by Robert Lanz LCSW
In the ER where busyness is one of the constants to overcome, the change of shift can provide some difficulties when patient information is passed from the leaving staff to the arriving staff. The night doc gets information from the day doc. Same with the nurses. Same with the social workers. Misinformation. Incomplete information. Or even flat out wrong information often leads to confusion and sometimes mistakes. Of course, when the daytime social worker hands off patients to me the same thing can happen. If it is a really busy change of shift mostly I just have to trust another person’s clinical assessment like I would my own. Here’s some advice. Don’t do that.
Apparently a father with an aging mother with dementia passed out from an overdose of Valium in the park while babysitting her. Someone called the cops and they called the paramedics. Dad and the mother were brought to the ER to get checked out. By the time I arrived for my shift at 3:30 she had already been admitted to be followed up by Adult Protective Services and the errant father was sleeping it off and was thought to be medically stable. He was waiting to be awake enough to talk to the police, sort of in a benzodiazipine holding pattern.
He was snoring in a room with three other patients and a nurse. No one thought he needed to be in restraints- possibly right but also possibly due to the extra charting requirements it would place on an already too busy nursing staff.
When there is a airplane crash or a boat sinking or a train running off the tracks the follow-up investigation always shows the same thing well summarized in the survival book aptly entitled “Deep Survival” by Laurence Gonzales. ” …unexpected interactions arise naturally out of complexities of the system. Such accidents are made up of conditions, judgements and acts or events that would be inconsequential by themselves. Unless they are coupled in just the right way and with just the right timing, they pass unnoticed.” Or, as my friend Paul, a commercial airline pilot for over thirty years says, “sequential fuck-ups ” are the problem. Small oversights and small mistakes add up until disaster hits and in retrospect everyone asks the same questions- Why didn’t we see that coming? And that? And that? The mistakes have increasing consequences and turn into into “And thens.”
The first “And that” in this disaster scenario was not restraining the patient. The second “And that” was me not bringing it up. The next “And that” was the cardiac arrest patient who needed the bed space occupied by the sleeping dad along with the nurses full attention. The next “And that” was when the OD dad was rolled into the hallway to make the necessary space for the cardiac arrest with no mention to anyone that he now had free range and was essentially off tether- no restraints. The “And then” list started about there
When I returned to the ER from a consult in pediatrics all I saw was an empty bed in the hallway where sleeping dad had previously been. Sleeping dad had obviously converted to waking dad while the staff continued trying to resuscitate the full arrest. And that’s how I discovered my patient had disappeared. No one had seen him leave. Too busy.
I called security and we fanned out over the campus to try and locate the escapee in the hospital gown and bare feet. A five hundred bed hospital has a lot of places to hide out in or fall down in or go back to sleep in. After a few moments I saw the patient crumpled on the ground with his eyes closed. Back to sleep? Maybe. I gave him a shake and he opened his eyes but I wanted to do a quick physical survey before moving him. I knelt down and gently moved his joints and checked his pupillary reflexes. I looked for bleeding or deformities. I noticed him wince slightly when I gently grasped his elbow.
Pulling his gown up a bit I could see a badly deformed ankle fracture. I looked up over his shoulder and saw the top floor of the three story building that housed the psychiatric unit on the first floor. If he went up there to the top and somehow got onto the roof and then jumped he would land just about exactly where he was now curled up. About that time one of the security officers helping in the search showed up with a wheelchair.
“That’s not going to be enough Hal. Go call a trauma code. We’ve got a jumper.”
Pretty embarrassing to have my patient escape, jump off the roof of the psych ward and then having to call the paramedics onto the hospital grounds and then transport the patient less than a hundred yards to the trauma center. I would have to tell the chief trauma surgeon all the “And thens”, starting with my own. And then I would have to make an embarrassing list of the “And thens” the first being the assumption he was a simple overdose and missing that he was just an over medicated psychotic and then it went down hill from there.
The next time someone passed me a patient they said they had evaluated I listened politely. And then did my own work up. And then it never happened to me again…