‘Oh what a tangled web we weave when we try to transfer a patient.’
This is a column of mine from Emergency Medicine News, from 2018. My monthly column is titled ‘Life in Emergistan.’ In fact, I’m in my 19th year of writing that column!
Because the columns are purchased by the magazine I’m not supposed to post them (except as links) for a year. So I’m catching up.
Few things make a shift seem longer, or more painful, than the complicated transfer. If you work in small-town or rural America, you understand what I mean. Our colleagues in large teaching centers have enormous stresses and do heroic work. They accept transfers all day and night; transfers to specialists which they in the ED will frequently end up seeing anyway (since emergency physicians are everyone’s interns).
However, those who work in large centers miss out on the singular delight of making the call to transfer those patients. And for those whose entire careers, from residency to faculty, have been in large hospitals, this is a delight you’ve really missed.
I will attempt to recount it for the reader, in the style of a play.
Setting: Dr. Leap is calling to transfer a critically ill young woman from Tiny Memorial Hospital to the bright, shiny world of Massive Regional Hospital.
Having no secretary, and since all the nurses have important clinical duties to attend to, Dr. Leap picks up the phone, his styrofoam cup of tea close at hand, his phone playing choral music on Pandora to soothe his frazzled spirit. (Don’t judge, it’s my thing.)
Brandi: Hi, this is Brandi on the transfer line at MRH. Is this an Emergency?
Dr. Leap: Well, it’s complicated. It’s an unresponsive 25 year old female with stroke-like symptoms. She was found at home and intubated by EMS. No apparent trauma. She appears to have a small right frontal subarachnoid hemorrhage. She’s also 28 weeks pregnant. I need an accepting physician to transfer her. She will require several services most likely. (Dr. Leap sighs, knowing what this portends.)
Brandi: So do you need neurology?
Dr. Leap: Actually probably neurosurgery.
Brandi: (Obtains demographics) Just so you’ll know, we’re completely full except for stroke and STEMI. But I’ll connect you with Dr. Evans of neurosurgery.
Dr. Leap: tells story again (emphasizing things that make neurosurgeons care).
Dr. Evans: Well, we aren’t going to do anything with that tonight. She probably needs to go to the hospitalist service, in the ICU.
Brandi: I’ll get Dr. Cannon, he’s the medicine resident.
Dr. Leap: (tells story including all required numbers and porcelain levels for internal medicine report).
Dr. Cannon: Well I’m internal medicine. I can’t take that without an OB consult. Or neurology consult. And I haven’t delivered a baby in years.
Dr. Leap: she’s not exactly in labor…
Dr. Cannon: well, still…
Brandi: I’ll get OB. It’s Dr. Andrews-Guttman.
Dr. Leap: tells story.
Dr. Andrews-Guttman: Wow, that’s terrible! But she needs neurology. I mean, we can manage the baby part, but not the neuro issues.
Brandi: I’ll get the NP on call for neurology.
Dr Leap: tells story again. (Dr. Leap notes as an aside that NP’s don’t have last names).
Susan, NP: I’ll run it past my staff, but we don’t accept any transfers or do any admits. What did neurosurgery say? It sounds neurosurgical.
Dr. Leap: they said to call the hospitalist. Who said to call OB. Who said to call you.
Susan, NP: Well I guess that makes sense. OB didn’t want to accept her?
Dr. Leap: (Ever so snarky by now.) They only take care of baby brains…
Brandi: Shall I call critical care? It’s Dr. Morgan. She’s very nice.
Dr. Leap: considering slitting wrists as patients pile up. ‘Yes please.’ Dr. Leap tells story again. (He dares not leave his post even to urinate.)
Dr. Morgan: I’m sorry to hear that! Of course I’ll manage the critical care side, but what did neurosurgery say?
Dr. Leap: They said she needs a hospitalist.
Dr. Morgan: They don’t admit to the ICU.
Dr. Leap: So can I send her to you?
Dr. Morgan: Are neurology and OB planning to see her?
Dr. Leap: (Face on desk, mumbling now.) Yes. they just can’t accept her in transfer.
Dr. Morgan: I’d love to take her, but I have no ICU beds. Can you keep her there over-night? I’ll call you when a bed’s open. Just put her in your ICU and have your neurologist see her.
Dr. Leap: I don’t have any ICU beds either. And I don’t have a neurologist.
Brandi: We can call you in the morning when beds open up. Is that OK?
Dr. Leap: Sure. Calls Southern Teaching Hospital, 75 miles in the opposite direction.
Rick: Hi, this is Rick, the transfer coordinator at STH. Is this an Emergency?
Dr. Leap: Repeats story again with similar cast of characters. Patient finally transferred six hours after first call.
Dr. Leap binge eats King Don chocolate cakes after shift to clear head.
Rinse, repeat next day.
A few salient points:
1) Everybody is overwhelmed, at big centers and small. Not trying to make anyone the villain here. In fact, I hate sending things to busy centers because I’ve been there. It is, however, almost comical when you’ve told the same story six times and just one other person needs to hear it ‘from the top’ again.
2) There has to be a way we can streamline communication and patient acceptance (or rejection). Last time I checked, doctors can read summaries as surely as they can listen to them. Heck, in an age of constant texting, younger doctors may prefer it!
3) Hospitals, small and large, need to consider these situations when staffing. Number of patients seen per shift isn’t the only metric that matters. Transfers, both sending and receiving, are complicated, dangerous and extraordinarily time-consuming. This is especially so in small hospitals with little to no back-up. When docs and nurses are on the phone and at the desk, completing the tomes of papers needed for a transfer, they can’t see sick people. In fact, they’re trying to send very sick people to other places with more resources. Dear administrators: have mercy. We chart non-stop in order to document and bill. We need help so that we can do all of this in the most thorough but efficient way possible.