An elderly lady presented to an academic emergency department with a syncopal episode in her retirement residence. She has just been discharged from the same hospital following a subdural/subarachanoid hematoma sustained earlier that month. After receiving both neurosurgical and medical management, and convalescing as an inpatient, she was returned to the retirement facility. Upon arrival from the retirement facility a CT head shows further evolution of the intracranial bleed, an ECG demonstrates ST elevation and bloodwork indicates rhabdomyolysis from the fall. The Neurosurgery team has nothing to offer further and refuses to be admitting MRP. The cardiology service attributes the ST elevation to intracranial pathology as there is no chest pain prodrome and refuses to be the admitting MRP. The medical ward refuses to assume care either as there have been prior referrals made to Neurosurgery and Cardiology who should, in their opinion, assess the patient. As commonly happens in the ED, we have multiple services able to care for a patient, and yet they all sign off, leaving you a very sick patient who cannot be discharged and needs an inpatient team that you cannot seem to convince. What do you do?
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This case frustrates me because this patient’s disposition is very obvious – she needs to be admitted. Even if she felt like a million bucks after her fainting episode, I can’t see a reasonable discharge from the ED to a RETIREMENT home with the combination of a worsened intracranial bleed, incompletely investigated potentially ischemic ECG changes, and rhabdomyolysis. I can see the frustration from the inpatient services point of view as well – perhaps there is no neurosurgical intervention that can be offered, and perhaps cardiology can brush the ST elevations off to intracranial pathology; however I would be hard-pressed as the emergency physician to accept an “informal phone consult” for these potentially serious issues. I would do the following:
1) Request both neurosurgery and cardiology to provide a formal consultation in the ED
2) Ask medicine to admit the patient and make them aware that the specialty consults are pending
At the end of the day, all she might need is a little physiotherapy and discharge planning. But that is not going to be sorted out in the ED given the number of her acute issues. Interestingly, if I was working at a remote centre where I could admit the patient myself I would just do so and lessen the headache…
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I agree with Chris… Would at least ask cardiology to come and assess her. Although it does seem that medicine can be a “dumping ground” for patients like this, at this point she does have undifferentiated syncope (could be related to bleed but could still also be cardiac etc.). I think it IS an appropriate consult for them with specialty consults that can be done by ED doc to help facilitate.
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