This is my column in this month’s Emergency Medicine News.  The online version isn’t up yet at www.em-news.com.  But when it is, I’ll post the link there as well.

Have a great day!

Edwin

Last night, a sick child and his brother who were in our emergency department asked for crayons and a coloring book.  On the surface, it seemed like a great idea.  You know, distract them occupy them while the medical issues were managed.  But before the nurse went into the room to dispense the colored wonders, I did what any modern, caring, careful physician would do.  I instituted a ‘time-out.’

‘Now, are these the crayons you’re taking?  Are these the children who want to color?  Will this be the room in which the coloring children color?  Is this the right coloring book?’  Fortunately, the nurse’s answer to every question was ‘yes,’ so there were no Crayola ‘never events.’  There was, perhaps, so me whispered profanity directed at this physician.  Still, another life was saved by cautious use of yet another rule.  Hallelujah!

Here we are, in the era of the ‘time-out.’  For the non-medical who pick this up at a family member’s house, the time-out is a way to ensure that surgical patients don’t get the wrong procedure.  Hernia repairs don’t turn into vasectomies, regulation breasts aren’t accidentally augmented or removed, normal legs aren’t amputated as the diseased leg watches in relief.  I joke, but these are very serious issues.  Surgical errors like this have happened, and the results are tragic.

So, over the years, surgeons have developed systems.  For instance, they would write, in indelible marker, things like ‘right and wrong,’ or ‘yes and no,’ on the appropriate appendages of their surgical patients.  Procedures have been put in place to ensure that grave errors don’t occur while patients, who might otherwise justly and appropriately protest, are snoozing under general anesthesia.  This set of procedures is often called a ‘time-out.’  A fine idea, except that some surgeons I know already had good safety measures in place, and the updated plans made things more confusing.  However, the idea of making certain a procedure is done 1) to the right person and 2) in the right location, is a sound one.

However, the concept has trickled down, as so many things do, to the emergency department.  Now, before doing things like incision and drainage of abscesses, sedations and joint reductions or lumbar punctures, we’re supposed to do a time-out.

The thing is, our patients aren’t like surgical patients. Come at them with a large needle or scalpel and they’re apt to say, ‘what are you doing?  I’m here for my blood pressure!’  Offer to stick a needle in their back for spinal tap and you’ll be greeted with, ‘man, all I want is some Lortab and a work excuse!’

There’s a fundamental difference between what we do and what happens in the operating room.  When we emergently shove a chest tube in a dying accident victim, it’s evident that this is the dying trauma victim.  Put a chest tube in the non-chest trauma patient and she might say, ‘so does this mean I’m not pregnant?’  And it’s considerably harder to drain a bulging, pus-filled abscess in a surprised person who doesn’t have a pus-filled, bulging abscess.

Nevertheless, doctors being the fundamental idiots we are deemed to be, we have been rescued from cataclysm by legions of brilliant rule-makers, consultants and other assorted carpet-walking members of the human race.  Their extensive ‘time-out’ procedures are now being put in place in emergency rooms all over the country.  It goes roughly like this:

Before beginning the procedure, the nurse asks the patient his name and birth-date.  The patient responds with a sigh ‘for the third time, I’m Robert Heinz, 2-19-54.’  Nurse proceeds:  ‘And we are draining fluid from your knee, correct?’  Patient responds:  ‘do you see how swollen it is?’  Nurse looks exasperated (because he or she doesn’t like it any more than the physician).  Nurse looks at doctor, ‘Do you have all of your necessary equipment.’  Doctor asks:  ‘Do you have the chainsaw, block-and-tackle and donor brain?’  Patient laughs, nurse laughs, procedure…proceeds.

It’s all more of the same thing that bogs down our departments and reduces efficiency.  We were really good at this sort of thing.  I suspect that emergency departments were not the places where catastrophic errors were resulting in life-shattering accidental surgeries.

But, just like health reform, no one is really asking regular gals and guys who work in the real world.  Allegedly smarter people are looking at what we do and telling us how to do it better, without darkening the doors of our already overwhelmed national safety-net.

The ‘time-out’ joints a long list of speed-bumps, like every imaginable screening assessment asked of our nurses (nutrition, abuse, immunization, illicit drug and alcohol), the home-medication reconciliation form, the onerous restraint documentation form and the ever popular ‘one on one’ observation required for everyone who even thinks the word ‘suicide.’

Though no one believes it, we were doing a jam-up job before improving ED efficiency became a career option. And though accidents happened, we were remarkably careful and successful for a group of providers tasked with doing everything, for everyone, all the time for free.

So we’re stuck with the time-out.  Like every ‘good idea’ it probably won’t go away until a meteor wipes out life on earth (I mean, productive, healthy, functional life…some of our patients will thrive in the post-apocalypse).

But before it does, we’ll have to ask some final questions.  ‘What’s your name and birthday?  Is this the meteor that’s going to kill you?  Do you have all of the equipment necessary to be obliterated?’

Then we can rest in peace.

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