This week the new residents and med students were all around in full force which lead to a lot of clinical upheaval. I noticed quite a few cases of bungled or even negligent care this week in response to the influx of new people. In the SICU, and really in most hospital units, most of the patients are covered by a variety of specialist teams. Most commonly the SICU interfaces with the Emergency department, nephrology, cardiology, neurology, respiratory care, interventional radiology, nutrition, general surgery, and orthopedics. Most units are on top of charting after a procedure or consult and they update their information into Epic- the hospital's charting software system. However, not all teams use Epic. For example, interventional radiology does not which can lead to delays in care and misinformation. When interfacing with the Emergency Department, a clinical coordinator determines what teams need to be consulted for a particular case. This week there were some issues with team coordination from both the coordinator and the doctors sent by certain teams for consult that lead to or could have lead to poor patient care.
One case was a 3 year old child presented to Emergency after being struck by a car. The child was not just struck by a car, but indeed was run over by an SUV as evidenced by tire tracks on the child's torso. The coordinator called in pediatrics instead of trauma at which point pediatrics saw the tire tracks and called the correct consult team. The child had a fractured pelvis but no other injuries and was treated and released successfully, however, a longer delay in care could have had disastrous results. Another case was when a 67 year old pedestrian was out walking when they were struck by a portable commode that fell out of the 7th floor of a nursing home building. The commode struck her in the head and more or less, "scalped" her. While she showed no intracranial bleeds on scan, the giant laceration around her skull was quite concerning and being struck by a large object falling from 7 stories up is indeed a trauma. Instead the coordinator called plastics first. Trauma eventually saw them and wanted to take the patient to the OR for a full wash out of the wound as stitching up a wound inflicted by a commode without a thorough washing could harbor infection intracranial infection. As plastics was called first they determined they were going to stitch her up without an OR wash and sent one of the new residents to stitch the scalp back. She was discharged without antibiotics. The patient was seen two days later at an office followup and did not show any signs of infection but at that point was placed on antibiotics.
Those two cases luckily had no poor followup, but this third case probably caused a patient's death: A middle aged man with Crohn's disease had been feeling poorly and was unable to eat so he presented to the Emergency Department malnourished. He had a decent surgical history of abdominal surgeries related to the Crohns. Given that history he was taken for an exploratory laparotomy during which they found a bowel obstruction caused by cecal volvulus. So they resected and reattached the bowel. He was sent to a general step down unit for recovery and initially had flatus. But this subsided around day 2-3 and his abdomen began to become distended. The patient was no longer able to tolerate an oral post surgery diet. His abdomen continued to expand causing discomfort to the patient and by day 6 his abdomen was massively distended and the patient was febrile. He was taken for x-ray at day 6 which showed free air, a pneumoperitoneum, and and the beginning of a pneumothorax. The patient was still kept on the unit. Day 7 the patient loses consciousness and an exploratory laparotomy is performed. 4L of foul smelling brown fluid was removed from the abdomen suggesting an intestinal performation from his resection. They did not find a perforation but noted necrotic looking tissue near the suture line. Patient had drains inserted and was fully closed without locating the course of the leak and released back to the unit. Essentially they let an intestinal perforation go untreated for a week under hospital observation and radiological evidence, took out leaked fecal matter but didnt stop the source of the leak, and fully closed the patient when he would probably need more surgeries to actually locate the perforation. He was incredibly sick with mass difuse peritonitis and infection and his prognosis when he arrived at the SICU was very poor. Negligence and lack of coordination very probably killed this patient.
My research has been unfruitful. We still cannot get the program to work on computers here. David is consulting with IT back in Ithaca so hopefully they can lead us down the right road. Although I am enjoying all the time in the hospital I am getting, I am starting to get anxious about the project. If this doesnt work itself out soon, I may need to seek a new project.
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