One thing I’ve never gotten used to is being caught up in a no-win scenario.  The no-win scenario is a common occurrence in the medical world (even more so in today’s hospitalist environment).

Let me explain. Patient X presents with high-risk symptomatology, and you recommend he/she go to the ER and be admitted for further testing and monitoring.  The differential diagnosis is lengthy with the potential for permanent damage or even death.  The patient insists that nothing is wrong and does not want to go to the hospital.  After some arm twisting, the patient relents and goes to the ER by paramedics.

In the old days, I met my patient in the ER and controlled the workup and the referrals.  Things moved quickly. In today’s world, the ER doc runs the show until the hospitalist takes over and both the ER doc and hospitalist are incentivized to send the patient home for outpatient workup. It’s a win for the ER as the patient didn’t want to be there in the first place. Unless, of course, the patient worsens or dies while awaiting the outpatient workup.   

Prior to retiring, I sent a patient to the hospital ER and requested that the ER doc order a CT scan.  The ER doc called me to tell me that he refused to order the CT as he had been “dinged” too many times for ordering CTs.

I got out of bed, drove to the hospital at 3 am and ordered the CT.  The CT showed a bowel rupture as I suspected it would.  By the time the ER doc saw the patient, the bowel had ruptured, temporarily relieving the pain and, rather than believe the patient and my assessment, was ready to discharge the patient. The patient went to surgery and did fine. There is often a calm before the storm as the pressure is relieved by the rupture and pain goes away, then infection sets in.

So, back to the original story, my patient is pissed off that he is in the ER.  The ER doc and staff want to send the patient home for further workup but ultimately do the right thing and order some tests.  The tests are positive requiring specialty care.  It’s decided to transfer the patient to another facility for specialty care, but the transfer never occurs.   Communication between the docs, patients and hospital is poor.  Ultimately, the patient is discharged several days later and is frustrated that he stayed in the hospital and perceived no benefit.

In the latter years of my practice, the above scenario became more and more common.  Frankly, it made me think twice about sending my patient to the ER. I, too, was being incentivized to send patients home and do outpatient workups.  Experience trumped the hassle factor; and, to this day, if any symptom could be associated with permanent injury or death, I advise people go to the ER.             

When I’ve advised that my friend or relative (I am no longer a practicing physician so I no longer have patients) go to the ER, I hope and pray that nothing serious is found, knowing full well that they may be mad at me if they turn out to have nothing.  I often pray that I am wrong.  However, in most cases, I am right.

So, what do you do if things are not going well in the hospital?  If communication breaks down?  If you need assistance, ask to speak with the DON (Director of Nursing) or the CEO. They can usually help. Which brings me to my favorite blessing.  May you be so blessed as to never know what disease or injury you prevented by going to the ER in a timely manner.

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One Reply to “NO WIN”

  1. Thank you for this this thoughtful advice
    I didn’t want to go to er for Tia. After all I was ‘fine.’. Except I wasn’t. The drs insistence that I go was key. I know you would have said what he said. ‘ Go! Then stay there!’

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