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This story is from the Anamnesis episode called At a Loss and starts at 12:15 on the podcast. It's from , an emergency room physician and chief medical officer of Vituity.
Following is a transcript of his remarks:
I'll start in 2006 or so when I was a senior resident in a busy urban hospital in Los Angeles and at the time I was thinking about what I wanted to do with the rest of my career. That day, a young woman checked into the ED and she was accompanied by her father. She was about my age, in her late 20s. In fact, she might have been 26, if I remember right, and she was complaining to our triage nurse about some weakness.
The triage nurse, her name was Lola, and Lola was, like, a great triage nurse. Lola was one of those nurses who could just tell sick from not sick and she had the ability to kind of control a rowdy county trauma center emergency department waiting room. She was just, like, an amazing triage nurse, and so Lola talks to her.
She's got some vague weakness, some dizziness. She doesn't really have any major past medical history that we know about. She has got something going on with her kidneys, but she's not quite sure what it is. Nobody really knows. Her dad doesn't know.
She's got stable vital signs and her eyeballs are OK. So Lola looks at her. "A young, healthy woman. No specific complaints. She can wait." It's a busy day, just like every single day in this county hospital. It's a busy day and this patient is overall low acuity. She can wait in the emergency department waiting room.
So she waits and she waits, and she waits. In the meantime, I'm in the back of the emergency department. I'm seeing patients. I'm sitting on like admitted boarders. I'm managing traumas as they come in. I'm waiting for consultants to call me back so that we can dispo some patients.
There just wasn't any bed turnover, which meant that lots of patients out in the waiting room were just sitting there waiting for a bed with absolutely nothing being done for them. This is pretty status quo for EDs in the early 2000s, or at least in this particular ED, that you'd just have a full waiting room and absolutely nothing being done for those patients out there until they make it back to a bed.
She's out there and she keeps on waiting. She waits some more. She starts to feel a little worse and she goes up to Lola, and Lola repeats some vitals and finds that they're okay. Lola asked her to sit back down and just keep waiting because we need some beds to open up before she can go back and we can start treating her.
She's Getting Worse
I keep on seeing patients in the back, in the main EDM. I'm like waiting for CT scans to get read by radiology so I can dispo some patients, I'm waiting for lab tests to come back to make some decisions about admit versus discharge, and I'm completely unaware of this young woman who's sitting out there in the waiting room. I'm completely unaware of everybody out there in the waiting room, just like any day in this emergency department.
Unfortunately, she starts feeling even worse, and now she's too weak to stand up and go tell Lola that she's feeling worse, so her dad does. Her dad goes up and is like, "Hey, my daughter's getting worse. What can we do for her?" And the answer is nothing. Lola can't do anything for this poor woman. The ER is completely full, full of boarders, full of traumas, full of psych patients. All the beds are full.
This young woman keeps on waiting, and she waits and she waits, and then suddenly she collapses. Lola rushes over, finds her pulseless and apneic on the ER waiting room floor. She hauls her onto this gurney that we have in the waiting room exactly for situations like this and Lola rushes her back to our resuscitation room, trailed by her dad.
So I get called to Bed 1 immediately. I still remember it was Bed 1 in the resuscitation bay and we started to code her right away. We had really good nurses. I mean, we had great nurses in that program and I remember Alison was our charge nurse who was on, and she gets an IV right away, and we've got her hooked up to the monitor, and we're doing compressions, and she's in VFib, so we shock her. We got pulses back, like briefly. It's this weird, like wide complex rhythm on the monitor.
Her pressure is low. We lose pulses again. We push some epi. We do more compressions and I intubated her, and she keeps on going in and out of VFib and PEA, and we keep on shocking her, we keep on doing CPR, we keep on giving her epinephrine. We give some bicarb. It's a really intense code and her dad is standing right next to us the whole time. I was just too busy running the code to really talk to him much other than to introduce myself, let him know that we are doing everything possible for his daughter, and just to say, "What can you tell us?" He sits down. The internist's able to get him a chair, and he sits down and starts telling the intern like the history that he knows.
No One Told Her
The intern is able to figure out that this patient had been to see a nephrologist a few weeks ago for her kidney condition, and we're not sure what this kidney condition is, but it was bad enough, at least, to get her into a nephrologist. The nephrologist had ordered some blood tests and those blood tests had just been drawn at our county clinic, at the outpatient center, a couple days ago.
So the intern logs into the computer, and at the time, this is like the early 2000s, so we don't have like a sophisticated EMR or anything, but at least we have access to labs and radiology results. The intern goes over the computer and looks her up, and her potassium was 8 like two or three days ago, and that's like a super-high, life-threatening level for potassium. She's hyperkalemic and nothing had been done about this critically high, lethal level of potassium. No one had called her. She didn't know. Her dad didn't know. Lola didn't know, and Lola doesn't have time in triage to look up people's old labs. I don't have time in the middle of a code to look up patients' old labs. I'm too busy coding her. But the intern like told me right away, so it's clear she's hyperkalemic, dangerously high potassium.
We pushed calcium. We pushed insulin, bicarb, glucose, albuterol, kayexalate at the time, all of the treatments for hyperkalemia, but absolutely nothing worked, and so it was too late.
She was dead and it was just terrible. It was absolutely horrible. She was my age. She was the nurse's age, but she's still like daddy's little girl, and he was just sitting right next to her like sobbing, and we were crying too.
I mean, god, it was just the worst case. It was the worst case, all right? I mean, I'd like to say it was the worst case in my life, except we all know that we've had plenty of other cases like that where the medical system had plenty of opportunities to help out a patient and we missed it. We missed all the opportunities and our patients suffer, and sometimes even die as a result.
Our ľֱ System Failed
This young woman didn't have to die. Our medical system had completely failed her. No one had called her about her lethal level of potassium, about this abnormal lab. No clinician at triage in the waiting room had looked it up. No one had done lab work on her. No one had drawn her blood in the waiting room despite the fact that she'd been there for three or four hours because we're not supposed to touch patients when they're in the waiting room. If they don't have a bed or a nurse assigned to them, you can't start a history, you can't start a physical, you can't start a workup. Or at least those were the regulations at that time.
We had so many opportunities to save this young woman, but no one had built a system that would do that, and no matter how good a doctor you are, you're only as good as the system you work in.
I had been debating at that time about what I wanted to do with my career after I graduated. I was debating maybe a pediatric emergency medicine fellowship, maybe an ultrasound fellowship, but I had also been thinking about an administrative fellowship that was focused on physician leadership. The goal of that fellowship was to build physician leaders who could change systems, and so this patient and a few others that I saw that year really convinced me that that was the right path for me. I decided to do that admin fellowship and really focus on becoming a physician leader.
Now I've been a medical director in a few different emergency departments. I am the chief medical officer of a group that works with about 150 different emergency departments. We put systems now into place so that something like this would never happen again.
We staff PAs and NPs, sometimes even doctors in waiting rooms, so that they can spend a little more time with the patient than a busy triage nurse can. Even if that patient doesn't have a bed and if they don't have a nurse assigned to them, those docs, those PAs can do a rapid medical evaluation.
They can look up old labs right away when the patient comes in. We can put in systems in place to draw blood right away when those patients come in. Even if they don't have a bed, even if they don't have a nurse assigned to them, we can still get their blood drawn, and that used to be a big no-no. But now, it's like it's accepted. This is how we do emergency medicine now in 2020. We have mechanisms in place for the lab to call us immediately if there's something that's terribly abnormal.
It's a new world now and we've made a lot of improvement. I'd like to think that a situation like what happened to this young woman would never happen again, but I know that these systems still aren't perfect.
I know that EDs are still overwhelmed with boarders, we're overwhelmed with behavioral health patients who are caught in limbo waiting for psych beds, and we're overwhelmed with elderly folks who are just too weak to go home but not sick enough that the hospital will take them as inpatients or even obs patients. They just sit in limbo in the ED waiting for somewhere to go.
We Have a Lot of Work to Do
There's just so many inefficiencies still in our system and we're seeing that now, especially with COVID. Our EDs are just so disrupted. The entire healthcare system is so disrupted with COVID and it's a strong reminder that we still have a lot of work to do. I guess that's my key message here to anybody who's listening to this podcast, is that it's not enough to just take care of patients at the bedside.
You really have to get involved in something bigger and COVID has really proven that. You can't just show up to work and work your shift. You have to get involved in the system. You have to work to change the system. We can't just by ourselves dramatically fix this dramatically broken healthcare system. We can't by ourselves cure the COVID pandemic, but we can teach, change our work environments piece by piece and we can slowly make that change over years, over a career. No one else is going to do that except for us. We have to step up. We have to get involved. I have to do that. You have to that. We all have to do that. We owe it to our patients.
I think medicine is a lot better now and I think that young woman probably wouldn't die in most ERs now in 2020. We would find that hyperkalemia a whole lot sooner and I think we've made a difference, but we still, I think, have a lot of work to do. I think the COVID pandemic has shown us just how much work we have to do to fix such a broken healthcare system. I want to encourage all of our audience to step up and to lead that change. It's up to all of us to do what's right for our patients.
Other stories from the At a Loss episode include "Growing Close Then Saying Goodbye" and "What Could I Have Done Differently?"
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