The patients peer at the gaggle of white coats at signout, trying to size up the night team. The outgoing team has already welcomed us as liberators. And they tell us about the ongoing workups, the lab results and consults still pending, and the patients already dispositioned but still waiting for a bed.
In signout, the essentials are all there, but some nuance is inevitably glossed over. And so it was on one particularly busy Monday, when I received at least a half-dozen patients, including a hypotensive febrile encephalopathic young man who had been rejected by the MICU. My mind was still preoccupied with him when an outgoing intern started telling me about the simple, straightforward elderly woman with back flank pain and hematuria who was "probably in the CT scanner even as we speak." Just get the read, confirm the stones, give her some 'scripts and she'll be on her way.
Not surprisingly, it only took a few minutes for that neatly-bundled package to unravel (though enough minutes passed for the intern to be on well the way home). I got a call from radiology that my new patient was requesting pain meds (the scanning table was too stiff) and something for her nerves (she didn't like moving through that heavy donut of a machine).
I checked the record, and was amazed to see the patient had already received three generous rounds of opioids and benzodiazepines before signout. Combined, it was enough for procedural sedation in a young adult -- and my patient was well past retirement age. Her outpatient summary mentioned a xanax prescription, but none of this had been covered in signout.
A nurse, grappling with her own monstrous signout, graciously provided me with round four of this patient's morphine-and-ativan regimen. I scurried down to radiology, myself pretty anxious to meet this new patient, and to return to the encephalopathy case in the resuscitation bay.
When I got to radiology, which seemed so serene in comparison to the ED, I was greeted by a tech who directed me down a near-deserted hallway, to a distraught woman in a stretcher. By her side was an affable husband, holding their coats, bags, and various papers. He smiled broadly and asked, "are those her medications?"
His wife was hyperventilating and clutching her side. After introducing myself and confirming the story, I pushed the meds and reconnected her IV fluids. I apologized and hurried back to the busy ED.
The code was called overhead, about ten minutes later. Every doc's ears perked up in the ED -- we're responsible for the coding patients in some part of the hospital, but not others, so we waited to hear if we'd need to gather our gear and run.
As it turned out, the code was in radiology. We were covering. And I started to run, worried -- really panicked -- that I had just killed a patient.
I was the first from the ED to arrive, but there were already some long white coats surrounding a stretcher. And, to my eternal relief, it was not the stretcher of my patient.
Even better, this was not even a real code -- the long white coats belonged to neurosurgeons, who were concerned their head-bleed patient from upstairs was breathing funny, and wanted anesthesiology to tube him. I volunteered, but they held out for the anesthesia team, who arrived a minute later. My services were not needed, so I slung some gear over my shoulder and trudged back, stopping along the way to talk to the woman with flank pain, and her husband.
"I've got to confess," I remarked, tapping on the airway equipment, "I thought we were called to use this on you."
"She's alright," the husband responded.
"No I'm not!" the woman exclaimed. "All this activity has made me very anxious..."