Sunday, May 15, 2011

Weekly Whine: Don't you CARE?

Doctors make mistakes. That's not really a surprise. I mean, we're human. And we don't know everything, so sometimes we do the wrong thing.

But what really baffles me is how often doctors, maybe GOOD doctors, wittingly do something very questionable.

For example, I remember in residency, we once got a transfer to our rehab unit from another hospital. The patient arrived with a high fever, looking like he was about to go into septic shock. When we checked, we discovered that the physician who sent the patient to us knew about the fever and that the patient was unstable. But he still decided to transfer the patient to rehab.

I could give several more examples, some of them truly horrifying, but I don't want to violate HIPAA in any way. A lot of them involve extremely sick patients being transferred to rehab on a Friday night or right before a holiday, to a unit where there was no telemetry or even an in-house physician. I'm sure if you're in medicine, you can come up with your own examples of doctors who have knowingly acted against their patients' best interests.

I don't get it. Really. I always beat myself up for things I did wrong on call during residency, usually poor decisions made at 3AM. But these doctors were wide awake and aware that their decisions were putting their patients' lives in danger. Is it all about bottom line? Avoiding work? I have no idea.

I mean, even if you don't care about your patient, don't you care about not getting sued and maintaining your license?


  1. This is why I love reading your blog. You care. I love that you to think about caring, and you've decided it is not only ok, but required. It's evedent in nearly everything you write. Please stay that way :-)

  2. (This is a long comment, b/c I really do care!)
    As a Medicine intern I transfer a lot of people to rehab. Maybe some docs do knowingly transfer unstable patients, but I have a hard time believing it's common as most internists don't want the patient to decompensate in a setting not prepared to handle it. At a minimum, they've convinced themselves the fever is an isolated incident rather than part of a bigger trend in the wrong direction.

    I think it's pretty easy to play Monday morning quarterback as I fight the urge to do it all the time when we get transfers from "lesser" outside hospitals. But really, it's hard for us to know exactly what happened at OSH prior to transfer.

    Off the top of my head I can think of 5 specific patients over the past two weeks who we thought were stable for transfer but then experienced sudden and unexpected changes in their status (e.g., sudden gross hemolysis from a delayed transfusion reaction, sudden-onset Takotsubo cardiomyopathy, sudden respiratory distress we had no reason to expect).

    Each of these patients had a long list of stable yet serious medical issues. We caught the changes in their status before transfer but easily could have missed all but the respiratory distress, which could have instead occurred post-transfer the same day. Hell, I just happened to see cardiac tracing changes on the monitor that prompted me to get an EKG when I examined the very stable-appearing Takotsubo patient (the EKG showed diffuse deep TWI and a QTc of 630ms).

    My point is that a lot of people who go to rehab are prone to fast decompensation from their major medical issues. I can think of two rehab candidates who suffered torsades --> V-fib arrest with no clear reason other than underlying old cardiac scar in the setting of normal ejection fraction which would not have warranted ICD placement prior to the event. Could have happened at rehab, but just happened to occur in the safe hospital environment where I've seen more successful codes than not.

    This scares the shit out of me because I'll be in a junior version of your position next year and realize all too well that an internist's assessment of patient stability really only applies to what s/he observed on the morning of transfer. At least if they come from teaching hospitals the patient has been observed by at least three physicians that day vs. just one [only human] doc at a non-teaching institution. But still, human bodies with a lot of medical issues are a lot more at risk than a "stable for transfer" order implies.

  3. PGYx: I agree that a patient might look different the morning of transfer than they do when they arrived at the facility. But sometimes it's a little more objective. Like for example, transfering a patient to rehab directly from the ICU at another hospital. I find it very hard to believe that anyone would feel that a patient should go from ICU level care directly to rehab level care. Shouldn't they have ONE DAY of some sort of transitional care unit, being observed?

  4. I have occasionally transferred a patient from the ICU to home. It's pretty common at my hospital for stable patients in the ICU to wait 24-48 hours for floor beds in which case the patient has been observed for at least a day without ICU-level of care (even if they happen to have remained in the ICU).

    Most times they still go to the floor for a day, but if the patient is truly stable I see no reason to unnecessarily keep him in the hospital when he could be getting much-needed rehab or walking around freely at home instead of in the cramped ICU. Again, if we have even the slightest reservation that they're not ready (e.g., even a single episode of slightly low BP) then we insist they go to the floor to be observed for at least another day.

    It's tempting (yeah, I totally give in) to judge what the docs in the unit, on the floor, or in the office have done before but sometimes there's a reasonable explanation for what looks like bad judgment.

    That said, my recent floor month on a team that gets a lot of step-down patients will forever remind me to never assume a patient is out of the woods b/c some doctor somewhere deemed the patient stable for transfer. I've got to assess the patient myself and say something if I think something isn't quite right.

  5. OK, maybe. But how about this one: we once got a transfer from a hospital where a sick brain injury patient was cared for over THREE MONTHS. The only discharge summary we got was one sentence, which was handwritten. I have to believe that other things happened that were important to the patient's care over those three months that could not be summed up in a single sentence.

  6. Now that sounds like one of the worst handoffs ever.

    I agree there's a lot of work to be done to boost quality of intra-facility patient handoffs. I've had zero training in what outside facilities would like to know about a patient, other than standard required elements like follow up appointments, dietary and fluid restrictions, weight bearing status, etc. We aren't required to submit a discharge *summary* on transfer, just a set of instructions, which strikes me as pretty strange since I'll end up dictating a discharge summary, anyway. The scary thing is that the instructions from my *very* quality-focused institution seem to be better than what I've seen from outside hospitals when we get a transfer.

    All this talk is scaring me for next year (next month!), as if I wasn't scared enough already. :-)

  7. If it makes you feel any better, when I was a senior resident, I chewed out many an intern for pulling this kind of crap.