Welcome to my final POTD of this block, and the 9th installment of “Lessons Learned from The Pitt”. Rather than focus on a singular case, I’ll end with a potpourri.
Spoilers and anguish ahead.
It is now 3pm at this ED, and the ratio of “things happening” to “time elapsed” continues to steadily increase. When the episode begins with an interrupted debrief for poor drowned Amber, followed by shots of much of the cast going through their own trauma responses (Dr. Langdon calling home, so he can hear his son’s voice, just hits different), you know that things are probably going to keep going downhill. The purpose of a debrief is to give the team a little time and space to process and recontextualize the events, identify areas of improvement within a supportive learning environment, and assess the need for further support (such as a Team Lavender consult). The facilitator (usually the attending, or other designated staff member) will gather the team members, establish that the debrief is intended to be a safe space, establish the above objectives, and then step back and nudge the conversation as needed. One of the staff (usually the team leader) will summarize the events that occurred; the rest should hit upon three areas — the “plus”, the “delta”, and the “take home”; respectively, those are the things that were done well, opportunities to improve, and learning/action items. If an official Clinical Event Debriefing form is submitted, there is an ED leadership team that will discuss those points in a biweekly meeting and try to address said action items.
Back to the episode. With 4 hours left in the shift officially (though we all know that there are 15 episodes, so something’s coming), people start to hit their breaking points. The first two are on the patient side, and both occur in the packed-like-sardines waiting room. Mr. Driscoll, the chest pain patient who has become progressively more frustrated, hostile, and racist with each episode he continues to remain in the waiting room, finally decides he’s had enough and starts leaving after a tirade. Dr. Langdon calls Driscoll out over the speaker to tell him that he would be departing “Against Medical Advice”, with risks including dropping dead from a heart attack.
The AMA conversation is important when it comes to patient safety, as well as one’s own medicolegal protection (patients who leave AMA are more likely to have a bad outcome and more likely to sue). Patient autonomy is one of the ethical cornerstones of modern medicine, and restricting an individual’s freedom of movement without justifiable cause constitutes the crime of false imprisonment — thus, (most) patients cannot be physically stopped from leaving unless they are obviously impaired/dangerous. Ideally, before that happens, the treating physician is able to have a conversation with the patient; the discussion should allow the physician to assess the patient’s capacity to make this decision (briefly, displays understanding of their current condition, demonstrates insight into the benefits of staying vs the risks of departing including specific risks incurred by the suspected disease processes, and is able to articulate an intact thought process i.e. intact judgment regarding how they came to their decision), and then take steps to mitigate harms (such as giving prescription antibiotics, outpatient follow-up, et al.). The AMA discussion also may be the last opportunity for “service recovery”, a concept from the Patient Experience world; this can be an acknowledgement of the patient’s concerns, followed by explanations of what has happened and what can be done to improve. In this case, Mr. Driscoll has actually received a workup despite being in the ED; he’s had an ECG and troponin (plus other basic labs), with repeat troponin pending — and I don’t think anyone’s had the headspace to have an actual discussion about the plan and address his concerns with an empathetic veneer.
The second waiting-room blowup is a fight between two women, instigated by one of them taking offense at being offered a mask for her coughing child, which charge nurse Dana steps into and ends with a dressing-down worthy of a standing ovation. This isn’t the time or place for a deep dive into the politics of masking, I’ll just say that droplet precautions were definitely around before 2020. The medical lesson here comes from the “fight bite” from our anti-mask perpetrator, who now has a tooth fragment lodged in her knuckle. Evaluation of such an injury should include assessment of the integrity of the joint capsule, of tendon involvement, of potential fractures, and of signs of infection (especially if presentation is delayed). Lacerations over the dorsal MCP joint should prompt a specific question about fights, as patients can sometimes be reluctant to divulge (they don’t know about the risk of severe infection leading to amputation). Treatment for the uninfected-appearing acute “fight bite” with no joint/tendon/bone involvement is copious irrigation, prophylactic antibiotics (usually augmentin 875mg/125mg PO BID x 7 days), +/- TDAP, healing by secondary intention, and close follow-up. Hand surgery should be consulted (and IV antibiotics considered) for signs of infection (usually with delayed presentation) especially if there is reason to suspect joint/tendon compromise.
Back to the resus bay, another critical patient from this episode has hyperthermia and altered mental status in the context of MDMA abuse at a music festival. Her core temperature is 107 degrees, prompting the team to begin active cooling with ice-water immersion (with goal temp of 102 to prevent overshot hypothermia), as well as high-dose benzodiazepines (to oppose the centrally-mediated MDMA-induced component of her hyperthermia, as well as to prevent shivering). Later, when the patient begins seizing, Dr. Santos suggests that the patient has hyponatremia secondary to dehydration, orders 100mL of 3% saline (would raise serum Na by 2-3, usually given x3 to achieve effect), and goes above Dr. Mohan’s head to push the saline (100ml should be given over 10-15 minutes, not a 3-second push) (can also consider 1 amp of 8.4% sodium bicarb, which is in code carts and more readily available). The seizure terminates, and it’s the first resus win for Dr. Santos until Dr. Langdon returns furious and demands to know why no one bothered to come tell him about the seizure. Dr. Mohan freezes like a deer in headlights, and Dr. Santos throws herself under the bus and gives Dr. Mohan the credit for the save — prompting Dr. Langdon to go off on her, full-on shouting at her and berating her until Dr. Robby interrupts him. This is not how one should approach giving feedback to a learner — not in public, and not with such vitriol. The goal should be to communicate areas of improvement and concrete changes that can be made. If the learner has demonstrated a problematic pattern of behavior, pull them aside and address it before it becomes such an issue that you feel the need to scream at them. And if problems persist, there are people (i.e. attendings, charge nurses) to whom one can escalate.
Though Dr. Robby's response with Dr. Langdon is also not totally appropriate, shouting at him to “shut the f*ck up” when Langdon rushes to explain himself, and dressing him down in full earshot of the rest of the ED.
The episode ends with a sucker punch, delivered by a departing Mr. Driscoll to charge nurse Dana while she's stepped outside for a break. Violence against healthcare workers is a serious problem that often goes unreported or unprosecuted. Healthcare and social services workers are at the highest risk of workplace violence compared to all other civilian industries, with over a quarter of all workers facing victimization during their career. Reasons include perceptions that this is “all part of the job”, or that patients/families should be given passes due to their stress, or that they'll face censure for speaking up. Solutions include building a culture of safety and developing institutional policies. In the acute setting, early retreat and involvement of security are the best ways to protect oneself.
That's all from me today. I hope you've enjoyed this series because I've certainly had a blast writing each one!