A big topic in medicine today is accountability. From doctors being accountable for their medical decisions, to nurses accountable for medication errors, to social services being accountable in child custody cases. I could write a book on patient accountability for their personal health (or make a movie about it). As an emergency physician, when a patient walks onto the hospital ground (“the physical campus”) legally I become accountable for a medical screening exam and to stabilize any medical emergency the patient may have. Below are some examples how accountability is a source of daily frustration for me.
    Let’s say a patient named Mr. Clinton comes in the ER and says he wants to kill himself. He tells the triage nurse he ‘thinks about it” and thus the process of a mental health evaluation begins. This often involves hours in the ER getting blood work (legally required by law), medical clearance by me (making sure these thoughts of suicide are not because the patient has a head injury, or diabetes, etc.) and then an evaluation by a mental health professional, usually a psychiatric nurse. After about four hours the patient often gets sick of being in the ER (who wouldn’t) and then says, “I want to leave.” I say, “You can’t, not until you are evaluated by a mental health professional.” They respond with, “I was just screwing around, I would never hurt myself.” Now presents a situation of accountability that is difficult for the patient and myself. The law says anyone that wants to take his or her own life (gray area here) can’t be considered mentally stable to make that decision. Thus they can’t be trusted to be allowed to leave the ER, even if they say they are not going to harm them self. If I trust them, and they do harm to themselves, then in court I hear, “The patient wasn’t capable of making the decision of their own personal safety.” If I make them stay, they patient fells that their basic rights of free choice have been violated. The patient is suddenly in a kind of medico legal Catch-22.  This often becomes a nightmare in the ER to say the least.
    Another patient, Ms. Obama, comes into the ER with a painful and swollen left arm after having surgery two days previously for a broken elbow. I quickly make the clinical diagnosis of a Compartment Syndrome, a limb threatening build up of pressure in part of the inner structures of the arm that can cause loss of blood flow and thus quickly killing tissue and muscles. If not treated promptly, then Ms. O will loose her arm. Now I am accountable to get this patient treatment (surgery) in a prompt manner, and rightly so. I call the surgeon, Dr. X who just fixed the patient’s arm but he is in the Operating Room and can’t get to the patient for a few hours. I then call the on-call Orthopedist, Dr. Z, to come and see the patient, who says “That is Dr. X’s patient and he should take the patient back to surgery.” To complicate this, Dr. X is in a hospital nearly an hour away (where the patient had surgery) and the hospital I am working in doesn’t do a lot of complicated surgeries. I then call back Dr. X who now isn’t available to take my call.
    Next I scream. Then I call a third doctor, Dr. Z, in a third hospital. She finally steps up and accepts the patient to her hospital that is over an hour away and two hours from where the patient lives. Not ideal for the patient to say the least.
    Complicated cases, especially ones that have already been addressed by another physician, are sources of stress. To redo, undo or take another approach on a patient after the fact, is not a great situation. Some of us remained focused on the task by remembering to do what is right for the patient. This simple rule is easy to forget when it is buried under the weight of legal, logistical and economical concerns. Thus the reality has become; responsibility of healthcare professionals extends much further than the simple care of the patient.