In discussing the case of Lewis Blackman today, I could not help but think about the importance of good transfer of care. If the on-call weekend resident had a better understanding of Lewis’ immediate post-op progress (or lack of), the gradual change in his vital signs and exam may have sent up red flags sooner. It is easy to become overwhelmed with the number of unfamiliar patients one must cover as an on-call physician. One may not appreciate the subtle changes in a patient’s status when there is just a snap-shot view of the situation. We have all fallen victim to this, and the situation is worsened by sleep deprivation. I can recall a case when a patient had subtle labs changes over the course of her stay for preeclampsia. To the covering physician, these labs seemed relatively stable and the patient was sent home. She returned the next day actively seizing from eclampsia. Because of this, I am now in the habit of reviewing the record of all the patients I am covering before, or at the start, of my shift. This is an additional layer of protection beyond our otherwise thorough patient hand-offs. It is important to appreciate the “big picture” in addition to the details.
