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- Jun 24, 2014
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I will do my best to keep this concise. I am a nocturnist working at a 150-bed hospital with services available but not all of them. We are a tertiary hospital to a much larger system within a 30-60 mile radius where there is a main hospital with trauma level 1 and all specialties actually on-site overnight; I plus an ER doctor are literally the only MDs on-site in this hospital. We have GI we can call in for any emergent procedures but we dont have IR. We have ICU but our intensivists are simply off-site teleconsults so its really us running the ICU and giving them a call for questions and orders. I have made mistakes accepting transfers “too sick” for our hospital and had to transfer out: such as a patient with hemo-thorax needing CT-surgery (which we have) but our CT surgery noted the patient needs an aorta repair and needs to be air lifted to another hospital. I also was pitched by the ED that a pregnant woman is having “appendicitis” but they dont have MRI to prove it so I accepted when we MRI’ed it was actually an ectopic and we also had to airtransport her out for Ob/Gyn because she rapidly was declining and entering shock.
In this case, I was called about a patient with ETOH abuse and hx of gastric varices s/p Banding found down for unknown period with blood on the ground and around his mouth likely as if he had hematemesis. The ED noted he was hypotensive, Hb of 5, obtunded, and cold clammy in clear shock so they did massive transfusion protocol, stabilized him, intubated and placed a central line and wanted me to accept him to our ICU for GI eval. That was their whole pitch and I told them let me chart check but of course they didnt tell me things that I had to discover for myself on the EMR that he also had acute renal failure, his Cr gone from 1 to 7 (but we do have HD, vascular and nephro support so no biggie) and although they trended a Lactate (which did improve); they never repeated the H/H and the only value we have is the pre-transfusion 5Hb. I also asked my ED doc why there was no scan. I felt he bought himself a CT and we still dont know what kind of bleed this is nor do I know the tempo, severity, or rate of blood loss. Overall I was quite frustrated and refused saying I appreciate them overall stabilizing him but with the limited information I have; he may have a more lifethreatening bleed that may require IR and more emergent intervention.
I never heard any flac since until the next day; the hospital administration and housing supervisor were furious and said the patient ended up going to a competitor hospital and all he had there was just GI: an EGD and banding and he was stable without needing IR. I said hindsight is 20/20 and argued we have GI but always need IR in case but then they argued that in that case we can send him to our main hospital (we are a feeder hospital to a larger system). I disagreed saying it was best for the patient to not make multiple pit stops while critically ill, actively bleeding, and in shock. Then they said it was obviously varices as he had it in history and was resolved with banding which we can offer but i said that is anchoring and they gave me limited information to clinically say this was vx in nature. Also my GI rotation was now a distant past but if I recalled anything from those attendings, I remember that artery embolization may not be first line but should be considered in the super unstable and although patients may not need it, its best to go to facilities with both GI and IR communicating together in case crap goes south; whether failed EGD or where a CT scan when actually done could reveal something more ominous.
Overall I am quite sure I felt I did what is best for patient but now I am second guessing myself. I’m trying to replay the scenario again because I always admit GI Bleeds for about 20% of my admits and I wonder if I am called and get pitched about this same exact presentation, would I change my response. But my answer to myself would be a No. I considered maybe saying “lets CT then call me back” or “call my on-call GI” but time is Blood for this patient and a GI doc overnight in his mansion miles away with his blonde wife and Porsche would wake up to this l biased story and say “sure” without chart checking and seeing how sick he really is. I think if replayed, my answer still remains firm no.
In this case, I was called about a patient with ETOH abuse and hx of gastric varices s/p Banding found down for unknown period with blood on the ground and around his mouth likely as if he had hematemesis. The ED noted he was hypotensive, Hb of 5, obtunded, and cold clammy in clear shock so they did massive transfusion protocol, stabilized him, intubated and placed a central line and wanted me to accept him to our ICU for GI eval. That was their whole pitch and I told them let me chart check but of course they didnt tell me things that I had to discover for myself on the EMR that he also had acute renal failure, his Cr gone from 1 to 7 (but we do have HD, vascular and nephro support so no biggie) and although they trended a Lactate (which did improve); they never repeated the H/H and the only value we have is the pre-transfusion 5Hb. I also asked my ED doc why there was no scan. I felt he bought himself a CT and we still dont know what kind of bleed this is nor do I know the tempo, severity, or rate of blood loss. Overall I was quite frustrated and refused saying I appreciate them overall stabilizing him but with the limited information I have; he may have a more lifethreatening bleed that may require IR and more emergent intervention.
I never heard any flac since until the next day; the hospital administration and housing supervisor were furious and said the patient ended up going to a competitor hospital and all he had there was just GI: an EGD and banding and he was stable without needing IR. I said hindsight is 20/20 and argued we have GI but always need IR in case but then they argued that in that case we can send him to our main hospital (we are a feeder hospital to a larger system). I disagreed saying it was best for the patient to not make multiple pit stops while critically ill, actively bleeding, and in shock. Then they said it was obviously varices as he had it in history and was resolved with banding which we can offer but i said that is anchoring and they gave me limited information to clinically say this was vx in nature. Also my GI rotation was now a distant past but if I recalled anything from those attendings, I remember that artery embolization may not be first line but should be considered in the super unstable and although patients may not need it, its best to go to facilities with both GI and IR communicating together in case crap goes south; whether failed EGD or where a CT scan when actually done could reveal something more ominous.
Overall I am quite sure I felt I did what is best for patient but now I am second guessing myself. I’m trying to replay the scenario again because I always admit GI Bleeds for about 20% of my admits and I wonder if I am called and get pitched about this same exact presentation, would I change my response. But my answer to myself would be a No. I considered maybe saying “lets CT then call me back” or “call my on-call GI” but time is Blood for this patient and a GI doc overnight in his mansion miles away with his blonde wife and Porsche would wake up to this l biased story and say “sure” without chart checking and seeing how sick he really is. I think if replayed, my answer still remains firm no.
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