome. When it was time to talk to the patient’s oncologist, I first thought that it would be a good opportunity for the PA to interact directly with the specialist. But after some consideration I realized that he, too, needed to know that our institution (the patient required transfer) was giving his patient our best.

In the end, the patient was treated in an appropriate and timely fashion. A transfer was arranged and received by a grateful treating physician. And the patient, though seriously ill and frightened, was comforted and reassured by the knowledge that he had received the best medical care possible.

When I finished the shift, I knew the patient was on the right path, yet I couldn’t shake the feeling that things could have gone very, very differently that night.

*************

Throughout my career playing basketball in high school and then college, it was always a big deal to be on the ‘first team’. The ‘starting five’ were the best on the team and got introduced to the crowd at the start of the game. In a close game, the bench never stepped onto the floor. One time, however, my coach decided to start the second team. He meant well. The opponents were weak and the first team needed a rest. I’m sure he thought he could put us in if they got in trouble. But our opponents, surprised by their ability to overpower our second team, began to play ‘over their heads’. The starters, possibly overconfident by the bravado of our coach, had become disinterested in the game until we were far behind. When the coach finally put the first team in, we were sluggish and had difficulty regaining the momentum. We were cold and surprised that this “easy” team was really rolling. We fought back before a cheering crowd with a brilliant comeback, but lost a stunning upset in the final seconds. As I watched our fans sit in stunned silence while our opponents were celebrating wildly, I turned to confront our coach. Our expressions reflected the same thought. ‘This should never have happened.’ It was a lesson that has stuck with me for a lifetime.

 

Comments   

# Hmmm.Mike Kays 2011-04-04 20:02
Sounds like the Doc needs to first learn to converse about patients in an area away from where they can hear. Sounds like they also need to learn that ANY provider can catch an error made by another, even a nurse catching an error by a Doc ... while I'm glad that the situation worked out in the end, I'm a little wary of the bravado.
Reply
# Dr.SourbuttSam Pearson 2011-04-07 12:45
I "rode the pines" @ UT-Knoxville... as I tell recruiters, administrators. ..re: ER Docs (and I'msure is applies to midlevels)...Ma ny are called...few are chosen
Reply
# second team memberJoel Stoia 2011-04-07 16:04
Wow, thank you Dr Plaster. I can honestly say I have never been so thoroughly insulted by a published professional article in my career. I want to remind you what the rest of the entire medical staff thinks of emergency medicine physicians. I have sat through many a hospital meeting where EPs were referred to as second team. Kinda like a specialist but not quite. So if we want "first team" only we should staff our emergency departments with Orthopedists, OB/GYNs and Cardiologists! Maybe it is because I am getting long in the tooth, but patients VERY RARELY ask me if they can "see the doctor." And YES I introduce myself to EVERY patient as a PA! But almost daily our department hears requests from both patients and family expecting to see an Orthopedist or Dermatologist or Cardiologist.

And I am SURE you walked uphill both ways to practice! If any TEAM could play an entire season with just its starters, it would. But no TEAM can. Just as your basketball did not have 5 starting centers or guards. No, it had 5 starters each with a specific roll or job, just like a medical TEAM. I contend you started your second team to prove your superiority over the other team. "The other team was weak." Sounds like a cocky SOB wanting to strut around campus. Or maybe you are suggesting you should have had a team of 10-13 starters? Reminds me of an Alex Baldwin line, in a movie where he was playing a doctor "I don't have a God complex, I am God." BTW IF you really played an entire game where your starters NEVER got off the floor for a rest or breather then your coach was an idiot! Or are you truely not just all knowing but all powerfull as well? BTW in "your" navy were there position players or just admirals?

The more I re-read your article the more I am struck by the question, is this an issue of PA's abilities or of you being a control freak that can't believe anyone but you is competent to see patients? (Don't answer that one, let your wife answer it!) I wonder how much you trust the ability of your fellow physicians! Does signing out a patient to another physician give you anxiety? Before you break your arm patting your back let me ask you . . . This patient, according to you was a "healthy-appear ing young man." How many "doctors" would draw labs on that patient with just complaints of a sore throat? How many doctors would even do a rapid strep? MOST doctors I work with would have been too busy working on critical patients to sit down and take a thorough history from a "health-appeari ng young man" with complaints of a sore throat. They would just write the Rx for antibiotics, pain medications and a work/school note and sent the patient home! You should be thanking God that the PA had taken the time to obtain a complete history and knew enough to draw labs on this "healthy-appear ing young man." Sounds like the PA saved the day. But no, just like so many God complex physicians you came swooping in at the last minute to rescue the stupid, untrained, incompetent, poor PA, (who had the situation well under control) and then go off to remind yourself how smart you really are.

Let me remind you PAs have been practicing medicine a lot longer than there have been board certified emergency medicine doctors. If you can't handle that go find a job where you are the only player on the team.

