I had this bad call recently...no many patient in the ED after 12 MN. The ward was quiet...I had just admitted a patient to ICU by midnight. A case of hypoglycemia coma due to insulin overdose. He was fully alert after glucose infusing but his brain CT had revealed subarachnoid hemorrhage.
At 2:30am, the combined ED from the south call( the ED, I had part time before while I was working in my ex-hospital...). A nurse at the other end of line. I was told that the male patient had an intracranial bleed and presented to their ED with Glassgow coma scale(GCS) of 7/15. They asked me if I could take over the case. I saw the admission board. I had already + 3 beds in my ICU but still 1 ventilator left(minus the one in ED). I said ok and advice them to intubate the patient as his GCS was only 7/15. I got this answer," well, the patient was better after his arrive and we don't think he need intubation now...". Another standard crap-shit answer- I did not insist any further, after all is their call as the patient was currently under their care. Asking a nurse to do a referral over the phone is a very rude thing, but that is what they have done most of the time...
By 3:00am, the patient arrived and he was moved to the active resuscitation area. I saw the brain CT scan - rt putaminal hemorrhage with minimal mid-line shift. The blood clot esmitated around 50cc. However my nurse told me the patient's GCS was only E1V1M2 and he was not intubated. The family did not came along with the ambulance. The nurse told me they drove and would arrive later. I intubated the patient stat and sent him for another scan. No mannitol was given, only some steroid and fluid in the combined ED. My nurse started to curse .... I pacified them while waiting for the further CT scan. Well, intubation for my team is kacang putih( eating peanut , i.e piece of cake), but for those staff in the combined ED down south - it might be a very stressful procedure. Lack of training and on hand experience made their situation worst. I been there before.... nothing to blame and covering their ass is our job : afterall those case landed in our hospital would increase our bussiness. If they are competent and capable those patient might not have to transfer or stabilized and transferred further up north to Kaohsiung.
The follow up scan was worst. The bleeding had increased and the midline shift was more prominent. The younger son had arrived then. I explained about the patient's grave condition to the family. I told him, surgery was needed for this kind of bleeding but even if the surgery is done successfully and the patient survive the surgery; they could be facing a vegetative patient. The younger son said he had could not make any decision and his elder brother was coming from Kaohsiung. I told him, before they made any decision, I would proceed with my current management but the patient is definitely going to die if no ops is done. The patient was sent to ICU and by the time he reached ICU, I got this call again from the combined ED. This time the doctor talked to me over the phone. He told me that he had a patient presented with SOB and diagnosed as acute pulmonary edema. He had given her a furosemide injection and put in a Foley catheter. He said she was better and wish to sent her over. At this moment, I had only 1 ventilator in the ED left. I hessitated for 1 seconds and told him ok. I accepted the patient. My nurse asked me about the case and was worried with my decision. I told my nurse, I never trust their diagnosis, we should see what was coming to hit us and decide. There were a few times, when we turned down such referral, they still sent the patient over to us - because the patients were too ill to make it to Kaohsiung.
I saw the ICH patient in ICU minutes later and his pupil had fully dilated. I informed the condition to my neurosurgeon and he told me if the patient's son agree for ops he would come over. Later, His elder son came and I told him about the situation. He said that they would consider the option and would told me later about their decision.
By 3:40am, the SOB patient had arrived. She was noted with mod SOB. She was a esophagus cancer victim s/p radiotherapy with gastrostomy done. I saw no physical sign which support the diagnosis of acute pulmonary edema when I examined her. The picture looked more like pneumonia to me. I grinned when I read the referral note - the doctor had given her furosemide but also infuse her with NS 1000cc !!!! Such a controvesial management....
The x-ray confirmed my diagnosis and she was sent to ICU. I did not intubat her as she was better on oxygen mask use.
At this moment, the ICH patient's elder son had told me that they wanted an operation. I called my neurosurgeon and informed him about the decision. 10 minutes later, the elder son came to me again said that they wanted a transfer. He said that the second son is currently working in Chang Gung Memorial hospital( one of the biggest hospital in Kaohsiung) and wished to transfer there for ops. I gladly complied and called my neurosurgeon again. He was on his way then and told me not to worry about the change of decision. When I called the relevant hospital and was told no ICU bed was available. The ED physician had also spoken personnally that they should not go over as the patient would not recieved proper treatment.(fromt he conversation, I found that the second son was not working in CGMH after all, he work in one of the sister company only..). After 10-15 mins of making phone call, the elder son had come to me and told me that they still want to try their chance there. I settled everything and was just about to take a nap, the nurse told me that the son had again changed his mind - they wanted to go over to another big hospital in Kaohsiung. Again, I called the hospital and was told that no ICU bed was available as well. I informed the family and when the family was about to ask me to try for another hospital, I told them that our hospital was capable to manage such patient and I was not going to continue with the wild goose chase. If they wanted to transfer, they need to asked for ICU bed themself. They finally went to CGMH and tried their luck there. I doubt any ops would be done as no NSICU was available. The patient is gonna die as his BP was dropping before he left our hospital. The patient's son does not care actually - if they just wanted to make the event look nice: they had tried their best taking their father to a very big hospital....
Well, I hit the bed around 6:00am after I made a morning call for Ving and Yun....there was only 5 patient from 12am to 6am and I did not sleep....
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