The hospitals have been really overcrowded lately. I had two calls the other day that are becoming increasingly common.* The first was for a woman with a low oxygen saturation called in by the visiting nurse who was concerned the 90-year-old woman's oxygen saturation was at 90, her heart rate 100, and her BP 180/90. The woman herself had no complaint other than the effects of age. She spent most of her day in front of the TV and didn't want to be a bother to anyone, but she did require a good deal of assistance just standing and pivoting onto our stretcher.
The second patient was a sixty-seven-year old woman with arthritis who's right knee was quite badly swollen. Unfortunately for us she lived on the second floor in one of those houses where the stairway had two flights just to get to the second floor. She wasn't able to walk herself and her son had called us only after being unable to move her himself.
When I told the triage nurse that the 90-year-old woman had no complaints herself and that her saturation on a few liters of oxygen was now 100 and that we had only been called because the visiting nurse was concerned, I saw immediately in the triage nurse's eyes that this patient could be dismissed as another bother to be put in the hallway. I tried to reemphasize the woman was weak, frail and had a history of CHF, but the nurse was too busy typing the patient's meds into her computer. We were told to put her in the hallway. Of course we had to then find a bed, make a bed and then find an oxygen tank for the bed. When I came back two hours later, she was still there and had yet to be seen. She was frightened since she was there by herself and had no one to advocate for her. I mentioned to the nurse that no one had seen her yet. She asked me if she was stable and I couldn't say she wasn't and the nurse quickly said, we're really busy. And they clearly were. Over head I heard a page for two more incoming medical alerts.
The woman with the swollen knee, taken to the other hospital, was dispatched immediately by wheelchair to the waiting room. She could sit up so better out there than taking up a scarce bed in the main ED. We found a couple pillows that helped better cushion her in the chair and left her at the desk after giving the external triage nurse a quick report.
Four hours after leaving the woman in the waiting room we were dispatched back to her house for a fall. The dispatch didn't seem right as we had just been there and transported the woman of the same age they were saying this patient was. Dispatch confirmed it was the proper address. When we got there we found the same woman and her son in the living room. She was on the ground leaning against the wall. Evidently, she had been discharged with a prescription for pain medicine and sent home. Somehow her son had managed to get her up the front steps and into the house, but when he'd told her to wait by the door while he ran upstarirs and got her commode, she had lost balance, fallen and hit her head. She was trembling to such a point that I did not think she recognized me. Her neck, back and right shoulder hurt. We c-spined her and as we were carrying from the house on a board, two of her other sons arrived and began yelling at the son who had been with her, blaming him for everything that had happened to the point where this tall strong son was in tears.
As for the 90-year-old woman, I learned the next week that an ambulance crew of ours picked her up at home the next day this time for shortness of breath. She had been sent home after a six-hour wait only to now the next day be back at the hospital, finally admitted for pneumonia. the visiting nurse, who knew the patient, was on to the fact that something was going wrong. The message got lost in the system.
I have titled this post "Mistakes" and I am not saying neccessarily that there were mistakes made on the initial care of these two women, although clearly you could have wished for better prompter care, care more aware of the patients as people -- holistic care.
My point is that in today's world with rising medical costs and short staffing, high taxes, rising poverty, an aging population and a host of other factors, the environment is not forgiving. A growing pneumonia can be missed, a woman can be sent home to a home that she can not live in safely.
Ambulances and ERs maybe shouldn't be the clearinghouses for all medical and social problems, but it doesn't change the fact that's what they have become.
I could have advocated more strongly for the 90-year-old woman and won her a better placement in the ER, but that might have come at the expense of another borderline patient. I could have thought to point out to the son of the woman with the swollen knee that in the likely event his mother was sent home, he should make sure he had more help there to get her in the house. I could have ofered to have him call us to help him carry her back into the house. Niether neccessarily my jobs, but both of these patients could have had better outcomes if more responsibility had been taken for them beyond wanting to, in the words of one ED physician, "move'em in and move'em out."
This is all a preface to an article I read in the New York Times called A Doctor's View of Medical Mistakes which is an interview with a doctor whose life was devestated by a mistake made by his medical team many years before. The Day Joy Died is the article he wrote about it.
There are mistakes of many degrees. Fortunately the catastrophic mistake made by the doctor's team -- an esophageal intubation -- is much harder to do nowdays because of capnography's ability to detect bad intubations. Long ago in one of my books, I wrote about an asthmatic patient I had who was in respiratory arrest when I arrived on scene, and who I had a very diffciult time bagging and then intubating. She arrested, but we got her back, athough she suffered an anoxic brain injury. To this day I still think if only I had been better at my job she might be living a full life rather than dying a few years later of an infection in a nursing home after never regaining the ability to even recognize people. Being less than perfect has its consequences.
The other day I was working on a city ambulance and needed to give my patient Zofran for their nausea. As we traveled through the streets toward the hospital, instead of getting up and reaching for my house bag (the med kit) which was beyond my initial reach, I reached into one of the cabinents and took out the small plastic bin of spare drugs and fished out a green topped drug vial. I was just about to clip off the cap when I noticed the color scheme was a little off. The cap was too green. I looked harder at the vial. Vasopressin. Oops. While I did not even open the top, with a sudden distraction, I might have committed a fatal error. Vasopressin and Zofran are in different areas of my med kit. I would never mistake them. But here, by slightly altering my routine I exposed myself to a situation that with other alterations, could have led to disaster. The patient suddenly vomiting, might have caused me to forget the important step of reading the vial label instead of just assuming I had the right med due to its size and near same color(the light in the ambulance was distorted and caused the green to not be as distinct). And then you inject the wrong medicine and there you are in the midst of it -- your patient crashing and then you look down and see the empty vial and reading it, think oh f----!
What does this all mean? There are degrees of mistakes and none of us are infalliable or seers of the future, but as busy as we get, we need to always be vigilant and always consider what is at stake. It can't be, despite the load upon us, just a matter of moving'em in and moving'em out. We forget sometimes that our "calls" are people even when we are treating them well in the moment. Our responsibility goes beyond a smile and pleasant manner. Who is going to look out for the 90-year-old woman by herself after we go? How is that woman with the swollen knee going to get back in her house with just her son? What happens if I stop double-checking my meds as a part of my normal routine because it has never been a problem before?
And the same goes for looking out for ourselves. A little mistake, a moment's innattention can wreak havoac on our lives as well, whether it's suddenly getting creamed in an accident or to not be vigilant to our own or someone else's medical error and the resulting burden upon so many lives.
We are far from perfect, but the stakes in this game require our daily efforts to be perfect despite all the obstacles we face.
Best of luck and fortune to all of us and our patients.
Here's an old post I wrote on EMS Mistakes, which also gets into the topic of ambulance safety.
* multiple ambulance calls and ED stays.
