Welcome to season 5, episode 7 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Drs. Tamara McColl, Teresa Chan, Eve Purdy, John Eicken, Sarah Luckett-Gatopoulos, Alkarim Velji, and Brent Thoma) is pleased to welcome you to our online community of practice where we discuss the practice of academic medicine!

This month, we present a case that seems to have become a more common occurrence as patient flow has increased and hospitals must function beyond capacity. The case describes a junior resident tasked with transferring the care of a clinically deteriorating patient to another service. She unfortunately receives significant pushback resulting in no primary service taking responsibility for the patient’s care.

Check out the case and join the conversation in the comments section! We’d love to hear your thoughts on this important topic!

The Case of the Orphaned Patient

By Kaif Pardhan, MD, FRCPC

It was midday on a Sunday at a large academic teaching and trauma center. It had been a rough night with several unstable traumas and all of the consulting surgical services were playing catch up. There were now several admitted and consulted patients boarded in the emergency department, as the hospital was at 115% capacity, a phenomenon much too common these days.

Dr. Patel, one of the emergency physicians, was only a couple hours into her shift when she overheard the orthopedics off-service junior resident – who she recognized as Jenny Wu, an emergency medicine resident currently on her ortho rotation – having a long discussion over the phone with the internal medicine senior resident. While she could only hear one side of the conversation, it appeared that a patient referred to orthopedics the previous night did not have a primary orthopedic problem and, over the past several hours, had started to clinically deteriorate. The patient was still in the emergency department and easily visible from Dr. Patel’s work station. Jenny was pleading with the internal medicine team to see the patient for consideration of admission. After a long discussion, Dr. Patel watched as Jenny slammed the phone down and sighed, clearly frustrated.

“That sounded unpleasant,” said Dr. Patel, fishing for the story.

“Horrible,” she replied.

“What’s going on?” Dr. Patel asked.

Jenny dropped into one of the nursing station chairs and the story unfolded: the patient had a recent total knee arthroplasty, and presented the previous evening with joint pain and swelling, but no fever. Orthopedics was consulted for a potentially septic knee and performed a tap, which yielded minimal fluid and a lab analysis inconsistent with a septic joint. Meanwhile, the knee remained largely unchanged, despite the patient becoming increasingly unwell. She was febrile, tachycardic and without a clear source of infection. A full workup, however, had not been performed. The senior resident and staff orthopedic surgeon were in the OR and instructed Jenny to consult the medicine service for further workup and admission. Jenny felt thoroughly out of her depth, unprepared, and unqualified to tell them that this patient does not have a surgical problem. She was also concerned that something more sinister was going on: no service was taking responsibility for this patient and her care may be compromised as a result. The internal medicine team felt that the source of infection was likely the fresh surgical joint. They agreed to add the patient to their consult list, but declined admission.

“Would you like me to call your staff or the internal medicine staff and help facilitate this?” asked Dr. Patel.

“No, no, it’s my problem. I’ll take care of it. Thanks for listening to my rant.” replied Jenny as she picked herself back out of her chair and walked out of the department, clearly anxious and frustrated.

Discussion Questions

  1. If, after an appropriate work up, a service determines that a patient is not appropriate for admission to their team, but still requires admission to hospital, who is responsible for consulting the second service? Should this be a job for a junior resident?
  2. If the patient is still in the emergency department, at what point should the emergency physician mediate between two services? Or should they at all?
  3. Many hospitals have a “one way” consulting approach from the emergency department. What are the benefits and potential risks of this system?
  4. How might we create the conditions for organizations to be successful when there are disagreements between services and ensure that the patient receives the best care possible?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses 2 weeks after the case is published.

Our 2 experts for this month’s case will be:

  • Dr. Aikta Verma
  • Dr. Colm McCarthy

On May 11, 2018, we will post the curated commentary and expert responses to this case! After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary. That said, we’d love to hear from you, so please comment!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the last Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we would love for you to get involved in the MEdIC series! Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

Tamara McColl, MD FRCPC

Tamara McColl, MD FRCPC

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba