Teach? Just Let Me Sleep!

I was on-call a few nights ago and I received a message from “Call-Transfer” at such an unholy hour of the night. I fumbled to reach for the phone in the dark and tried to shake myself off from sleep. It was a little past 1:00 AM.

“Call-Transfer” is our health-system call center (similar to the call centers that studded Manila) that handle all requests from other outlying hospitals and physicians to transfer their patients that they believe are so complicated to handle in their local institutions. These kind of patients they believed are better served in our tertiary, level-one trauma center, and academic hospital.

Most of the time, when I received these kind of calls they would like to transfer some kind of a “train-wreck,” a term we use for very sick patient with not just one but multiple problems. Usually they are intubated and on ventilator, or in critical cardiac failure, or in shock.

Frequently these patients will be fetched by our air-ambulance (helicopter), and would arrive after 30 to 45 minutes after I approved to accept them. Though almost 100 % of the time we consent for these transfers, except if there are no more available beds in our ICU. If the weather is too dangerous for the helicopter to fly, then they would be transferred by land ambulance and would arrive in our institution after about an hour to two hours depending on how far they are. Sometimes, we would receive a patient from more than 100 miles away.

I returned the call to the Call-Transfer and was soon connected to the Emergency Room (ER) of the outlying hospital. The ER doctor started to give me the history over the phone of the patient they are treating – a young volunteer firefighter who was fighting a brush fire for a few hours, and was brought to their hospital due to exhaustion, difficulty breathing and headache. My dreamy mind started to paint several different scenarios in my thoughts on why they would want to transfer this patient……..

Maybe the patient succumbed to smoke inhalation and was in respiratory failure and was intubated and required ventilator. Maybe he had airway thermal burns that requires me to do bronchoscopy (a procedure where a long flexible scope is inserted into the nose or mouth and down into the throat thru the vocal cords, and into the trachea and bronchial tubes, to directly visualize the upper and lower airways) to determine how extensive is the burn. Maybe he had significant smoke inhalation and suffered carbon monoxide poisoning and needed to be treated in our hyperbaric chamber (a pressurized chamber where patient is placed and subjected to 2-3 atmospheric pressure with 100% oxygen, like diving in a submarine, to eliminate the carbon monoxide in the body rapidly to prevent long-term neurologic sequelae). Maybe……

As the ER physician gave me more details of the history of the patient, it was nothing of the different scenarios I imagined. The patient was awake, alert and is not in severe respiratory compromise. In fact, he was even feeling better after several minutes in the emergency room with the application of supplemental oxygen by mask. His carboxyhemoglobin (carbon monoxide level in blood) is less than 10 %. A 20-25% or higher is dangerous and definitely need intervention, but less than 10% is usually insignificant.

I told them then, that I don’t think the patient needs to be transferred, and I don’t even think he needs to be admitted in the hospital. He just needed to be on supplemental oxygen for an hour or so and then can be released.

I was glad that I can go back to sleep and that I don’t need to leave home and drive back to the hospital. But before I can hang-up the phone, the ED physician told me that he was a senior resident, a doctor-in-training, who was moonlighting in that emergency room. He asked me what were the “teaching points” in this case.

“Are you kidding me? Do you have any idea what time of day it is?!!” Maybe that was my first thought, but that was not what I said. For I obliged, and was able to muster a few teaching points about carbon monoxide poisoning to this young physician even in my half-awake brain.

I know I was in that situation before. And I am thankful for all the teachers and instructors that gave their time and effort to teach and guide me. If it was not for them, I would not be where I am now. Now it is my turn to do the same. That is one reason I practice in a teaching hospital.

I laid awake for more than an hour afterwards and cannot get back to sleep after I hung-up the phone. Darn! So much for teaching points.

(*image from here)