Heartfelt with Dr Melissa Walton-ShirleyView all posts »
Hospitalists, specialists, primary-care physicians: It's game time!Feb 4, 2013 10:41 EST
From kickoff to halftime, there is no greater example of the importance of teamwork than the annual Super Bowl. The Ravens proved that tonight.
Although less popular, more crucial than the outcome of any football game is the responsibility to coordinate, communicate, and improve the well-being of our most vulnerable patients. Recently, I received a phone call from a patient's daughter. Her mother, "Mrs Smith," was hospitalized in another town 40 miles away with GI bleeding, on warfarin with chronic atrial fibrillation. The daughter was greatly distressed because this wasn't just a "little bleeding"; it was major league BRBPR, "doctor speak" for "bright red blood per rectum." Having just gushed 50% of her blood volume into the toilet bowel, her hemoglobin dropped to a dangerous level of 6.
She had received multiple units of packed red cells but was holding her own. That was on a Monday. The worried voice at the other end of the line belonged to someone attempting to quarterback her mom's medical team. She was trying desperately to avoid a fumble deep into a game she had obviously never played. She simply asked, "Dr Walton-Shirley, does mom have to stay on this Coumadin?"
I replied, "Right now, although her risk of stroke is very high off blood thinner, I'm sure they are holding her Coumadin. If we are lucky and they can fix what's bleeding, we might be able to resume it. Just have the hospitalist call me. I'm at the office all day. I have her chart right here in my hand. I'm glad to help." The nice daughter thanked me profusely for the conversation and hung up.
Wednesday, my secretary came to the exam room door. "Someone needs to speak to you about Mrs Smith," she said, chart in hand again. "Sure," I said, apologetically to the waiting patient in my exam room. "Hello, I'm a nurse taking care of Mrs Smith," the cheery voice at the other end of the line proclaimed. "And the doctors here need to know if she can stop her blood thinner." Patiently, I replied, "I spoke to her daughter yesterday and explained that she's elderly and has atrial fibrillation, a pacer, and a high CHA2DS2-VASc score, but certainly she must stop the warfarin for now. The salient point is that someone needs to locate the bleeding source if possible. Please ask the hospitalist to call me," I requested. "Here is my cell number in case it gets late," I added. The polite nurse thanked me and hung up the phone.
Thursday, I was examining a patient when I saw him look toward the door over my shoulder. With the stethoscope still on his chest, I turned to see my secretary mouth that I was needed on the phone. I apologized and stepped outside. "Hello Dr Shirley, I'm a nurse taking care of Mrs Smith, and the hospitalists need to know if she can stop her blood thinner."
"Okay," I said. "I know this is not your fault, but in our medical system, this extreme lack of communication is exactly why patients die."
"I know", she said in total agreement.
"I really appreciate your phone call," I added, "But this is a conversation that needs to happen between the attending physician and the patient's long-term providers. Can you please have her physician call me?" I asked.
"Yes, I most certainly will," she replied.
The day passed and I heard nothing.
I awoke Friday morning with that thought that as soon as I could see the first few patients of the day, I would page Mrs Smith's hospitalist. At around 3 pm, just as I was standing in front of my secretary and the words were literally coming out of my mouth to page the in-patient provider, another secretary rushed up to me and said, "They are frantic for records. Mrs Smith just coded, was shocked, moved to the ICU, and again arrested in Vfib. She's on the vent."
I don't care how much money the system makes or saves or whose feelings are hurt. The absolute worst thing that could ever happen to an in-patient is to change quarterbacks every day. Although I may not have had information that could have prevented this turn of events, they would have never heard it if I did. The best thing that could ever happen to the legions of patients whose only option is to bow to the current march of hospitalists across our country is to create a hybrid program that actually works in favor of the patient. Relative value unit–minded CEOs need to pay primary-care physicians well to round daily, give them a schedule that allows enough time to get to the office, and then have nighttime and weekend coverage provided by hospitalists. This coordinated effort would score touchdown after touchdown for the patient who is currently at the mercy of a system driven by the opposing team's "quarterback sneak equivalent" known as the 23-hour admit. For those patients who get to stay long enough to actually receive the duration of therapy they need, we owe them our best plays. Right now, it seems no one's holding the playbook, or it seems that in the busy mix of a 12-hour shift, no one really has the time to care.
It's Sunday evening. The hospitalist quarterback is in place. The coach on the sideline communicates through the earpiece the result of the patient's last office visit and tests. The teammates—consisting of nurses, techs, and ward clerks—line up for the field goal. The whistle blows and the team goes into action as the patient is passed back to the placeholder. The specialist kicker runs forward, leaps into the air, sending the patient into orbit. The patient is hurled through the goalposts for a successful completion of an in-patient admission.
Congratulations, Ravens. Wish you could coordinate every in-patient hospital admission for every patient struggling in our current healthcare delivery system. You knew it was game time and through perseverance, communication, and determination, despite momentum-busting power surges and blackouts, you delivered.
So should every in-patient provider in America.