Night Shift
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This is fiction. Or maybe it’s not. You decide.

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 is going to kill himself. Or it could be a mixed up teen 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 well dressed young woman wearing a wedding band. 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 I could help her.

“I just needed someone to talk to,” she said. I was busy writing on the chart the time I 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.”

“We?”

“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. “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 weep. I felt embarrassed for coming off as so hard hearted. But I really didn’t know what to do to help her. Then I struck on an idea.

“Would you like to just 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 as I was 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” and “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. 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 medical legal reasons.”

“Oh, and can you co-sign these orders?” 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. 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 unnecessary testing and treatment by doctors.”

“Fraud?” the anchor said in menacing tones.

“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.

[When this work of fiction first appeared in EPM several years ago it received a lot of comments (mostly negative). So we decided to run it again to see how you feel about it now. How many of you have ever felt inappropriate pressure to do things that were not in the patient’s best interest? Be honest. ]

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

 

Comments   

# MDmike evans 2014-05-07 14:52
In my ED, its my call. We are so overwhelmed by psych and "pseudopsych" that if I release someone it is met with applause rather than criticism
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# Medical DirectorTom 2014-05-07 16:12
I personally am tired of the psychiatrists' rules when they won't come in and see the patient till the am. I also would not have signed the social worker's orders since I disagreed with them and would have made her call the psychiatrist and had him give verbal orders to the nurse for the IV and labs.
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# RE: No Good Deed...Dr. Cynic 2014-05-07 16:36
“No. But the chart said she was suicidal. I can’t talk to her and discharge her if the chart says she’s suicidal.”

With triage clerks diagnosing patients and nurses making discharge decisions, why does your hospital administration bother paying you? The only pressure I have ever felt to do inappropriate things have come from the rules imposed by CMS to try and force discharges or observed status on patients who need to be in a hospital.
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# RE: No Good Deed...Michael Maxwell 2014-05-07 19:58
I would have cancelled the orders that the Psychiatrist requested and cancelled the consult and discharged the patient. I would have quoted the patient's statements in the record. Then the next staff meeting I would have brought up the issue of SOP for consultants refusing to see patients without 'screening labs'. Unless the patient is theirs, they should not dictate what orders need to be done and they have a legal requirement to see them within 30 minutes if I say so. If they find that inappropriate then we can hash it out
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# ED Medical Director, Trinity Hospital, Weaverville, CAHenry Edelstein, MD 2014-05-08 02:08
It's been fairly well established that although nursing notes have to be addressed, especially if they are not in concert with the doctor's, it is OK to explain how/why yu disagree. In this case, an explanation of how the misunderstandin g occurred would suffice and the patient could have been treated and dispositioned exactly how you wanted. If no one wrote for an involuntary hold, then it does not exist and the patient's needs can be addressed, not the "system's".
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# Common sense is everything... but commonAdan 2014-05-08 04:53
Hi Mark.. I feel your pain. The "protocols" are sometimes worse than the problem they are supposed to help. I've had the same issue with "psych" patients who don't need psych, they just need someone to talk to and some good common sense advice, but the orders have been entered way before I even pick up the chart and once started, is like a nuclear chain reaction that cannot be stopped! So much waste for nothing... (Sigh)
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# Emergency Dept. DirectorJulie Foster RN 2014-05-15 18:01
I have been an ED nurse for 26 yrs and have seen this happen so many times I can't even count them. One good thing I have ween with our EMR is that the nurses do not enter orders...only the ED doc can do so. Therefore, YOUR decision would be the one to count....and saved this poor lady time, money and dignity! Now it is in her MR that she is a psych patient....how is that going to help her??
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