Annoying Hospital Politics

 Annoying Hospital Politics

Brian Fishman, DO, General Practice, 06:45PM Dec 21, 2012 (Medscape)

   A couple of weeks ago, I saw a young girl in the ER who came in with her husband to be evaluated for postpartum psychosis. We tend to get a lot of psychiatric patients coming through our emergency department because we have an entire floor (roughly half of our hospital) devoted to inpatient psychiatric care. This girl had a history of bipolar disorder and was 9 weeks postpartum. She was extremely depressed and hearing voices. She is normally very compliant with her medications and has a good support structure. Her husband was very attentive, and it was obvious they both cared a lot about each other. Unfortunately, that's more than I can say for a lot of the patients who come through the ER, psychiatric or otherwise. After she was evaluated, the psychiatric team adjusted her medications, and she went home.
   A couple of days ago, she came back to the ER. This time, her psychiatrist sent her in to be evaluated for neuroleptic malignant syndrome. We were a bit skeptical of the diagnosis, because it's so rare, but we did have a patient with NMS a few months back who used up our hospital's entire supply of dantrolene. Her psychiatric symptoms from her previous visit had resolved completely, but she was complaining of muscle rigidity and tremors (that were obvious on exam), skin burning, and tongue stiffness (that was obvious from a notable change in her speech from her last visit). Apparently, her CK level was elevated earlier that morning, but we didn't have the results from her doctor to confirm.
   We decided to consult with a neurologist about whether he thought she required admission to a medical floor. He was skeptical of the NMS diagnosis, but he recommended she come in for observation based on the severity of her symptoms. It's the policy of our hospital that any patient without a primary care physician be admitted under the care of one of the community physicians rather than to the hospitalist service. That way, they have a new doctor to follow up with on discharge. The hospitalist, however, just happened to be walking by to see another patient. I mentioned the case to him because I thought he might be interested. He took care of the patient with NMS a few months ago and helped me prepare the grand rounds presentation. He stopped in to see her, and he came back with a diagnosis of tardive dyskinesia. He recommended she go home with heavy hydration if her CK came back normal, but the community physican had already accepted the admission.
   A few minutes later, when he found out that she was being admitted, he got upset. He came back into the ER and had a few words with me and my attending. Since he didn't feel the patient needed to come in, he assumed that we'd gone over his head to find a different doctor to handle the admission. In reality, the admission was done before he was even aware of the patient, but there was obviously some miscommunication.
   The next morning, after some aggressive hydration and symptomatic treatment, our patient was doing much better and was eager to get home to her newborn. The attending who'd yelled at me the previous day approached me in the ER and apologized for yelling, saying that the way he reacted was unprofessional. I appreciated that he made a point of apologizing, and it was probably one of the first times I felt an attending was addressing me as a colleague rather than a student or intern.