The Emergency Department is the place where most diagnoses are made.
Quite frequently, patients in the Emergency Department will be admitted without a firm diagnosis. Not being able to give an exact diagnosis is not in itself a failure of management. It is a matter of simply describing the patient’s current illnesses
I’ve always emphasized to myself and other medical officers to clearly state their diagnosis/impression. Lets face it, how often do you think doctors in the ward will read the whole documentation once patients have been admitted? Most of time they will just read our Impression: e.g., Acute Inferior MI.
By not reading the whole document, the team upstairs will not know some of the important things (why the diagnosis was made, findings, management and etc.) that happened in the Emergency Department.
Therefore during their morning rounds, the consultants will not be fully informed regarding the initial management and will assume most of the patients’ management has been done by their team rather than otherwise.
Once, I encountered a cardiologist that did not realize most patients with AMI in his center received their thrombolytic agent in the ED (without the presence of the cardiology team). In fact, patients’ complications will be fully managed in the ED as needed (central venous line, arterial line, inotropes, temporary pacemaker, etc.) and yet it is presumed that these things were done by the cardiology team.
So my suggestion is simple, we spice up the only thing that we are sure the receiving team will read, i.e., The Impression.
Here are some of the examples that I have started to write during my rounds.
Suggestion #1:
Imp: Acute Inferior MI
Change to
Imp: Acute Inferior MI with right ventricular involvement complicated by acute pulmonary edema (Killip II), reperfused post-Streptokinase
Suggestion #2:
Imp: Thyphoid
Change to
Imp: Clinical Thyphoid (Awaiting serology) in view of
1) Relative bradycardia
2) Constipation preceeding diarrhea
Suggestion #3:
Imp: Septic shock secondary to pneumonia
Change to
Imp:
1) Septic shock secondary to pneumonia (currently on single inotrope, SvO2 improving)
2) Intubated for respiratory distress with difficult airway (Comark Lehand III)
Suggestion #4:
Imp: AGE with severe dehydration
Change to
Imp:
1) AGE with severe dehydration - failed outpatient therapy
2) Hypokalemia secondary to 1 (K correction started)
3) Lactic acidosis secondary to 1 (improved after initial fluid bolus)
Suggestion #5:
Imp: MVA with left femur fracture
Change to
Imp:
1) Alleged MVA with close fracture of left femur
2) Complicated by Class II shock (Improve with fluid bolus and traction)
5 comments:
Yup.. agree! Sometimes the next team managing the patient will have no idea on the patient condition. During my A&E rotation, I discuss with MO medical managing the patient that has been pass to them. Asthma patient and receive mag. Sulphate.. the MO keep on saying that A&E team over treat the patient.
Un satisfy with that + I’m curious to know what actually happen to that patient, I went to the A&E registrar who manage that patient.
Than I found out that his assessment during pt presentation is severe asthma. After the management, pt stabilized and become just mild-moderate asthma…
Absolutely right my friend. But we must make sure we do not confuse our colleagues with fancy classification because most chronic ward doctors dont give a rats ass about emergency classifications of complications or disease. Do u really believe the orthopods would know what or even care abt the shock classification?? They wud be more appreciative if they knew what kinda fracture it was( ie open, close, off ended etc). I think they wud understand better if u said compensatory shock then they wud know...aaah not so bad lor! Anyway anyone who has an MVA coming with shock, pls dont give them to ortho, they wud be better off under surgery for observation.
Lastly you would argue that APO would be Killip III. Having said that as you know the killip classification just tells u the % who will die in 30 days regardless of what you do.
See you still have the ED fighting spirit the same as 4 years ago in Penang. Good on you. Hope u are well my fren. and congrats again.
Hi mate,
Look this is a great idea my friend. But to cut a long story short:
1.those chronic ward Dr dont give a rats ass abt Emergency classification. They wouldnt know what they mean anyway.
2. Best to use lay medical terms like: compensatory shock etc...
3. The ortho people dont want to know and dont know abt shock classification, not to say that the ATLS shock classification is perfect esp since it is not evidence based. There wud rather know if the fracture was open close off-ended, site etc
4. And one may argue that APO would be KILLIP III rather than II. So it is contentuos, so better just write APO or cardiogenic shock or bibasal crepitations...etc But so what, many people havent even heard of it and as u know already it only tells us how many % will die regardless of what we do in 30 days. Is it gonna change our management? not really. Well maybe tell the family and the patient that he has a 80% chance of dying (Killip IV) in 30 days.
Anyway my fren, how are things? still having the ED fighting spirit like we used to in PENANG? Congrats again my fren. U make a darn good EP.
moe
http://www.ncbi.nlm.nih.gov/pubmed/20619954
http://www.ncbi.nlm.nih.gov/pubmed/20619954
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