Captains, call for help!

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Keeping an ED running smoothly shouldn’t be a one person job.

“Loneliness is the penalty of leadership….”

-Ernest Shackleton

Fresh out of residency, I headed for my first job in a community hospital in Los Angeles where the ED director gave me a pep talk and told me to never forget that the emergency physician is the “captain of the ship.”  That oft-repeated saying about emergency physicians is both a blessing and a curse.  The psychiatric consultant can say that the suicidal patient is OK to go, but the final word is ours. We manage the dissatisfied patients and problems with ancillary services and we negotiate with consultants about the value of testing and admission.

But do we recognize when we are tempted to make decisions that are best left to a hospital administrator like the house supervisor or administrator on call? This article is designed to help EPs recognize when they have crossed over into the realm of what I call ‘Administrative Macguyvering’ so that you can avoid regretted decisions and career risks.

Case 1: Intoxicated and unmanageable

Emergency Physician: “The police brought in a patient who was walking in the middle of the street, mumbling and stumbling.  I had no way of knowing whether the patient had meningitis, a stroke or some other neurologic emergency and it is my responsibility to figure it out.  He was violent, striking at the nurses and trying to leave.  It was just two small female nurses and me, so I grabbed him as he was running out of the room and got him back in the gurney for an exam.”

Nurse: “I was frightened first by the patient’s behavior, but also by the doctor’s reaction to him.  I thought the doc was on the borderline of violent.  He was yelling at the patient and I noticed bruises on the patient afterwards.  After that, the patient was not honest answering the doctor’s questions and I was a little worried about working with the doctor after that.”

Risk management: Should the patient bring a tort claim against the physician, it is not covered by his malpractice insurance.  Malpractice coverage is only for events that occur while providing professional services.  Restraining a patient is not part of this doctor’s professional services and malpractice does not cover criminal complaints for assault and battery.

Discussion: There is a conflict, both morally and professionally, in stepping outside of the therapeutic physician-patient relationship.  The moral hazard starts with not recognizing your own reaction to an angry or violent patient.  You may think you are speaking calmly and using restraint in any physical action, but others may perceive you as aggressive, violent or even abusive.  You take a chance of alienating not only the patient, but also your staff.  Sadly, otherwise respected and liked emergency physicians have lost their jobs over interactions that they thought were appropriate responses to aggressive patients.

The professional hazard is a fight with your insurance company over whether they have a duty to defend or indemnify (pay any judgement) that occurs as a result of non-medical or potentially criminal acts taken against patients.  It could end up costing you tens of thousands of dollars hiring a personal attorney to fight your carrier, and much more if that battle is lost.

Resolution:  No one will fault you if you act to protect yourself or your staff from immediate physical danger.  But what about the verbally abusive patient who is swinging? That is the job of the hospital staff that is trained for those patients, security staff if you are lucky enough to have them or the “strong man” team if you don’t.  Every hospital has a plan for violent patients and it almost never involves the physician.  An injury to the EP in a single coverage emergency department leaves the doctor—and the ED—without coverage.  Call your house supervisor and the local police or let the patient run out the door and call the police—no take downs, please—because it is their job to physically restrain patients while we provide chemical inducements to cooperation.

Violent and abusive patients, sadly, are as predictable as patients with chest pain in our emergency departments today.  It is worthwhile to lobby your legislators for a better response to this crisis of workplace violence that we must routinely face, but when confronted with a hot situation at work, stay cool and stay medical.  Help hold an arm or a leg if three nurses have the other extremities so you can keep them safe, but don’t be the sheriff.  And please, take care so you don’t get hurt.

Case 2: Delay in care

Emergency physician: “The patient arrived to the emergency department with what looked like a stroke, but it was after hours and the MRI tech was not on call and the CT scanner was down.  I ordered the tests immediately, and even called the CT tech to inform him that we had a stroke patient.  The tech assured me that they were doing everything they could to get the scanner functional, and the delay was only two hours. What was I supposed to do—go to CT and fix the scanner myself?”

House supervisor: “If only the emergency physician had called me I could have asked the MRI tech to come in to do the scan or had the patient taken to the hospital a few blocks away for a CT.  I’ve done both of these in the past in emergency situations, and had we known that there was a stroke patient in the ED we would have gotten neuroimaging done and been able to give TPA.  The hospital isn’t at fault for the patient’s poor outcome, the ED doc is!”

Discussion: 

The scanner being down seems like it is your problem, but it really affects the whole hospital.  In this day of code stroke and the pressure to provide timely care, delays are not acceptable.  You have a department full of other patients who need you and it is a paperwork mess to transfer to a non-higher level of care or to transfer to another facility for a CT scan alone.

Last year at ACEP Dr. Robert Bitterman moderated a discussion with the Office of the Internal General and attendees heard the OIG attorney state repeatedly that hospitals must use all available resources to treat patients in the ED.  It is a new world for emergency physicians, who must now be responsible for resources that we may not know are available.  If you are faced with a situation where patient care is delayed, compromised or impacted by something out of your control, don’t be an administrative Macguyver!  Call—and document—that you sought help from hospital administrators to provide the quality emergency department care that was needed.  This may lead to an improvement in patient care and will certainly decrease your risk.

Call the house supervisor if you are getting the urge to buck hospital protocol and send a suicidal patient to another facility by police car rather than ambulance because EMS isn’t available any time soon.  Or when the intoxicated patient says that they he was drinking all day with his spouse and that spouse shows up as the “sober” ride home.  Or when the nursing home patient comes in with a living will, but the family wants you to not honor it.

We are not told often enough that sometimes even the captain needs help, and it is a skill to know when to reach out.  Great leaders know when to lead, when to follow and when to get out of the way.

 

ABOUT THE AUTHOR

Keri Gardner, MD, MPH, FACEP is the Chief Medical Officer and Chair of the Malpractice Claims Committee for NES Health.

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