Decision-making in a community emergency medicine department.
It is an already busy Saturday morning in my community hospital, and the following three patients are sitting in rooms 2, 3, and 4, directly in my line of sight…
Room 2: A 59-year-old African American female presents for evaluation of altered mental status. She has a history of metastatic squamous cell carcinoma of the anus, status post chemotherapy and radiation therapy. She originally presented to her outpatient cancer center today for another round of chemotherapy and was found to be very drowsy. The oncologist called the ambulance for transport to the ER.
Upon arrival, the patient is confused and her daughter is bedside to report that she has been confused for the last 24 hours and has stopped eating and drinking. Daughter also reports that her mother has a history of a thoraco-abdominal aortic aneurysm status post repair many years ago. Physical exam reveals an ill-appearing woman who thinks it’s 2015. Her systolic blood pressure is in the 80s.
Head-to-toe evaluation reveals a less than 1 cm open wound on her right superior gluteal cleft that is draining black material with an extremely foul odor. After intravenous fluids, antibiotics and a CT scan confirming a large abscess requiring emergent surgery, given her unstable condition, I noticed her platelets of 32, Hemoglobin 15.5, glucose 775, INR 1.2, and continued low blood pressure of 70/47.
Room 3: A 61-year-old white female with metastatic lung cancer to her liver and biliary system, presents from her regular scheduled outpatient appointment at the cancer center for abnormal labs.
Her hemoglobin is 6.4 (8.8 three days ago), platelets 42, INR 1.0, BP in the ER is 114/74. She has grossly positive bloody stools on rectal exam. BP is 126/78. She has no other complaints except for the two days of bloody stools that she was not going to mention to her outpatient cancer doctor today.
Room 4: A 66 year-old white male presents with black stools this morning, who was just discharged from the hospital two days ago after a TEVAR procedure for a thoracic aortic aneurysm, complicated by upper GI bleeding while admitted, found to have angiodysplasia of the duodenal bulb, cauterized on EGD, discharged on aspirin and plavix. Rectal exam in the ER reveals jet black stool, hemoccult positive. Labs: Hgb 7.9 (Up from his discharged hemoglobin of 6 two days ago.), INR 1.2, Platelets 225, BP 144/85.
The community medicine factor: My community hospital only has two units of platelets for the entire hospital, at any given time. Again, I said, two!
Question: So, who gets the platelets?
My decision-making process:
First, I made a phone call to my hospital blood bank to confirm that we had our usual two units of platelets. We did. I then asked the nice lady in the blood bank; how do we get more. She informed me that the hospital has an agreement with another “local” blood bank who will “rush” more products to our hospital if needed. This process would take three hours. I explained my situation and asked if she could mobilize more platelets. She agreed.
Room 4: Surprisingly (and thankfully), the 66-year-old man had no abdominal pain or other complaints and seemed more annoyed that he had to go back to the hospital after just being discharged. He knew that having black stool was not ok, but he really preferred to be at home recovering. Given his stability, I did not rush to transfuse PRBC. His platelets were at least above 100, so I was not going to consider platelets for him unless he became unstable or started having active bleeding in the ER.
Room 3: She was actively having several bloody bowel movements in the ER, which we confirmed by direct observation of the toilet bowl. However, her BP remained stable. I elected to start with two Units of PRBC, keeping in mind she would eventually need platelets as well.
Room 2: This woman was my most unstable patient and rapidly deteriorating in front of me. I called and spoke to the general surgeon, who quickly saw her and mobilized the operating room. We agreed on thawing the only available two units of platelets for this patient and having the platelets meet the patient in the OR, to be transfused in the OR.
Outcome: Only one unit of platelets was used for my patient who went to the operating room. After touching base with the surgeon, she was recovering well in the PACU. The second unit of platelets then went to my Room 3.
Did I also mention my hospital did not have a GI doctor on call this Saturday?! I had to arrange for the transfer of patients in rooms 3 and 4 to another facility, to be seen and scoped by a gastroenterologist.
After sign-out to the night shift ER doctor, Room 4 decompensated, dropping his blood pressure while waiting to be transferred. He required transfusion of 2 Units of PRBC. There were no platelets available for him at that time.
Decision-making in a community emergency medicine department can vastly differ from that at a large academic institution with many resources and specialists available at the click of a button or a dial of a phone.
As ER physicians, it is not just critically important that we are good at textbook medicine, but we must also be excellent at logistics. We must be knowledgeable of our hospital’s resources in an effort to make the best time-dependent decisions for our patients’ care.
Often, we are creating treatment plans with knowledge of how quickly a disease process evolves in conjunction with resources available immediately versus resources available only after transfer to an institution with a higher level of care. ER physicians must be constantly up to date on their own hospital and transfer processes, as well as having knowledge of neighboring institutions and their resources.
When patients present with pathology that we can not definitely treat at our own hospital, we must then coordinate what care we can administer immediately to temporize the situation, with more definitive care solutions down the road. Additionally, we must arrange for more definitive care down the road. As a result, patients are in the emergency department for long stretches of time, with progressive pathology, requiring flexibility and adaptability on the part of the emergency physician.
Decision-making in a community emergency medicine department is a challenging and dynamic process, not always well-laid out for us in a textbook or online academic resource.