Stepping on a fellow intern's toes?

[Rendar5]

---

Members don't see this ad.

There was a recent case last week that's been bugging me the last 2 days. I was around when a teenager came into the peds ED with R leg pain from EMS, carried in on a stretcher. it looked a bit strange so a couple of the residents went in to just help out with initial. The story was that he had leukemia, getting chemo, and just began complaining that day of R leg pain. And it struck me as strange because he looked alert, but wasn't really talking when we were asking him questions. When we realized it wasn't a trauma and was a medical case, the rest of us cleared out and he went to the pediatric intern who was next to grab a patient. I glanced and noticed he was slightly hypotensive, so after finishing up with my patient I asked the peds intern if she was considering treating it as a sepsis case because of the patient's neutropenia, pain, and BP (normal pulse and temp). She had just gotten off the phone with the oncologist and said that his vitals were within the patient's personal norm per the doctor who knows him

Now this is not a weak resident by any means, rather I think she's a really great intern, more than carries her weight, very knowledgable clinically, and also very into peds EM so I'm happy to step off at this point. It's not my patient anyhow...

I found out yesterday that this patient died from C. Perfringens sepsis in the PICU over the weekend 🙁. I know that there was nothing to indicate gas gangrene when he came in. I know he perked up and wasn't as incommunicative after I left. I know that he probably would've died regardless. And since I was busy afterwards, I don't know if she and the attending changed their minds and gave fluids and antibiotics before admitting to the floor. But I can't really get it out of my mind.

Should I have been more intrusive and pushed her to consider sepsis more, despite not knowing more than a glimpse of the patient's full story? Should I have involved myself in the case a bit more knowing this wasn't an average patient? Or was I actually too intrusive in the first place? I'll admit that my social skills are not that great, so I do have problem judging what's enough and what's too much sometimes.

 

[Hawkeye Kid]

If the Peds ED attending and his personal oncologist were both comfortable with his VS and presentation, you would have been stepping on more than the other intern's toes by pushing this. I'd suggest that a better approach would have been to ask the ED attending to educate you on the topic (in a very non-confrontational way). Perhaps they overlooked the hypotension and this might have alerted them to it. More likely, though, they had info, experience, etc. that you didn't and probably would have been able to teach you something about it. It's definitely possible to do this, but be aware that if done without tact it can come accross as being arrogant.

No doubt a sad case, and one that will help you in the future. It might help you to talk to the other intern now to see if they changed plans after you bowed out of the case or if they learned any other info that could help put things in perspective.

 

[Apollyon]

It's a good question, but, if you have to fight over it in your mind, remember that, ALWAYS, the patient come FIRST. Feelings can be hurt, and there may be lingering attitude, but the patient is there, and more brains are better than fewer. You will find in practice (just like in residency) that you will bounce things off of your colleagues, because more eyes looking at the patient help.

This one wasn't your fault, but, if you make your feelings known (and present the low probability of downsides), you can possibly help out. For example, if you say, "You know, I might give this kid antibiotics, because he just looks sick; if he doesn't need them after a dose or two, it's no harm and nothing lost. If he's infected, though, this might do it. It's just my gut feeling."

 

[docB]

Tough case. I don't know that there's anything different you really could have done given your position other than telling the intern and the attending you were concerned.

It does illustrate an EM rule which is that you should always pay attention to the "little voice" that's telling you badness is afoot.

It also speaks to the difference in philosophy between EM and other specialties. EM assumes badness and treats it or rules it out while other specialties deal in most likely. You always have to factor in a doc who kows the patient and is saying "No, this is normal for them." but often a fresh set of eyes sees new things.

 

[Aloha Kid]

I'm sure the intern who had the case knows about the death, which probably is eating him/her alive as well.

Beating the drum of failure gone wrong is counterproductive to the education process. Don't forget, you may be next on the chopping block with a sick patient at anytime as well.

Peer review, educational reports, and simply talking about the case in a educational and confidential fashion does wonders and helps everyone learn, grow, and become better physicians.

 

[deleted109597]

Part of my concern over this is as follows. Why were you following up on a patient that you didn't actively take part in their care? By all standards, that is a HIPAA violation.
However, I agree with Apollyon in that you always do what is right for the patient. I don't consider it overstepping bounds when you do something that someone who hasn't seen the patient sets in motion. All of us have seen people who tell the attending over the phone what they want the attending to hear, not necessarily what they need to hear. Sometimes it is innocent, sometimes it is because they're lazy and don't want to do the work. Besides, giving a one time dose in the ED after cultures are drawn isn't likely to hurt the kid, as long as he isn't allergic to the medication.
End of the discussion is that you can only do what you do. If you wanted responsibility for the patient, you shouldn't have let the intern have it. If you didn't take responsibility then, why kick yourself now? You can't save everyone, unfortunately.

