Actually took place in a place far away and long ago.
Med student goes and sees pt with chest pain, he presents to the attending. The patient is chest pain free so the attending suggests he order some
Nitro Paste.
The nurse picks up the chart and notes orders for labs,
Xray, EKG and 4" of
Nitro Paste!
Nitro paste is a
vasodilator and the usual dose is 1/2 to 1 inch. This order is a 4 to 8 time overdose which has a good potential to cause serious drop in blood pressure and possibly death.
The nurse blurts out "4 inches!" and the med student overhears her.
"Well what do you usually order?" He asks.
Oh no you don't, if you don't know what you are doing then look it up, call the pharmacist or ask your attending who, by the way, is supposed to be supervising you.
This was one of many experiences I had at 'great big teaching hospital.' When I went there I had the picture of the immaculately attired attending leading a pack of residents and med students around, teaching them and supervising them. Instead, I found the
attendings rarely around (except for in the ER) except during rounds and boy, they didn't want to be called either. And the most junior resident, who had the least knowledge and experience, was left as house officer at night when everyone else went home. Because they would get reamed out when they called there supervising resident they were afraid to and would try to blunder through instead of asking for help. For instance, the medicine resident was
responsible for admissions. when the ER was busy the resident would be backed up for hours, delaying admissions and clogging up the ER. But they would never, ever call for backup to get caught up no matter how long it meant the patients languished on the ER gurneys, sometimes twelve or more hours waiting to get admitted.
What kind of a system is that? And what kind of hospital lets that happen? I haven't worked there in a million years or so, I wonder how things have changed with all the quality measures? How do you get a door to antibiotic time in under 4 hours if it takes 2 hours to get to the triage nurse and another 4 to 6 hours to get into a bed? And why does it take that long? Part of the reason is all the patients waiting to be admitted , waiting for an open bed, waiting for the nurse upstairs to take the patients.
I'll say it before and I'll say it again. The solution to ED throughput is not getting them in the front door faster, that is why provider in triage is a farce. The real solution is to fix all the endless problems that prevent them from leaving the ER.
Have the expectation that the ER doc will make a disposition decision in a reasonable amount of time.
Expect the consulting doc to respond and write orders withing a half an hour or give phone orders or give the ER physician the ability to write quick holding orders then the consult can see them at their leisure while they are comfortable in their room.
Expect an immediate bed assignment. Period. I'll post later about the million things that clog up inpatient rooms.
Expect the floor nurse or charge nurse to accept the patient within 1/2 hour of the bed being assigned. Have an admissions nurse to do all the reams of paperwork that has to be done. Always, always, always have a ward clerk. Ridiculous to save $10 and hour and make a nurse take time away from the bedside to input orders. Criminal really.
Have enough transporter to take the patients in the hospital where they need to go. Transporting a patient to their room takes time, that is time where the nurse gets further and further behind and time added onto the ER nurses stay. Again, why save $10 an hour here? Stupid.
Hospital administrators like to spend a million dollars to save a dime. It is terrible business and very short sighted. I hope in my lifetime I will see them get a CLUE!
