Difficult encounters part 1

13 12 2013

With the primary exams out of the way…. new levels of expectations are set. Often in ED we do get difficult patients.
What if we encounter difficult staff ?
Often at a junior level ; whether you’re an intern or a registrar; you find your decisions overriden by a senior. Usually this is a good things
say for example :
you want to discharge the 80 year old female who had a FOOSH and currently has an undisplaced distal radius fracture (which is in a backslab). BUT your senior points out that she lives alone and would benefit from admitting her to Short Stay having allied health input to allow assessment for safe discharge … (physio/OT) as she lives alone and does everything on her own.

Now thats a good thing isn’t it ?
Most of us wouldn’t mind that, would we ?

Or the low-to intermediate chest pain (TIMI 0 ) we see in ED which we think should just get a repeat 6 hour Troponin and be discharged with GP to organise stress testing if the trop is negative….
(only to have a senior veto you and say you should refer to the medics for inpatient testin)

Once again….safe isn’t it ?

What if this was the OTHER way around … where a senior supervising member’s disposition is less safe ? or conflicting with yours…

At the shop I work at, during a day shift we have consultants covering the floor who often provide good support and advice. But this differ from SMO to SMO…. and often the advice can be conflicting.

Different EDs will have different sort of SMO covers.
Some models of care from my limited experience :

a. free reign – i.e everyone does their own shit and make their own decisions especially discharge dispositions (only if you are PGY2 and above)….. this is for super busy EDs with lack of medical/nursing staff

b. full control – – all patients will need to be run past the SMO on the floor…. (including fast track patients e.g. ankle sprains… “groan”)
very safe

c. registrar led teams – – – all patients will be discussed with the registrars on the teams.
a model demonstrated at the tertiary hospital I used to work. consultants allow registrars to make disposition and only step in when a conflict arise

How do we approach differences in disposition ?
What if there’s a difference and a concern about where the patient is going ?

Case 1.

A 39 year old man presents from a GP with referral ? pancreatitis (he had 3 days of upper abdominal pain) with a raised lipase of 800.
ON assessment today he is well albeit slightly nauseated.
All vitals normal (heart rate 70, normotensive and BSL 6)
Abdomen today some discomfort.
“today’s the best i’ve felt doc”

His lipase is 350.

The resident’s impression was that this was “ongoing resolving pancreatitis – mild with a RANSON score of 1 (raised WCC 3 days ago) and needs to come in under the surgeons for Ix ”
The registrar who saw him felt his abdomen —says “this abdo was soft —- SEND HIM HOME. HIS LIPASE is only 250. WHAT WOULD THE SURGEONS DO”

at this juncture the resident wanted to call the surgical registrar and get an opinion but his ED registrar vetoes that and removes the cannula and starts typing the letter himself.

Comment : conflict of different assessment and management opinions.

This case was resolved when the resident subtly blurted out the case to the consultant on the floor.
The SMO on the floor had a quiet word with the ED registrar and directly admitted the pt under the surgeons (with a new cannula the SMO inserted herself)
Needless to say the ED registrar never really spoken to the resident again.



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