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Life in Emergistan: A Tale of a Transfer One Patient, Six Hours

Leap, Edwin, MD

doi: 10.1097/01.EEM.0000542250.08089.37
Life in Emergistan

Dr. Leap practices emergency medicine in rural South Carolina, is a member of the board of directors for the South Carolina College of Emergency Physicians and an op-ed columnist for the Greenville News. He is also the author of four books, Life in Emergistan, available at www.nursingcenter.com, and Working Knights, Cats Don't Hike, and The Practice Test, all available at http://www.booklocker.com, and of a blog, http://edwinleap.com/. Follow him on Twitter @edwinleap, and read his past columns at http://bit.ly/EMN-Emergistan.

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Few things make a shift seem longer or more painful than a complicated transfer. You know what I mean if you work in small-town or rural America. Our colleagues in large teaching centers have enormous stress and do heroic work—and they accept transfers night and day.

Those who work in large centers miss out, however, on the singular delight of making the call to transfer those patients. This isn't exactly the Great White Way, but the experience is rather like a Broadway show.

Setting: Dr. Leap is calling to transfer a critically ill young woman from Tiny Memorial Hospital to bright, shiny Massive Regional Hospital. Having no secretary and because all the nurses have important clinical duties, he picks up the phone, his cup of tea close at hand and his phone playing choral music to soothe his frazzled spirit.

Massive Regional Hospital: Hi, this is Brandi on the transfer line. Is this an emergency?

Dr. Leap: Well, it's complicated. It's an unresponsive 25-year-old woman with stroke-like symptoms. She was found at home and was intubated by EMS. No apparent trauma. She appears to have a small right frontal subarachnoid hemorrhage. She's also 28 weeks pregnant. I need a physician to accept her. She will most likely require several services. (Dr. Leap sighs, knowing what this portends.)

Brandi: So do you need neurology?

Dr. Leap: Probably neurosurgery.

Brandi: (Obtains demographics.) Just so you know, we're completely full except for stroke and STEMI, but I'll connect you with Dr. Evans of neurosurgery.

Dr. Leap tells story again (emphasizing things that make neurosurgeons care).

Dr. Evans: We aren't going to do anything with that tonight. She probably needs to go to the hospitalist service in the ICU.

Brandi: I'll get Dr. Cannon. He's the medicine resident.

Dr. Leap tells story, including all required numbers and porcelain levels for the internal medicine report.

Dr. Cannon: I'm internal medicine. I can't take that without an OB or neurology consult. I haven't delivered a baby in years.

Dr. Leap: She's not in labor.

Dr. Cannon: Still.

Brandi: I'll get OB.

Dr. Leap tells story.

Dr. Andrews-Guttman: That's terrible! She needs neurology. We can manage the baby part but not the neuro issues.

Brandi: I'll get the NP on call for neurology.

Dr. Leap tells story again. (He notes that NPs don't have last names).

Susan: I'll run it by my staff, but we don't accept transfers or do admits. It sounds neurosurgical. What did they say?

Dr. Leap: They said to call the hospitalist, who said to call OB, who said to call you.

Susan: That makes sense. OB didn't want to accept her?

Dr. Leap: (Snarky by now.) They only take care of baby brains.

Brandi: Shall I call critical care?

Dr. Leap: (Considers slitting wrists as patients pile up.) Yes, please.

Dr. Leap tells story again.

Dr. Morgan: I'm sorry to hear that! Of course, I'll manage the critical care side, but what did neurosurgery say?

Dr. Leap: They said she needs a hospitalist.

Dr. Morgan: They don't admit to the ICU.

Dr. Leap: Can I send her to you?

Dr. Morgan: Are neurology and OB planning to see her?

Dr. Leap: (Face on desk.) Yes, but they can't accept her in transfer.

Dr. Morgan: I have no ICU beds. Can you keep her there overnight? I'll call you when a bed's open. Just put her in your ICU, and have your neurologist see her.

Dr. Leap: I don't have any ICU beds, and I don't have a neurologist.

Brandi: We can call you in the morning when beds open up. Is that OK?

Dr. Leap: Sure.

Dr. Leap calls Southern Teaching Hospital, 75 miles in the opposite direction.

Rick: Hi, this is Rick, the transfer coordinator. Is this an emergency?

Dr. Leap repeats story again with similar cast of characters. Patient finally transferred six hours after the first call. He binge-eats King Don chocolate cake to clear his head.

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Have Mercy

Everybody is overwhelmed at big centers and small. I'm not trying to make anyone the villain. I hate sending things to busy centers because I've been there. It is almost comical, however, when you tell the same story six times and one more person needs to hear it from the top again.

There has to be a way we can streamline communication and patient acceptance (or rejection). Last time I checked, doctors can read summaries as surely as they can listen to them. In an age of constant texting, younger doctors may prefer it!

Hospitals need to consider these situations when staffing. Number of patients seen per shift isn't the only metric that matters. Transfers, sending and receiving, are complicated, dangerous, and extraordinarily time-consuming. This is especially so in small hospitals with little or no backup. When physicians and nurses are on the phone and at the desk completing the tomes needed for a transfer, they can't see sick people.

Dear administrators: Have mercy. We chart nonstop to document and bill. We need help so we can do all of this in the most thorough but efficient way possible.

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