BLOG: An embarrassing encounter in the emergency department
For 3 days last week, both of our junior fellows have been attending the annual American Association of Clinical Endocrinology Endocrine University educational program.
Our fellowship program encompasses three fellows, two junior fellows and one senior fellow, but our senior fellow has just graduated, being an off-cycle trainee.
That meant that we, the teaching attendings, would act as first-line responders receiving pages from the hospital for new consults, various calls about other patients seen prior and followed, and pages from the after-hours answering service about patients’ urgent requests and urgent questions.
I was on-call last week so it was I who did all of the above. And, I haven't done that for a long time, and I am not good in EPIC for writing consult notes, ordering labs, medications, etc. This 3-days call stretch was been extremely busy.
Last Thursday was my non-clinic day — luckily. I had planned to sit in the academic office to finish numerous patient-related and administrative works. Instead, I spent most of the afternoon in one hospital: three new consults, six follow-up hospital encounters, additional pages from hospital nurses and other miscellaneous pages.
And an additional encounter in the ER: the embarrassing encounter.
I got the page seen in the figure: Consult #3, in the ED room C38. A middle-aged woman with hypercalcemia and hyperparathyroidism.
I understood that the patient had moderately severe hypercalcemia (calcium about 13 mg/dL) and metabolic encephalopathy. So, an hour later, I went to the ED. It is huge with more than 150 beds. I went into room C38. The patient was indeed confused with her husband at the bedside. So, he answered for her: Her age and the altered mental status presentation fit the description of the consult.
I started: “Are Mrs. So and So?”
She and husband said: “Yes.”
I introduced myself.
I then took a thorough history: “Are you aware you had high calcium prior?”
The husband was answering, while the patient was intermittently mumbling.
“No.”
And the husband added: “What you are saying is news to us. Nobody in the ED told us about a high calcium. They just took blood sample a while ago. They have paged the stroke team and they will come soon.”
I did not pay attention to these confusing pieces of history. Something was not adding up, but I kept going. I finished the history and did a thorough and concise physical exam. It was a very confusing ordeal of history taking; I got lost, and so did the husband. The patient did not have much of a clue in view of the altered mental status.
But then I wondered: Why did the husband say that they were suspecting a stroke and they were calling the stroke team. Really? I said to myself. But why stroke? This altered mental status is logically explainable by hypercalcemic encephalopathy.
The husband kept saying that no one had told them about a high calcium level. But my understanding was that that patient had pre-existing, diagnosed hypercalcemia with known primary hyperparathyroidism and that she was followed by an endocrinologist and was managed conservatively, since er calcium has stayed just above normal.
Total confusion.
I left room C38 telling the patient and husband that I would follow the results of the ultrasound and would start high-rate intravenous normal saline and monitor the calcium. They did not understand why.
I got out of the room and asked the RN on the counter: “So, what was the patient’s ionized calcium?”
She asked which patient. I said room C38. She asked what specialty I was, and I said endocrinology with desperation!
“But why the endocrine consult, and why are you asking about calcium? Labs are not back yet,” the nurse said.
I said, “But what about the calcium?”
The nurse was also confused.
“So, which patient are you asking about”?
I said, “Patient So and So in C38.”
Then it occurred to the nurse: “Doctor, you saw the wrong patient. The patient you are talking about was moved up to the floor about an hour ago.”
I said, “Oh My God!”
I was so embarrassed, but then I almost let out a laugh!
I was overwhelmed with all the pages and the consults, but here I was seeing a patient by error for at least half an hour spent when I needed all my time to finish the hospital work.
But it was what it was. I went to room C38 and I apologized to the patient and her husband for the inconvenience. I wished the patient the best. And, then I went upstairs to see the who was the original occupier of ED room C38, whom I was supposed to see as consult #3. Sure enough, she was about same age as the wrong patient and also with neurological symptoms similar to those of the wrong patient. But after more than 12 hours of aggressive fluid therapy she was less confused. She confirmed her known case of primary hyperparathyroidism and hypercalcemia.
One last point: When I went back into room C38 to clarify the situation to the wrong patient and her husband, I asked the husband why he said yes when I asked if the patient was first and last name.
He said: “I am hard of hearing and did not hear clearly, and just assumed that you were saying her name.” I guess that also because of my Covid mask and my accent, the miscommunication occurred when I asked the patient’s name.
Though this encounter was embarrassing and confusing, I am grateful that no harm has resulted from this mistaken identity encounter. And, it surely is a teachable moment.
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