Night Shift
I picked up the first chart of the night and read the chief complaint. “Suicidal.” You never know what that means. It could be an old man who has sat all day with his shotgun in his mouth and finally thought better of the situation. It could be a belligerent drunk who was thrown out of his house by his wife and knows that he can stay in the hospital over night if he claims he’s going to kill himself. Or it could be a mixed up teenager who has experienced her first break up. It might mean a long work up and a lot of hand holding. Or it might be a quick “get out of my ER.” You just never know.
 I suspect that I’m a bit cynical after years of manipulative behavior by those wanting ‘three hots and a cot,’ so I was a little surprised when I entered the room to find a calm, well-dressed young woman sitting on the bed. Her demeanor was one of sadness, not the flat expression of depression. After introducing myself to her I sat down beside the bed and asked as sincerely as I could, “How can I help you?”
“I just needed someone to talk to,” she said. I was busy writing on the chart the time I’d entered the room. I put down the chart and looked at her intently.

“Well, that’s what I’m here for.” I folded my hands and tried to focus on just her but I could hear all the chaos in the ED. I didn’t know how long I could afford to just sit and listen. “Tell me what’s been going on.”

“We live with my mother-in-law.”

“My husband and I and our little boy. He’s two.”

“Go on.”

“She’s just so critical. I can’t seem to do anything right, according to her. She doesn’t think I’m a good mother to my little boy.”

“What does your husband say about this?”

“He’s afraid to upset her for fear that she’ll tell us to move out.”

“Why are you living there? Does your husband work?”

“Oh he’s a hard worker. But his plant closed down. And he can’t find any work in his field right now. We tried to hang on to our house. He’s working at all the day jobs he can find, but it’s just not enough. So we had to move in with her. She means well. I’m just getting tired of hearing her criticism.”

Seeing my opportunity to address the chief complaint directly and possibly start to take some action I asked her, “Have you been thinking of hurting yourself or anyone else?”
“Oh no, I would never do that,” she said with some surprise. This was consistent with my impression so far, but what about the triage note? 
“The triage nurse wrote that you were suicidal. What did you tell her?”

“I just told her I couldn’t take this much longer.”

“You didn’t say anything about hurting yourself?”

“Oh no, I love my little boy too much to do something like that.”

“So let me be clear. You didn’t say anything at all to suggest that you might be thinking about killing yourself?”

“Oh no.” She was emphatic. “I told her I just couldn’t take this any longer. But I never said I wanted to kill myself or anything like that.” I was relieved, but frustrated.

“Well, OK then,” I said slowly while considering my options, “and please don’t take this wrong. But what exactly did you hope to accomplish by coming to the emergency department tonight? If there is something I can do to help I’ll be glad to do it. But it doesn’t sound like you have a medical emergency tonight.”

“I’m sorry to bother you with this. I shouldn’t be here.” She started to cry. I felt embarrassed for coming off as so hardhearted but I really didn’t know what to do to help her. Then I struck on an idea.

“Would you like to talk to one of the social workers? She might be able to help you work through some of your options for other housing arrangements. And if that can’t be done, she might at least be able to connect you with some counseling to help you cope with the situation with your mother-in-law.”

Her countenance brightened. “Yeah. I’d like to talk to a social worker.”
“I’ll see what I can do,” I said, already half way out the door and thinking about my next case.

“This’ll be a case you’ll enjoy,” I told Becky the night social worker when I finally got her on the phone. “This is not a placement. All you need to do is talk to this young woman about her options for moving out of her mother-in-law’s house. I know you’ve got all kinds of connections with the community. She’s not crazy. She’s not suicidal. She’s not an abuser. She just needs some good solid common sense advice. And I know you can give it to her. OK? Great!” Another problem solved. I felt good. Somebody might get some real help from social services tonight. I grabbed an arm full of charts and charged off to work up a “belly pain,” an “ankle pain” and a “short of breath,” which I decided to see first.

An hour or so later the nurse assigned to the psych rooms passed me as I rushed by. “I put an IV in the lady in Room 7 with her blood draws. Do you want anything else? And she couldn’t pee, so we just cathed her.”

“What? Who are you talking about?”

“Your suicidal lady in the psych room.”

“She’s not suicidal. And NO I don’t want an IV. And why is she getting blood drawn?”
“The psychiatrist won’t see her without medical screening and that includes a blood draw and a tox screen.”

“Hold everything.” I grabbed Becky as she walked by. “What’s going on with Room 7? Did she tell you she was suicidal?”

“No. But the chart said she was suicidal. I can’t talk to her and discharge her if the chart says she’s suicidal.”

“But I wrote on the chart that she completely denied all that.”

“I know, but once it’s on the chart, we have to assume that it’s correct and call the psychiatrist. You know, for legal reasons.”

 “Oh, and can you co-sign these orders?” the nurse interrupted. She was impatient and wanted to get back to the backlog of patients.

