Last night, a sick child and his brother in our emergency department asked for crayons and a coloring book. On the surface, it seemed like a great idea. You know, distract them while the medical issues were managed. But before the nurse went into the room to dispense the colored wonders, I did what any modern, caring, careful physician would do. I instituted a time-out.
Figure. No caption a...Image Tools
“Are these the crayons you're taking? Are these the children who want to color? Will this be the room in which the children color? Is this the right coloring book?” I asked.
Fortunately, the nurse's answer to every question was “yes,” so there were no Crayola “never events.” There was, perhaps, some whispered profanity directed at this physician. Still, another life was saved by cautious use of yet another rule. Hallelujah!
Here we are, in the era of the time-out. For the layperson who picks this up at a family member's house, the time-out is a way to ensure that surgical patients don't get the wrong procedure. Hernia repairs don't turn into vasectomies, regulation breasts aren't accidentally augmented or removed, normal legs aren't amputated as the diseased leg watches in relief. I joke, but these are serious issues. Surgical errors like this have happened, and the results are tragic.
Over the years, surgeons have developed systems. They would do things like write in indelible marker things like “right” and “wrong” or “yes” and “no” on the appropriate appendages of their surgical patients. Procedures were enacted to ensure that grave errors didn't occur while patients who might otherwise justly and appropriately protest were snoozing under general anesthesia. A fine idea, except that some surgeons I know already had good safety measures in place, and the updated plans made things more confusing. The idea of making certain a procedure is done to the right person and in the right location is a sound one.
The concept, however, has trickled down, as so many things do, to the emergency department. Now, before doing things like incision and drainage of abscesses, sedations and joint reductions, or lumbar punctures, we're supposed to do a time-out.
The thing is, our patients aren't like surgical patients. Come at them with a large needle or scalpel, and they're apt to say, “What are you doing? I'm here for my blood pressure!” Offer to stick a needle in their back for spinal tap, and you'll be greeted with, “Man, all I want is some Lortab and a work excuse!”
There's a fundamental difference between what we do and what happens in the operating room. When we emergently shove a chest tube in a dying accident victim, it's evident that this is the dying trauma victim. Put a chest tube in the non-chest trauma patient, and she might say, “So does this mean I'm not pregnant?” It's considerably more difficult to drain a bulging, pus-filled abscess in a surprised person who doesn't have a bulging, pus-filled abscess.
Nevertheless, doctors being the fundamental idiots we are deemed to be, we have been rescued from cataclysm by legions of brilliant rule-makers, consultants, and other assorted carpet-walking members of the human race. Their extensive time-out procedures are now being put in place in emergency departments all over the country. It goes roughly like this:
Before beginning the procedure, the nurse asks the patient his name and birth-date. The patient responds with a sigh, “For the third time, I'm Robert Heinz, 2-19-54.”
The nurse proceeds: “And we are draining fluid from your knee, correct?”
The patient responds: “Do you see how swollen it is?”
The nurse looks exasperated (because he or she doesn't like it any more than the physician). The nurse looks at the doctor. “Do you have all of your necessary equipment?”
The doctor asks: “Do you have the chainsaw, block-and-tackle, and donor brain?”
The patient laughs, the nurse laughs, the procedure…proceeds.
It's all more of the same thing that bogs down our departments and reduces efficiency. I suspect that emergency departments were not the places where catastrophic errors were resulting in life-shattering accidental surgeries.
But, just like health reform, no one is really asking regular folks who work in the real world. Allegedly smarter people are looking at what we do and telling us how to do it better, without darkening the doors of our already overwhelmed national safety net.
The time-out joins a long list of speed bumps, like every imaginable screening assessment asked of our nurses (nutrition, abuse, immunization, illicit drug and alcohol), the home-medication reconciliation form, the onerous restraint documentation form, and the ever-popular one-on-one observation required for everyone who even thinks the word “suicide.”
Though no one believes it, we were doing a jam-up job before improving ED efficiency became a career option. And though accidents happened, we were remarkably careful and successful for a group of providers tasked with doing everything for everyone for free.
So we're stuck with the time-out. Like every “good idea,” it probably won't go away until a meteor wipes out life on Earth. (And by that, I mean productive, healthy, functional life. Some of our patients will thrive in the post-apocalypse.)
But before it does, we'll have to ask some final questions. “What's your name and birthday?” “Is this the meteor that's going to kill you?” “Do you have all of the equipment necessary to be obliterated?”
Then we can rest in peace.
© 2009 Lippincott Williams & Wilkins, Inc.