The trauma team has a running contest with the ER. It’s kind of like a slow-motion version “hot potato,” where the patient is the object of interest, and the question is which bed they end up in. The ER has a laudable goal of getting all patients out of the ER as fast as possible. To them, trauma patients are a golden opportunity, because pretty much everyone who comes in as a trauma alert is guaranteed at least an overnight admission, until we get the Cspine films officially cleared by radiology (such a stupid liability issue), or for observation after a concussion, or until ortho fixes the broken bones, and so on. So the ER nurses are on us, basically from the minute we finish the secondary survey in the trauma bay, to find out where the patient is being admitted to, so they can stick it on the bed board and start the process of waiting for a bed.

We, on the other hand, don’t have such a simple equation, especially when it’s the trauma ICU residents working the alerts. We have a very strong interest in the patients not coming to the ICU – partly to save ourselves work in the morning, but more because if we let the trauma ICU get filled with not-so-serious injuries during the afternoon, that means the really bad gunshots and motorcycles and high-speed drunken car crashes that won’t come in till midnight or 1am won’t have a bed open in the trauma unit, when they really need it. Which means we might do a desperate operation at 2am, and then have to stick that patient, with drains coming out of everywhere, and an open abdomen, and four pressors, and reverse ventilation, in the medical ICU, which really gets kind of flustered with these patients.

So we insist on waiting till all the scans have been completed before we announce whether this patient needs an ICU bed, or just a plain monitored bed will do. It’s tricky, because sometimes the ER nurses catch us out, and we slip up and say, “ok, ICU,” or “ok, monitored,” and then later on in the workup something turns up, and we change our minds, and by then the patient has already been assigned a bed – maybe report has already been given – and we make everybody very upset by insisting on changing the arrangements. Which is why it’s better to get it right the first time. (It’s also a shocking reminder of what a responsibility it is to be the MD: the nurse can be as senior as she likes, and as angry as she likes, but if I put my foot down and say, it has to be this way, that’s what happens. Just because I’m the doctor. So I try not to make an issue of things that don’t need to be major. . . or things like, this 300lb patient needs to be turned over and have dressings changed three times a day . . . and the nurses make a face, and do it. . .)