Oh, and yes. As a PA I was only able to read your article because a doctor helped me with the big words.
Reply
# Joel 2011-04-08 05:24
I am sorry, where was the error? PA learned the results the same moment the doc did. Doc took over case - NO mention as to whether PA could handle case or not, just assumptions and bravado on the part of the doc. NO ERROR WAS MADE. PA knew enough to test and not just treat and street. Again - WHERE IS THE ERROR?
Reply
# PA-CDan Friedman 2011-04-08 10:55
I read Mark Plasters "first team" article because a PA friend of mine gave me the heads up to check it out.

shifts ago, a 61 y/o gentleman was sent to our fast track with a big swollen leg. I bounced him back to the ED because he needed a DVT w/u.

The ED doc(read, "first team")sent him away with a dx of "cellulitis". Fortunately for the "first team" , he had the smarts to have to patient f/u in the fast tack for a "wound check". I ultrasounded the "wound" and there was a clot from his iliacs on down. I, in colaboration with the admitting hospitalist and clinical pharmacist, admitted the patient, started anti coagulation and everything went smoothly.

medicine is a team sport and, at least at the hospital I work in, the docs, PAs, RNs, pharmacists, techs, etc, etc work as a team. We have each others backs because people are imperfect and make mistakes; even those on the "first team". The doc who missed this DVT, he is one of the smartest, most competent ED doc I know and I would entrust my life, as well as my wife and kids to his care. I cannot say what evolution of events lead this MD to miss an obvious DVT, but he did and I am glad that we have the professional relationship and trust which allows us to cover each other without elitist, arrogant attitude.

So here is my message to Dr PLaster. Get over yourself. I know for a fact that you have made medical errors that have lead to bad patient outcomes. I am willing to bet that one of your bounce backs was met with disdain by the next ED doc who probably thought that you were a big idiot for missing the "obvious" dx.

so why don't you curb your arrogance and elitism. It is clear that the PA in question did nothing wrong and that the patient received "first team" care
Reply
# Kthompson 2011-04-09 03:15
I agree with the previous comment -- it's easy to find the error someone else made, and easy to miss your own. The PA in this case heard the crtical lab value exactly at the same time as the doc -- if it had been completely normal, would the doc have been as concerned? And how does he know the PA wouldn't have immediately consuted him when the value was learned? And yes, you don't discuss cases within hearing of patients!!
As far as the first comment, maybe the "2nd team" lost precisely because the coach never let them play, they were not used to working together under pressure, and were "disinterested" as a result. The bravado is on the writer's side, not the 2nd strings'!!
Wake up people, this is ALL about team care of patients, rspect for colleagues of all levels, and our number one priority being our patients, not protecting ones' turf!
Reply
# Ms.Kthompson 2011-04-09 03:22
The PA learned of the critical lab values at exactly the same time as the doc -- how does the doc know the PA wouldn't have immediately consulted him when the results were received? It's easy to catch mistakes of others, but not always easy to catch your own, so be careful of assumptions.
Also, in the first comment, maybe the "2nd team" lost BECAUSE the coach never utilized them, they were not used to playing together under pressure, and hit the court "disinterested" because of the clear disregard for them that the coach had shown all season! The bravado sounds to me like it is on the write of the comment's side, not the 2nd team! And yes, patient's cases should NEVER be dsicussed within earshot of the patients!
WAKE UP people, our top priority is our patients, not protecting ones' turf. We are a team of health care workers, all supposedly working TOGETHER for the benefit of the patient. I would take experience and eagerness to learn over a title or degree any day, as length of training does not guarantee competency.
Reply
# John Graykoski 2011-04-10 13:58
Another thought provoker.

As a PA, I had a similar case on New Year's eve... a new diagnosis of acute monocytic leumkemia. I briefed my back up physician (who is not on site) after I had an oncology acceptance and the transport team was called.

This underscores the reality that PA's are seeing these patients, frequently in ER's that have telephone back up, sometimes to on call family practice docs who may have less emergency medicine experience than the PA.

It reinforces the commitment of the American College of Emergency Physicians and the Society of Emergency PA's to continue developing standards and resources to support PA's who are doing front line emergency medicine, especially in the rural and underserved communicties where residency trained EM Docs are in short supply.

This is a dynamic tension that requires our ongoing close and collaborative work to assure that Americans receive the best emergency care wherever they access the system.

Thanks for highlighting an important issue.
Reply
# Mario 2011-04-13 19:36
I hope every ED physician gets to read not only this article(Dr Henry's as well)but more importantly, the comments as well. There are countless of similar examples and increasing litigations. The camel is in the tent and it now feels it owns it. I have a new title for so called mid-levels: "gomers" I see no need for any of them in an ED. Why are we (physicians) so accepting and allowing to dumb down our profession.
Reply
# MDStuart, MD 2011-04-14 12:23
Possibly this was not intended for "midlevels" to see, given the journal is billed for Emergency Physicians, but it is indeed insulting to them. I usually enjoy Plasters articles but I now see him in a new light - an arrogant, cocky, intimidating man. If you take this attitude with the rest of the ED staff at your new site, then you will not last long. The ED doctor may be the chief on the ED team, but all the Indians can take him down very fast. One team, not first team. The PA did nothing wrong and you certainly did not save the day. Learn to play well with the team, Plaster.
Reply
# MoreEDL 2011-04-16 19:52
Dr. Plaster: Could you please clarify the lesson to be learned from this story?
Reply
# SEMPA Response to "First Team"Society of Emergency Medicine PAs Board of DIrectors 2011-04-17 12:50
"We are writing in response to your most recent column “First Team". There needs to be clarification regarding certain points in the article, particularly the vital role Emergency Medicine PAs fill within the health care system and the continued focus on building the MD-PA team.