I looked at the order sheet with a sigh of frustration. Since the psychiatrist didn’t come in at night, the patient would have to stay in the ED all night. Even if she wanted to go home, which she did, she would not be allowed to sign out AMA because of her complaint. Because she was “suicidal” she had to have a sitter to watch her to prevent her from hurting herself. In the morning, the psychiatrist would quickly discover the same information that I did and discharge her, but only after he had charged $300 for the consult. All totaled she might run up a $1000 bill that night, just for wanting to talk to someone. And if I tried to circumvent the system at this point and simply discharge the patient, it would surely be reported as a breach of care. I apologized to the patient for the inconvenience. I felt terrible for initiating this fiasco and I ruminated on it all the way home.

“Did you take out the trash last night before you went to work,” my wife asked as I munched granola and watched the morning news. I cringed as the commentator said, “Some experts suspect up to 10% of all the money spent by Medicaid is spent on unnecessary testing and treatment by doctors.”

“Fraud?” the anchor said in a menacing tone.

“No,” I said defiantly to the TV. “So go ahead and prosecute me already.”

“Hey Buster, I was just asking. You can lose the attitude or you’ll be wearing the rest of that breakfast.” She stood over me with raised eyebrows and coffee pot.

“Huh?” I was tired and confused. But something told me I had just dug the hole I was in a little deeper.

Mark Plaster, MD, is the executive editor of Emergency Physicians Monthly


# Stupid rulesChuck 2009-09-23 20:01
If YOU don't challenge stupid rules, you're part of the problem. Take some responsibility.
# Stupid is as stupid doesChristopher Walton, DO 2009-09-24 00:10
Chuck- you beat me to the punch.

First of all I would like to tell you how much myself and my wife (non-physician) enjoy your Nightshift column. I was also in the Navy for 10 years and can really appreciate your "sea stories". Some things never change!!

I've never written a comment before (i.e. first time caller, longtime fan), but after reading this article it seems to me more could have been done on your part as a physician to avoid this outcome.

I find it difficult to believe you work in an environment where the misguided assessment by a triage nurse can send a patient down a one-way irreversible path to a mandatory evaluation by a psychiatrist. If this the case then why do you need to do any type of psychological evaluation since you cannot override the triage nurse's documentation. Without even seeing the patient I can imagine how this all happened. The patient told the nurse the same thing she told you "I couldn't take this much longer". OK, this sounds like a psych complaint, if she can't "take this much longer" she MUST be suicidal. Writing "suicidal" takes less time then what was actually stated, off to the psych room!

I'm quite certain that when this patient left her house and came to the ED that a prolonged stay for being "suicidal" was not on her mind. I suspect she thought by going to the ED she would be able to talk with the on-call psychiatrist, placed on an antidepressant, and now have someone to see for her problems. Not spend the night in the ED, have her blood drawn, and have a sitter placed outside her room.

It seems to me that you felt hopelessly trapped in a silly hospital policy that was not subject to reasonable-man theory or common sense of any kind. This poor woman's fate was sealed by a few misguided strokes of a pen. While trying to fix hospital policy at 1AM is rarely successful, I feel you could have been a better patient advocate, and more proactive in your disposition of this patient. I'm not convinced that discharging the patient and providing outpatient followup on well documented chart on a clearly non-suicidal patient equates to a "breach of care". If anyone was subject to breach of care, wouldn't it be the nurse who inappropriately wrote "suicidal"? Perhaps a simple phone call to the on-call psychiatrist could have avoided this. As ED docs we all know how "reasonable" our consultants can be when awoken from Stage 4 REM sleep at 3AM! Once again, if you have no say in the disposition of psych patients then what is your role?

In the end I think a disservice was done to the patient. I'm sure she will have vivid memories of her evaluation and when she really needs acute psychiatric help may not seek our services.
# MDAmy Robins 2009-09-24 02:28
Usually love your articles, was disappointed to see that your nurses are ordering workups against your judgment as a physician.
# Dree Daugherty, MD 2009-09-25 04:59
I agree with Dr. Walton (and as a fellow night doc, look forward to reading the "Night Shift" column each month). One solution would be to have the triage nurse redo her note saying "suicidal". She might be able to chart, "Can't take this" and also note that the patient denies suicidal ideations. I don't feel compelled to write orders for blood already drawn. I also have the list of referrals that our social workers use, so with a bit of counseling by me, I sometimes can discharge the patient myself with good documentation and referrals. Also, the social worker may be able to follow up the next day if I save the facesheet with the patient's name and telephone number.
# Sav 2009-09-25 13:37
I thought nurse power over doctors was getting bad here in the UK, but thankfully I would still be in a position to override such ludicrous protocol driven actions on the basis of my, medically qualified, opinion.
# It's not about the patients, it's about the nursesJim Mensching, DO 2009-09-26 01:53
Although I do agree with Dr. Walton (I also helped train him), I can definitely see doing nearly the same thing in the same situation. There seems to be a growing trend among ED nurses (and their managers) that their input be ignored at your peril. Regardless of their experience they've been encouraged to question your clinical judgment and hide behind passive-aggress ive maneuvers such as "we have to follow policy" and "I'm only advocating for the patient." I won't even get into the damaging comments they can make in the chart when things go bad. Combine this with a medical staff that is less hospital-based (most PCPs admit to hospitalists) and a nursing-dominat ed administration it's no wonder Dr. Plaster shrugged his shoulders and moved on.