 

[bulgethetwine]

Part of my concern over this is as follows. Why were you following up on a patient that you didn't actively take part in their care? By all standards, that is a HIPAA violation.
However, I agree with Apollyon in that you always do what is right for the patient. I don't consider it overstepping bounds when you do something that someone who hasn't seen the patient sets in motion. All of us have seen people who tell the attending over the phone what they want the attending to hear, not necessarily what they need to hear. Sometimes it is innocent, sometimes it is because they're lazy and don't want to do the work. Besides, giving a one time dose in the ED after cultures are drawn isn't likely to hurt the kid, as long as he isn't allergic to the medication.
End of the discussion is that you can only do what you do. If you wanted responsibility for the patient, you shouldn't have let the intern have it. If you didn't take responsibility then, why kick yourself now? You can't save everyone, unfortunately.

That's super weak, dude. A HIPAA violation? Give me a freaking break. That's your first comment on this thread? You've drunk the kool-aid. You might as well quit clinical medicine now and go work for the paper pushers. 👎

 

[NeuroSync]

It's not a HIPAA violation. That's like saying that when I scan the patients in the waiting room, look at labs, look up their records and so forth, that I'm violating HIPAA because I won't see most of the people I am looking at. As a former medical attorney, I can tell you this is not a HIPAA violation. And being interested in and learning about the patients who come into the ED as a resident or an attending is a good thing that ought to be encouraged, not lambasted. Rant over...

 

[deleted109597]

If it's not, then why are people fired for looking at the records of famous people who come to the ED? Even if they are working when that person is there? Is it because the hospital is too scared? (I'm asking, because recently our hospital fired 5 people for looking into what they deemed a sensitive chart).

Also, as an aside, Neuro, are you saying that you routinely look up all the patients in the waiting room? I envy you if that's the case. We're frequently 30 deep out there, and since we can't convince them to even run U/A and Hcgs on patients in the waiting room, there wouldn't be anything to look at. My question is why you do it though? Trying to pick the sick ones out, helping them triage (BTW, also actively discouraged at our facility)?

 

[SoCuteMD]

Part of my concern over this is as follows. Why were you following up on a patient that you didn't actively take part in their care? By all standards, that is a HIPAA violation.

What the heck? Looking up intersting patients is now a HIPAA violation? I add my colleagues' interesting cases to my f/u list all the time, as encouraged by program leadership. At our community site I will scan the next few pt's awaiting eval by CC and vitals to pick the cases I might find interesting. Don't have that luxury at the university ED, but it's pretty accepted for juniors to do so at our community site.

 

[BADMD]

What the heck? Looking up intersting patients is now a HIPAA violation? .

If you aren't involved in that patient's care, you can't access their medical record unless you are covered by one of the exceptions.

I'm sure George Clooney would be an interesting case, but you will get fired if you look at his medical record and aren't part of the care team.

 

[southerndoc]

If you aren't involved in that patient's care, you can't access their medical record unless you are covered by one of the exceptions.

I'm sure George Clooney would be an interesting case, but you will get fired if you look at his medical record and aren't part of the care team.

It depends. Read that HIPAA release form carefully. At some hospitals, your signature allows access to your medical records for patient care, research, and "education." That allows residents to view your information.

 

[SoCuteMD]

If you aren't involved in that patient's care, you can't access their medical record unless you are covered by one of the exceptions.

I'm sure George Clooney would be an interesting case, but you will get fired if you look at his medical record and aren't part of the care team.

Not if it's for educational purposes. At least according to my institution's GME office.

 

[roja]

Rendar- tough case. First, before you beat yourself up, I would find out what was done after you stepped out. The patient might have gotten IVF and abx. Also, many things happen while patients are in the hospital.

For the future- patient care comes first. but you have to live with your attendings and colleagues and you don't want to make your life more difficult. So, how you straddle that line can be tricky.

There are a couple of options: Go to the attending and ask him what is going on. You are there to learn. This is a perfectly legitimate thing to ask. (ie: Can you tell me more about this patient? I was in on the initial evaluation and haven't seen many patients like x,y,z. NOT, I think this is sepsis, can you tell me why you haven't thought of that?)