Physician Assistants are trained in the medical model, similar to the training provided in medical school, but in an abbreviated, intense manner to allow for a shorter education time. Although we generally do not complete a specialty residency, we gain extensive clinical experience within our training programs and further build our knowledge base within our work sites. We are specifically trained to practice medicine under the supervision of a licensed physician and are very comfortable working in this environment. This collegial role is well ingrained through the education process and it serves as the basis for a successful MD-PA team.

In a recent survey commenced by the American College of Emergency Physicians and the Society of Emergency Medicine Physician Assistants, 2/3 of all PAs work in the main ED setting, seeing patients across the spectrum of acuity. Additionally, in many rural and under-served areas, PAs work alone, with off-site physician supervision. With a shortage of residency trained Emergency Physicians available to provide these services, extension of health care resources using Physician Assistants is a fact of life. We believe it is beneficial for Emergency Physicians and Emergency Medicine PAs to embrace this reality together. Population dynamics and economic realities are dictating our continued collaboration to insure quality and accessible health care. It is our hope that those working in Emergency Medicine continue to expand upon this powerful team which benefits those who need it most: the patient.



Reply
# Mark L Plaster MD 2011-04-21 12:29
Ouch!!! An "arrogant, cocky, intimidating man?" Check with my wife for some more nasty things to call me. Please, back away from the tar and feathers. I was not trying to insult anybody. If I did, I'm truly sorry. But the theme of this piece was communication and cooperation. There was no error. But there may not have been an appreciation of the potential severity of this case. This was simply an issue of judgement that might have been beyond the PA's experience. My point was not to accuse the PA, but to say that when PAs handle super sick people, the EPs that they are "assisting" (remember what the A in PA is for) should be in the loop from the get go, not as an "Oh sign this chart please", after the fact event. If that kind of supervision hurts someone's feelings, which in this case it did not, then that person needs to examine their motives. I'm not the one having trouble being a team player here.
Reply
# PApatricia kelly 2011-12-16 13:28
As a PA for over 30 years, and as an early participant in the LAC/USC PA ED residency, I must be redundant. Dr. Plaster admitted that the patient did not present as “super sick”; the PA was diligent enough to do a CBC (in the face of a positive rapid strep that would account for symptoms) because of the prior leukemia diagnosis. The PA would not have dismissed a critical value in any event and the patient would have been diverted appropriately even if Dr. Plaster had never been there. But if he had, the PA would have been right on his case immediately after getting the critical result. And the family would have bonded with the PA just fine. You really looked at this through the retrospectrosco pe of the lab value.

I’ve read your column for years but I am annoyed enough about this to never read it again.
Reply
# ACNP in ERAndrew 2012-04-06 09:47
I came into the ER, busy as usual and I knew that I, the lowly NP, would be seeing most of the patients as we had a locums doc tonight. Better yet, a locums who had never been there before. Great.

“Oh well”, I muttered as I dug into the charts picking up by severity, not by time of arrival. Chest pain, chest pain, abdominal pain, etc, etc. The locums was still trying to log-in the EMR.

After seeing my first group of patients I came back to staff them with the new doc. Still trying to log-in. I called IS, got his log-in (which someone else should have done long before his first shift, oh well).

I staffed my patients and got a cursory wave with a “Just do what you usually do”.

Okay.

The shift slugged on. I kept seeing sick patients. Kept trying to staff. Kept getting the wave off. He saw a few patients, mainly fast track.

Finally the locums shift was over and a regular attending came in. He thanked me for helping the new guy (or FNG as I was calling him by now) get started. He then thanked the locums for keeping the ER flowing and allowing him to start the shift with a clean board. Whhhhaaaaatttttttttt?????

Oh well, no time for self congratulations , I have seen that burn people before.

It was high school. My friends were in the state championship for swimming relay. They were ranked #1 but were up against tough competition. It was a struggle but the last member of the relay touched the wall first. THEY WON!!!!! And then, every other member of the relay team jumped in the water to congratulate themselves. OOOPS. Automatic disqualificatio n. They lost.
Reply

Add comment

Security code
Refresh

Popular Authors

  • Greg Henry
  • Rick Bukata
  • Mark Plaster
  • Kevin Klauer
  • Jesse Pines
  • David Newman
  • Rich Levitan
  • Ghazala Sharieff
  • Nicholas Genes
  • Jeannette Wolfe
  • William Sullivan
  • Michael Silverman

Earn CME Credit