Almost exactly a year ago, I wrote up a post
about giving a verbal handoff report in a “big room.” A couple of calls from this week got me to
thinking about handoff reports again.
Specifically, I was thinking about the location where I give a handoff
report to the receiving nurse.
The first call out of the chute, first thing in the morning,
so early it was before I even got a cup of coffee, was a leftover night call
that needed to be transported. When we
got the patient to the hospital, we moved her to the bed, got her settled, and I
asked the nurse to go out into the hallway for the report.
“Sally, there, is 36 years old. She absolutely swears that she is only high
on life and is positive that she isn’t high on meth. Looking at her tweaking* and scratching the
imaginary bugs off her arms, I am unsure how true that claim is - but I will
leave you to come to your own conclusion.
No meds, history, or allergies.
BP one-forty over ninety and a pulse of one-ten. Anything else I can do for you?”
The next call was to a clinic to transport a hypertensive patient
to the hospital. When we got to the
hospital, I put the ambulance pram next to the hospital bed and asked the
patient to move himself over. I stood
behind him, at the head of the bed, and waved to the nurse. When I got her attention, I silently made the
“watch this” sign by pointing at both of my eyes and then pointed at the
patient. The patient moved to the
hospital bed using both arms to lift his weight and swinging his butt from one bed to the other. The
admissions clerk asked to see his ID, and the patient fished it out of his left
front pocket and I asked the nurse to step
out into the hall for the report.
“Jimmy, there, is math-years-old from 1962 and went to the
clinic to get a lisinopril script filled.
He ran out two days ago and needed some more. The clinic found his pressure to be pretty
high, with left arm weakness and blurry left vision, so they called me. When formally tested, like with the
Cincinnati tests and all, he does indeed have left arm drift.
You saw his arm strength, though, when he moved from bed to bed. Plus he dug his wallet out of his pocket
pretty easily with his left hand. So the
clinic doc had some questions about how much of this is a factitious thing, and I
see his point. But on the other hand, he
does have a BP of two-twenty over one-thirty, so there is that. That’s not factitious. Heart rate of eighty-eight, sinus without ST or T changes or ectopy. Along with the lisinopril he hasn’t been
taking, there is Keppra that he has been taking. Anything else I can answer for you?”
The last patient of the day was under arrest. After moving the patient from pram to bed, I
asked the nurse (and doctor, this time) to step out into the hall for the
report. “Seventeen year old male, was
supposedly seen by the cops selling drugs.
There was a short foot chase and the cops say that he swallowed a bunch
of baggies while running. The end of the
chase seems to have been about as gentle as a chase can be ended – the cops say they didn't whoop him and he says he
wasn’t hurt. He denies selling or
swallowing anything, and was refusing all treatment. He is under arrest, though, with a pressure
of 130 palpated and a heart rate that went from one-thirty right after the
chase down to the nineties now.
Secondary exam is all normal and he denies meds, history, and
allergies.”
Several other calls went without issue that day. Patients were treated and handoff reports
given. All the other reports that I gave
that day – a dude who was trying to figure out why his can of bug killer wasn’t
working so he accidentally sprayed it into his eyes, a non-specific vague chest
discomfort patient, a guy with pancreatitis who had a belly ache, and a couple of car crash victims with minor pain complaints – all
heard my handoff report. One of the car
crash patients disagreed with my description of her dust-transfer accident as "minor." That’s fine – patients can correct anything I
have wrong with the nurse after I am done, and I tell them so. But I started thinking about why I decided to
give some handoffs inside the hospital room and others outside the patient’s
presence. Why did I give three reports outside of the patient's presence?
Maybe I think too much about the details of my job.
I considered how I would feel if the paramedics dropped me
off and then whispered out in the hall with the nurse, glancing at me over
their shoulders, gesturing, and laughing.
Even if the medic and nurse were laughing about something completely
separate from me and my case, how would I know that? Which got me to thinking about when it is
appropriate to give a “secret” report. I
mean, the meth chick knew I thought she took meth. That wasn’t a secret. She knew she was under arrest. The hypertensive guy could have heard what I
thought and corrected anything I had wrong.
I misunderstand things all the time.
The arrested kid knew he was arrested and knew that the cops accused him
of swallowing little tiny baggies.
Nothing here was secret. Why did
I move out into the hall for those reports?
It reminded me of when I was in the hospital for a night
after an appendectomy a few years ago.
In the morning after my surgery, my surgeon and a load of residents
and interns came into my room for rounds.
One of the residents (probably the one who actually did the surgery) gave the
group a report. Questions were asked and answered. Several of them took
turns examining my belly. It wasn’t
insulting or frightening. It was nice to
hear their thoughts and the plan for my discharge.
I decided that I need to move to the hall less often when
giving reports. Patients deserve to hear
the handoff report that involves them. I
am sure there should be exceptions. Each
decision needs to be evaluated for costs and benefits. That is true for everything from medication administration to handoff location. But for the most part, I have decided to talk
about patients right in front of them whenever possible. I can’t think of a whole lot of cases in
which my handoff should be secret from the involved patient.
Can you? What are
some examples of cases in which the patient shouldn’t hear the details of their
handoff report?
*As an aside, is there a medical term for “tweaking”? You know, shakes and tremors with the
constant need for movement, but trying to hide it – resulting in the
stereotypical meth dance tweakiness.
What is the medical description for that?
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