Getting your Trinity Audio player ready...

A patient in the emergency room of a training hospital required admission for a drug overdose. The ER doctor called the third-year resident who admitted the patient and wrote admission orders.

The resident was advised that Dr. Smith, the staff doctor (supervisory physician) listed as on-call for the emergency room, was out of town but had arranged for Dr. Jones to take his place. The resident stated he discussed the case with Dr. Jones over the telephone and wrote additional orders for the patient according to guidance he had received from that discussion.

The following morning, the patient was transferred to another hospital when his condition worsened. He was later diagnosed with an esophageal perforation. Because they had missed that diagnosis at the first facility, an investigation ensued.

When questioned about the matter, Dr. Jones claimed he never agreed to take call in place of Dr. Smith. The resident disputed that, stating he had discussed the case with Dr. Jones and believed he was certainly responsible.

Although the transfer order was recorded by the nurse as having been approved by Dr. Jones, Dr. Jones adamantly denied that as well. There was no entry in the chart by Dr. Jones, no hard-copy evidence of his participation in the patient’s care.

Who was the supervisory staff physician in the case? It could not have been Dr. Smith. He was out of town.

Yet Dr. Smith was on the schedule as the on-call physician for the emergency room, not Dr. Jones. If he had, in fact, agreed to take call, as was the understanding of the residents, there was no formal documentation of the agreement between Drs. Smith and Jones.

The issue was never completely resolved.

Dr. Witherspoon Says:

Not knowin’ who’s responsible for what is a dangerous situation for any hospital, let alone a teaching institution. My first criticism concerns how they’re doing business at this place.

Call responsibility for the emergency room should be buttoned down in an iron-clad policy. Like the officer of the deck on the high seas, when you’re relieved of duty, it must be a formal process that leaves no room for ambiguity. There’s no question about who’s got the con when a ship’s underway. Can’t be any other way.

Likewise, there should be no question about who’s on call for the various services covering the ER. Sure, you can switch around, as long as everybody’s in agreement and it’s indisputably documented. The bottom line is, there’s a name on the call list and when you’re on, you’re on. Period.

If Smith and Jones just had an informal agreement with no documentation of that, no formal means of codifying that transfer of responsibility, then they’re both at fault. When the missed diagnosis was discovered, the residents got caught in the middle of a game of denial and ended up shouldering the responsibility on their own. Sad state of affairs.

Our patients may not appreciate the significance of this issue, but emergency room coverage is an enormous problem in pledicine, owing to several factors. The health insurance crisis has pushed more and more patients to rely on the ER as their only means of obtaining treatment. They can’t be turned away. Because the number of uninsured patients is increasing at an alarming rate, the ER numbers are becoming overwhelming.

Doctors can only do so much. An orthopedic surgeon spent all night putting together a motorcycle accident victim with multiple fractures. By morning he was exhausted. An internist brought in a diabetic with a blood sugar of almost a thousand, nearly tens times normal, who spent a week in the intensive care unit. Same with patients with hypertensive crises, sepsis, you name it.

Nobody got a dime.

Pure liability, the doctors say.

Don’t shoot the messenger. I’m just laying out how things are. Despite our difficulties, we still can’t neglect the fundamentals. An iron-clad policy for responsibility is essential. It has to be and, if hospitals need to tighten up their by-laws in these days of adversity, then that’s what they must do.

When you’re on, you’re on.

J. M. MACDAVID M.D. also known locally as Dr. John Kona can be contacted at WitherspoonInstitute23@gmail.com or you can visit his website at https://www.docwitherspoon.org/.