(You can tell I’m on call, I’m blogging copiously again.)

This is why I’m uncomfortable with the team system, checking out handing patients off all the time: I just finished admitting an 11year old boy with a history of basilar artery aneurysm, now complaining of gradual bilateral leg numbness and weakness over the past five weeks. This morning he was unable to walk without a great deal of assistance, and his mom had just got her insurance back, so they came to the ER. I saw him, did the most thorough neuro exam I’ve done in months, went up and gave the senior such a report that she was about ready to start chasing the MRI techs in from home, and inquiring of the ER docs why they hadn’t already¬†consulted neurosurgery. I knew that wasn’t quite in order, so I got her to come down and look. Good thing, because she got an almost completely different neuro exam than I did. None of my positive findings, except for the unsteady gait. Partly her doing it differently, and partly I really wonder if the boy is “assisting” with some of the abnormal findings. He’s very dramatic about everything. But he has got the strongest possible history to explain just about anything. We settled for MRI and neuro consult in the morning.

But I can’t put all that in my note. I put the bare story as given by patient and mom, and a sort of tempered version of the neuro exam: my findings that I felt most confident in, and the normal things that the senior clearly found. Didn’t say anything about the social circumstances, about mom’s checkered relationship with past neurologists (one tried to put the boy on Prozac when he was 6, so she left; I don’t blame her). Couldn’t really document both of the different neuro exams, or our uncertainty about them. The senior isn’t going to have time to explain all this when she hands off a dozen new admits, including a couple sick heme/onc kids, in the morning. The intern isn’t going to tell the other team’s intern who picks him up. If I don’t catch the medical student who gets him on the other team, they’ll have to stumble and sort through all of this all over again, and who knows if they’ll miss something. It feels like too much could slip through here, details and nuances, if you keep doing this with dozens of patients every night for years.