Today's Last Patient of the Night

She had experienced chest and arm pain since early AM and strolled in at 10:50 PM (we close our doors at 11, but must stick around until the last patient leaves). Her medical problems included fibromyalgia (eyeroll) and Lyme disease. Her allergy list had 30 medications.

My doc asked her what about her pain had changed at that hour of the night that had not bestirred her to come to the ER earlier in the day: "I didn't want to go to bed with it". Uh huh.

In rapid succesion she was put on the monitor, given oxygen, an EKG, an IV, aspirin and nitro. (now 10:57).

Brian, my doc, is a take charge, no bullshit, straight shooting, decisive, action oriented ex Navy Seal who does not suffer fools. He is also committed to Getting Out of Work on Time at all costs. He can be funny as hell, too. At this hour of the night, though, he is all business.

"Don't even run that blood; she's headed downtown (to our Mother Ship) right now. I'm not dicking around with this for an hour when she needs to be admitted anyway".

Cool. He notifies the attending at the downtown ER, we call the local ambulance and she is out the door in 24 minutes.

This was not just an attempt to get her out so we could go home (well, part of it was, but not completely). We would have had to wait until the labs came back before we could entertain the idea of sending her to be admitted. This involves way more bullshit than it is worth sometimes. Since nearly all of our docs also work at the Mother Ship, when on the receiving end they tend to be most obliging with this sort of fast-tracked transfer, knowing that the majority of the patient's diagnostic workup needs to completed. Hey, they have all been there. And most will do anything to avoid the crap that is inherent in a direct admission, particularly in the middle of the night.

Direct admissions (from the ER to a hospital bed on a floor somewhere)are a pain in the ass. It takes hours, literally. Here is a recent timeline, from time of decision to admit to getting the patient our of the department:

8:01 PM Patient x needs admission to tememetry unit. Patient agrees
8:02 PM Call to beep hospitalist
8:22 PM Hospitalist returns call, speaks to ER doc, agrees to accept.
8:27 PM Call to hospital admission office notifying them we need a bed. All pertinent information is conveyed. The admissions office must speak first to the nursing supervisor.
9:00 PM 2nd call to admission office: nursing supervisor hasn't gotten back to admissions. I urge them to beep her for an answer.
9:16 PM 3rd call to admissions office: nursing supervisor is "busy".
9:17 PM In frustration I beep the supervisor 911 myself and bitch. She promises to get back to me in 10 minutes
9:30 PM Still waiting. Patient is tired, uncomfortable, hungry because we have no food, and impatient and is thinking her own bed is looking better. She is dissuaded from leaving.
9:40 PM Finally admissions calls and assigns a bed
9:40:14 PM Call to regional ambulance for transport. Standard response is "30-40 minutes". It is generally closer to an hour. I call rival ambulance service to inquire if their response time is quicker, using the information to play one against the other. It is generally effective and I am promised an ambulance in 20 minutes.
10:15 PM Ambulance dispatchers are liars. Call to dispatch to inquire as to whether or not they have fallen down a rabbit hole; "Just down the street!" they say. Yeah, right.
10:20 PM Ambulance arrives. The paperwork is exchanged, the ritual fiddling and diddling is accomplished and the patient is out the door at:
10:32 PM It takes about 20 minutes to get to the Mother Ship. 10 minutes to get to the room and into a bed, and the patient still has not been examined by the hospitalist. This occurs THREE HOURS after the decision to admit the patient has been made. Shameful.

This is why our Last Patient of the Night got a Fast Rail pass to the ER. It would have been 3 AM before she would have gotten out of our department.

Working at an ER that closes has given me a new appreciation for the dirty looks I get at Stop and Shop when I run in for one thing; I tend to go to the all-night WalMart instead, even though it is out of my way.