Monday, May 08, 2006

Triage Tales 13

Disclaimer: The following story is a work of fiction. All similarities to people, places, things and events are coincidental by nature.
I would start with a quote from the online British journal EMJ Online: Acute medicine: past, present, and future

So who should provide the initial care for the acutely ill medical patient? I don’t think that there is necessarily a single answer, for a number of reasons. Different hospitals will have consultant staff in both emergency and general medicine who have differing ambitions and enthusiasms for the early management of ill patients. Recent experience has shown that trusts are keen to recruit consultant physicians in acute medicine, but the early enthusiasts are all in post and the newly developed training schemes will not produce their first graduates for another three years, and even then the numbers will be few. It perhaps matters less who does the job than that it is done well. Best care will demand close working between all those involved and this will include practitioners of acute medicine, emergency medicine, and critical care medicine, who will need to develop uniform management strategies that are well founded, well disseminated, and used when any discipline is caring for similar patients. The Royal College of Physicians has recognised this and produced two reports, on the interface between acute medicine and the two specialties.


A 47 year old female is sent to the ER by an irate surgery senior resident because she has been exhibiting bizaare behavior while waiting for her OPD consult. 2 weeks before that, she had been admitted to the ER with jaundice and right upper quadrant pain, and without behavioral changes. She was discharged as a case of cholecystitis. Ultrasound done 4 days ago shows parenchymal disease and a neoplasm. She is apparently going into Hepatic Encepalopathy - 3 days of drowsiness, incoherence. Treatment Officer places plugs, an NGT, and starts Lactulose. Then he completes his notes on the workstation and refers the patient's case to the Medicine resident.

"Have you done a soap suds enema on this patient?" [sic]

Just then the Triage Officer comes with a 22 year-old patient for the Treatment Officer. Anterior neck mass for at least 2 years, with easy fatigability, heat intolerance, palpitations, and orthopnea. Also nursing a cough for some time. Cardiac monitor shows atrial fibrillation in rapid ventricular response. The Triage Officer, harried as she is with the constant flow of patients on a Monday morning, does a quick endorsement and disregards the Medicine resident entirely. Naturally, the Treatment Officer replies

"No, not yet. I'll get back to you on that."

And Treatment Officer never does, because the Medicine resident, for the next couple of hours, takes care of the patient herself.

Later in the afternoon, another Treatment Officer approaches the same Medicine resident to endorse a known aplastic anemia case, pale but otherwise without any signs of external bleeding.

"Why are you giving me that case already? Have you obtained the blood counts? Did your lab results return? What if your patient still has other problems?"

Treatment Officer #2 looks incredulous; she could just manage a "This patient clearly has a blood dyscrasia..."

"All of you are like that - you don't do anything. Even a simple soap suds enema can't be performed?"

Discretion is the better part of valor, and Treatment Officer #2 keeps her peace.

Ideally, the answer should be:
"Okay, let's dissolve the Triage and place all residents of the other services at the ER gate. Then let them, by consensus, arbitrate who gets the patient first. Sounds fair?"

I was amused by the fact that this blog shows up when you Google "Intarmed blog". Just mentioned it once, and totally forgot about it until it showed up in my SiteMeter.

Also, some big news coming out from E3 this year... but you wouldn't be so interested in a Nintendo Wii, won't you?

The hope of being able to study for the USMLE is still a hope, and looks like I should plan for a graceful exit soon if I am to get a decent score. I would be committing academic suicide if I continued my residency. I would just waste away $815 of my Tita's hard-earned money... I'll convince myself that the daily encounters with irresponsible "responsible companions" is still worth it.

Going home from a friend's wedding, my classmate says that there is no hope in the Philippines for doctors. This is the same classmate who eloquently lambasted those going to the U.S. through a poem masquerading as a yearbook write-up. And he is right. For the very few reading my random musings and are still in medical school, I envy you. You still have the innocence of not knowing the real score, of the frustration of treating a populace more willing to spend on their cellphones than the possibility of a medical catastrophe.

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