If you aren'tn sure if you should say something or not or how, ask a trusted senior resident to help you figure out what to do.

 

[Rendar5]

If it's not, then why are people fired for looking at the records of famous people who come to the ED? Even if they are working when that person is there? Is it because the hospital is too scared? (I'm asking, because recently our hospital fired 5 people for looking into what they deemed a sensitive chart).

Also, as an aside, Neuro, are you saying that you routinely look up all the patients in the waiting room? I envy you if that's the case. We're frequently 30 deep out there, and since we can't convince them to even run U/A and Hcgs on patients in the waiting room, there wouldn't be anything to look at. My question is why you do it though? Trying to pick the sick ones out, helping them triage (BTW, also actively discouraged at our facility)?

My understanding is that I'm allowed to look at patients in the ED that I may potentially be involved in the care of. This includes anyone in my section of the ED (in case someone's on break or busy when something comes up), anyone in waiting that I may see soon, and anyone in other sections of the ED if my section is considering taking on extra patients to balance out the crowding. I know that people were fired from my university before for looking at a celebrity's file when they came in, but those were people from other departments who weren't responsible or potentially responsible for their care.

In this case, even if what i consider above is HIPAA violations, I spoke with the patient for initial eye-sight eval to make sure there wasn't anything crazy that I should help with.

 

[Rendar5]

Rendar- tough case. First, before you beat yourself up, I would find out what was done after you stepped out. The patient might have gotten IVF and abx. Also, many things happen while patients are in the hospital.

For the future- patient care comes first. but you have to live with your attendings and colleagues and you don't want to make your life more difficult. So, how you straddle that line can be tricky.

There are a couple of options: Go to the attending and ask him what is going on. You are there to learn. This is a perfectly legitimate thing to ask. (ie: Can you tell me more about this patient? I was in on the initial evaluation and haven't seen many patients like x,y,z. NOT, I think this is sepsis, can you tell me why you haven't thought of that?)

If you aren'tn sure if you should say something or not or how, ask a trusted senior resident to help you figure out what to do.

thx Roja and everyone else in the thread for their advice. I'll definitely be using it next time anything similar comes up👍

 

[deleted109597]

In this case, even if what i consider above is HIPAA violations, I spoke with the patient for initial eye-sight eval to make sure there wasn't anything crazy that I should help with.

I'm not saying you are wrong for looking at that chart, just that if you don't watch out, big brother is. Writing a note in the chart to that effect when the patient came in that says something of substance could go a long way. Writing one now obviously would be tagged as odd. Otherwise, it could seriously cause you grief in the future.

 

[pseudoknot]

My understanding is that I'm allowed to look at patients in the ED that I may potentially be involved in the care of. This includes anyone in my section of the ED (in case someone's on break or busy when something comes up), anyone in waiting that I may see soon, and anyone in other sections of the ED if my section is considering taking on extra patients to balance out the crowding. I know that people were fired from my university before for looking at a celebrity's file when they came in, but those were people from other departments who weren't responsible or potentially responsible for their care.

In this case, even if what i consider above is HIPAA violations, I spoke with the patient for initial eye-sight eval to make sure there wasn't anything crazy that I should help with.

I think there is probably a disparity between HIPAA and institutional policies, which may be much more stringent. A friend of mine was a tech at UCLA's ED, and was fired for looking up random charts of people in the ED.

 

[Apollyon]

If you aren't involved in that patient's care, you can't access their medical record unless you are covered by one of the exceptions.

I'm sure George Clooney would be an interesting case, but you will get fired if you look at his medical record and aren't part of the care team.

Put it this way: if you saw the patient, you can hit up the record for education (radiology rounds and so on). If you didn't see the patient, how did you hear about the case? If you got the name or medical record number, the person that gave it to you, and you, are both in violation of HIPAA. If it was strictly the case and no identifiers, then it's a different story. The original provider can get the data, take the identifiers off, and then give you the case to present/evaluate for education.

 

[SoCuteMD]

I think there is probably a disparity between HIPAA and institutional policies, which may be much more stringent. A friend of mine was a tech at UCLA's ED, and was fired for looking up random charts of people in the ED.

There's a difference between a tech and a physician. As I said before, I quickly scan the triage notes, vitals, and most recent results of the patients awaiting eval in order to make sure I really am seeing the potentially sickest patient first (and, as I admitted earlier, to cherry pick a bit when I'm at our community site). Thus, I'm listed as having accessed their records even though I may never order anything on them or fully evaluate them.