Decision-making in a community emergency medicine department.
It is an already busy Saturday morning in my community hospital, and the following three patients are sitting in rooms 2, 3, and 4, directly in my line of sight…
2房間：A 59-year-old African American female presents for evaluation of altered mental status. She has a history of metastatic squamous cell carcinoma of the anus, status post chemotherapy and radiation therapy. She originally presented to her outpatient cancer center today for another round of chemotherapy and was found to be very drowsy. The oncologist called the ambulance for transport to the ER.
Upon arrival, the patient is confused and her daughter is bedside to report that she has been confused for the last 24 hours and has stopped eating and drinking. Daughter also reports that her mother has a history of a thoraco-abdominal aortic aneurysm status post repair many years ago. Physical exam reveals an ill-appearing woman who thinks it’s 2015. Her systolic blood pressure is in the 80s.
Room 3:A 61-year-old white female with metastatic lung cancer to her liver and biliary system, presents from her regular scheduled outpatient appointment at the cancer center for abnormal labs.
Her hemoglobin is 6.4 (8.8 three days ago), platelets 42, INR 1.0, BP in the ER is 114/74. She has grossly positive bloody stools on rectal exam. BP is 126/78. She has no other complaints except for the two days of bloody stools that she wasnot要提到她的門診cancer doctor today.
Room 4:一名66歲的白人男性在今天早上兩天以前的黑凳子，剛剛從醫院出院後兩天前在胸部主動脈瘤的TEVAR手術後，被上胃腸杆菌的患者複雜化，發現有十二指腸燈泡的血管病，在EGD燒灼，在阿司匹林和Plavix上排出。在ER中的直腸檢查揭示了噴射黑糞便，血液性陽性。實驗室：HGB 7.9（從他的排放血紅蛋白6兩天前。），INR 1.2，血小板225，BP 144/85。
The community medicine factor: My community hospital only has two units of platelets for the entire hospital, at any given time. Again, I said, two!
Question: So, who gets the platelets?
My decision-making process:
First, I made a phone call to my hospital blood bank to confirm that we had our usual two units of platelets. We did. I then asked the nice lady in the blood bank; how do we get more. She informed me that the hospital has an agreement with another “local” blood bank who will “rush” more products to our hospital if needed. This process would take three hours. I explained my situation and asked if she could mobilize more platelets. She agreed.
Room 3:She was actively having several bloody bowel movements in the ER, which we confirmed by direct observation of the toilet bowl. However, her BP remained stable. I elected to start with two Units of PRBC, keeping in mind she would eventually need platelets as well.
2房間：This woman was my most unstable patient and rapidly deteriorating in front of me. I called and spoke to the general surgeon, who quickly saw her and mobilized the operating room. We agreed on thawing the only available two units of platelets for this patient and having the platelets meet the patient in the OR, to be transfused in the OR.
Outcome:Only one unit of platelets was used for my patient who went to the operating room. After touching base with the surgeon, she was recovering well in the PACU. The second unit of platelets then went to my Room 3.
Did I also mention my hospital did not have a GI doctor on call this Saturday?! I had to arrange for the transfer of patients in rooms 3 and 4 to another facility, to be seen and scoped by a gastroenterologist.
Decision-making in a community emergency medicine department can vastly differ from that at a large academic institution with many resources and specialists available at the click of a button or a dial of a phone.
Often, we are creating treatment plans with knowledge of how quickly a disease process evolves in conjunction with resources available immediately versus resources available only after transfer to an institution with a higher level of care. ER physicians must be constantly up to date on their own hospital and transfer processes, as well as having knowledge of neighboring institutions and their resources.