Woe to the doctor who dares raise the nurse's ire or - God forbid - raises his or her voice. Soon you are a deemed as "having a problem with the nurses" and on your way to being a "disruptive physician" - a term we logically associate with the profanity-spewi ng, instrument-thro wing jerks we associate with other specialties. See how easy it can be applied to your raised voice or objective criticism of nursing care, policy, etc. Whether you are a hospital employee or a member of a fee-for-service group this can threaten your livelihood. In the end your triumph can be a Pyrrhic victory. Think about all those boxes you check each time you renew your license or your privileges, and then having to explain the "yes" to your medical board or hospital credentials committee.

Don't get me wrong - I really do appreciate and respect what our nurses do and how overwhelmed they are. I get along with most of them, and I married one. However in dealing with them and with hospital administrations you have to pick your battles carefully.
# No Good Deed...IndeedChristopher Walton, DO 2009-09-26 05:05

Great to hear from you!

Agree with your response. Just want to make one thing clear that may not have been apparent from my initial response (rant). I don't hold the triage nurse accountable for the chain of events that occurred. This to me is an unreasonable following of an in-place protocol that doesn't allow for any type clinically based input. I didn't feel that it was doc vs. nurse issue.
# ERMD 2009-10-05 16:28
I agree, it is up to US and only US as ED physicians to take responsibility and not allow this kind of madness to occur. Most appropriate response would have been to have a discussion with the RN who started an IV, drew blood, and did a foley without an order (assuming no standing orders/protocol is in place). If you get resistance, the next step would be to call the house supervisor or talk to the charge nurse.

For an RN to "override" your clinical judgment by saying "once it's on the chart we have to go down this path" is quite frankly, unacceptable.

Being passive in this process just contributes to the problem.
# authorMark Plaster MD 2009-10-13 19:42
Ok, I'm a wimp. Beat me. But you'll have to get in line behind my wife and she plans to be at it for a while. Hey, remember this is fiction. I was just trying to tell a story about how bureaucracy and rules can trump people sometimes. Would you have enjoyed the story more if I had taken the nurse into the back room and beaten her senseless? Uh oh. My wife is coming. I better change that last line.
# ED PhysicianBrad Wood, MD 2009-10-25 20:55
I sympathize with the good doctor. However, I see a different side to these issues here in rural Illinois. Most of the time, we cannot get anyone to ever come out to see a potential psych patient unless all of those tests and procedures are already on the chart, and absolutely not if even minimal abnormalities are found. More often what I encounter in the rural settings where I work is some county sponsored mental health counselor, through whom all psych admissions in this state must be triaged, decides after her/his eval that the patient does not require further inpatient eval---and they tell the patient and the nurse to discharge with some lame outpatient follow up. My "opinion" is just that---and essentially worthless. I can stop a discharge, and I have; but it is to no avail. The psychiatrists do not even come to the phone for the ED referrals anymore. They speak with the "counselors", arrange a bed, or deny the admission, and I hear about it later. All of this is sanctioned by the State of Illinois--indee d it is required to use this silly system for anyone on State Aid, State Insurance, or any minor child regardless of insurance. How it is that EMTALA with its requirement for a doctor to doctor conversation,do es not apply here is beyond my understanding. Oh yes, that counselor, if they are well educated will be at most a Bachelors Degree education; in this state no license is required if you work for the State itself. HA! So who do you think will be the object of the liability issue when something goes wrong? The only way I have ever found to circumvent and get a patient a bed is by calling on personal contacts/psychi atrists. But I do not always have that option--especia lly not now that all of this is simply a mandated cookbook process, geared to keep perople out of the system for care rather than bringing them in. The truly mentally ill are not really well cared for in our country, and generally not in our EDs. Even in your original case, the ultimate goal, and everybody knew it, was that the patient would not be admitted. Getting all of the labs, etc... was just part of a protocol so that the psychiatrist would even respond.Even then, he/she wouln't be arriving for hours. Can you imagine that being allowed of other specialties as a matter or routine and policy?I am not sure anymore who is actually using up all of these beds in the psych units, but they must be people who know how to play the game, and aren't too mentally ill to make the right plays at the right times. More importantly, they must not be too ill because their doctors don't do after hours work--and none at all if all the tests aren't done.

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