I noticed I was now six patients behind as I walked out of the trauma room, but I followed the nurses over to Room 3 where a 6-year-old crying boy was strapped to a backboard. I had just intubated and put bilateral chest tubes in his mother, the O negative was running, and the helicopter was on the way. She was also conscious and tearful.
I assessed Scotty quickly, even though he was next up to be seen by my partner. He was a rear seat passenger, belted, on the passenger side of the car opposite to where the Ford Explorer had T-boned his mother. No apparent injuries and alert, Scotty looked me in the eye as I palpated his cervical, thoracic, and lumbar spine.
I walked Scotty over to see his mom, warning him about tubes in his mom's mouth and chest. I stayed with them till the helicopter crew and Scotty's father arrived.
And that's when Dean confronted me. “He wasn't your patient! You are six patients behind!” Dean was the hospital's MBA consultant for LEAN management. Last week I had embarrassed him in our department meeting by asking how applicable it was to take a process meant for assembly line production of cars and apply it to the very cognitive, very complex management of living human beings in the ED. I had also asked Dean what they do when the line runs too fast, and a scrap car is produced. Producing scrap was not an option for us, I had said.
“Dean, the right thing to do was to take that kid to see his mom. I couldn't care less about your silly time study, frankly. We're not making cars here. Leave me alone.” It was a little more direct than I usually am with the C-suiters, but this came after dealing with mom, son, tubes, and helicopters.
Two weeks later, Dean, in his mid-40s, came to our ED in A-fib with RVR. It was 2 a.m., single coverage, and Dean was my patient. I spent a lot of time with him, as I would with any frightened father of two with a scary heart problem. We talked about alcohol — reportedly not the problem here — as well as about the thyroid and just plain bad luck while the diltiazem bolus worked its magic. I spoke about the electronics of the monitor and why the rate counter jumped from 90 to 180. My professionalism kept me from commenting on the excessive time I was spending with my “time study” patient.
Dean was back at work two weeks later. He was no longer my patient. “Dean, glad to see you're better,” I said. “They never found the cause?”
“Thanks for taking care of me. Dr. F said it was idiopathic. I'm on metoprolol.”
The dictation room was empty. “Dean, you got a minute?” A good question about time for a guy who claims we can be seeing four or five patients per hour regardless of what the literature says.
“Sure.” Dean looked like he knows what's coming, and it won't be fun.
“Dean, here take a seat. Are you allowed coffee? No? That would be tough for me. Wouldn't even be able to start a shift.
“Dean, I'm glad you felt like we took good care of you. I couldn't talk to you then. That would have been unprofessional and the wrong thing instead of the right thing.”
I had worked in the ED for 15 years, also serving as the county EMS director. We had done EMS research that was published that I presented at a conference of the National Association of EMS Physicians. I had helped get the hospital's name and reputation out there. I also had great Press Ganey scores. I had a right to speak.
“Dean, the time I spent with you talking about your heart was the right thing to do. You were worried. It was my job to talk with you, reassure you, teach you, and explain why the alarm kept going off. It was up to me to explain how the drug worked and what tests you could expect.”
Dean looked at me; he still knew it was coming.
“Dean, unlike like your cardiologist, who doesn't make my job harder, you do. It was the right thing to spend time talking with you while you were a patient. It was the right thing for me to take that kid over to his mom the other day. It could have been the last time he saw her. We can't see four to five patients per hour, what with the acuity here and a 30 percent admit rate. The emergency medicine literature says we can't. Too fast means mistakes, and I can't just scrap mistakes — someone dies. You tell us we are supposed to spend our time seeing the ankle sprains to get our LOS time down. You tell us the ankles are where our Press Ganey scores come from so we should see them first. Dean, with your A-fib, you were being admitted; you don't even get an ED Press Ganey. According to the 120-minute LOS and Press Ganey stuff you harass us with, you with your A-fib didn't even count! You would have counseled me to ignore you and go feed and water the ankle sprains!”
I talked about the analogy of measuring a fire department's performance not by how well they put out fires, but by how well they chat up granny while they get her cat out of the tree.
“You were the one on fire, Dean, and taking the time to take care of you was right. So was taking the time for me to tell you this.”
Dean gives me that blank look one gets used to as an ER grunt, the look from those who don't do what we do or understand it or think it can all be reduced to a time study or data spreadsheet.
A year later, my ED group did something unheard of. We “fired” the hospital. We walked away. I heard unsubstantiated and unprovable rumors that the administration wondered aloud in the hospital board room if they had been too hard on us. The new group wasn't living up to all their glad-handed promises.
My grandfather was a child laborer. He later gained self-respect and professional working conditions as a union member. He still worked hard and was proud of it, but he could hold his head high. Do we as a whole need to speak up and say there is a limit to how much we can tolerate and still remain professionals? It is past time to take emergency medicine back from the Deans, LEANs, and MBAs.
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