I was surprised when I came in, O Best Beloved. My patient who'd had chest pain with his AAA, got a CT scan without being pre-medicated and went into renal failure (I didn't tell you this story about nurses playing doctor, O Best Beloved, perhaps I will in time) was fine yesterday morning, going for a Cardiolite test and then if it were normal, home. I was post call - that means, at least here at $hospital where their residency program is strict about such things, home no later than 2 PM - 1 PM really, for me, since I was in at 7 AM on Tuesday. Cardiolyte was absolutely not going to be back before 1 PM. He was admitted on a 23-hour observation and it was due to run out at 1600; note from nursing read "Convert to admit or D/C today". No reason to admit him if the test was normal. I prepared discharge papers. I checked out with A, one of the Family Medicine interns, and told him. "Check the Cardiolyte results around 3. If they're normal, call a verbal OK to Discharge to the floor, I've done all the paperwork. If not, page Dr. Gray and ask him to continue consulting, convert to inpatient. He has to go today if the test is normal." Easy. Easy easy easy.
This morning: "Oh, Nykki, shoot, I'm sorry, I got busy and forgot to discharge your guy."
This is a serious issue, O Best Beloved. The hospital is losing a lot of money for an observation patient kept over the 23-hour period. And nobody pays for it. And it would be fraud to charge the patient. S got paged from case management. You can't make chest pain, rule out MI, an admit diagnosis with a normal Cardiolyte. Not good. We turned him into an admit for contrast-induced renal failure, effective yesterday, and promptly discharged him. What else could we do?
Then we got the call from the floor that his Cardiolyte had come back on the fax, and that now it showed ischemia. I promise, O Best Beloved, I looked over the chart this morning and saw normal tests. Nothing but normal tests. Did we still want to discharge him? No, not now. This is coming on the heels of my earlier failure this afternoon, which I will elaborate on. How did I miss it? Unfamiliarity with the system, I suppose.
All turned out well; Cardiology was quick to respond and told us he didn't need to stay, they would discuss elective cath as an outpatient. He went home. But I still missed the Cardiolyte.
On the other hand, A forgot to do my discharge. He didn't smile at me when I changed over to him. He's rubbed several people the wrong way. He apparently did an I&D on a patient's knee for no apparent reason the other night, and now as I told my story to staff one of our interns pipes up. "He discharged one of my patients last night." A patient, mind you, that we had not intended to discharge. Evidently, she wanted to leave. Why he had time to discharge her instead of telling her she'd have to leave AMA and yet was too busy to call the floor and say "Okay to discharge" for my patient, we don't know. My staff took careful notes, then asked who the chief resident and FM director were. Trouble is brewing.
I am trying to put my failures in context. I know, deep in my heart, that I am far from perfect and that mistakes will be made. But I made two today that I do not wish to make again. The first was the Cardiolyte.
The second, though chronologically first to be pointed out, was regarding my gentleman with cellulitis, whom we are trying to discharge home on the least invasive antibiotic therapy possible. This is important, because he grew MRSA from his abscess - the normal treatment is Vancomycin, for 4-6 weeks, which requires a line to be placed. He has a history of IV drug abuse. Sending him home with an easily-accessible venous catheter sounds like a bad idea. I glanced through his chart this morning, saw a note from Ortho stating that the CT of his leg showed no abscesses, and believed it. I talked to staff. Staff nodded and agreed.
ID, when we saw him, held up a hand. "Did you see the CT?" I saw a report, Ortho's note, no abscesses. Radiology called me with the read. I looked at the CT. Did you look at the Radiology report? No sir. It wasn't on my list of labs at 0700, O Best Beloved, I didn't see it! Did you look at the CT? No, sir. He tried to load the CT scan. Computer wouldn't let him. Here. Here's the report. Read that sentence to me. I read it. And this one. Yes, sir.
Abscesses, subcutaneous, small but there. Get your facts straight. You can read reports. Don't believe what doctors notes say. He laid it on heavy, half-scolding me, half-deriding me. I can't get into the X-ray system. "You can walk to Radiology."
If he had been wrong to scold me, O Best Beloved, if he had been wrong or out of line or I had not been scolded by him once earlier in the week for not having the pathology report from the bone biopsy at hand when I called, I could have let it run off my back. He was right. I should have checked the CT read myself, at least, and the fact that it was not in my system at 0700 is no excuse. It was in my system at 1400, and it was probably in my system at 1130 when I sat down and read e-mail instead of gathering my thoughts for the afternoon. And I should have checked.
I wrote the orders for the PICC line and I explained to the nurses that given the choice between the possibility of him using his IV for nefarious purposes and the probability that without adequate antibiotic therapy he would lose his leg, if not his life, we chose averting the probability. He told me today that he has spent the last week listening to his family tell him that we would kick him out of the hospital for inability to pay his bills. Social work has worked out home infusion with a company who will absorb the cost - "Duration of therapy?" 4-6 weeks. "Ouch." - and we are ready for discharge as soon as the line is usable. And I had a long talk with him and his girlfriend. I have been assured, although I am not reassured, that he is turning his life around thanks to her influence. I hope it is true. I still want to believe in people.
Two errors today, O Best Beloved, and important ones that were happily caught. I will be more careful. But the resolution to learn from my mistakes rather than allow myself to be bowed and bent down by them is a difficult one.