Another good day. I was running nonstop (although I admit that my commitment to patient care has declined to the point that I did take ten minutes for lunch, and thus missed a few items of scut, which will keep for tomorrow), and didn’t get much done other than put out fires. Bless their hearts, the nurses had a whole list of jobs for me (reorder the pain medicine, reorder the iv fluids, change the blood pressure meds to po, and so on)  none of which I considered essential except the ones needed to keep the PCAs (patient controlled iv narcotics – very popular with patients and staff) running.

We had a sweet little old guy go into afib with rapid ventricular response. The junior and I pushed some iv meds on the unmonitored floor (to the glee of the patient’s nurse, a very sharp young man, who had initially noticed the tachycardia and brought it to our attention, and the consternation of the nurse manager, who nevertheless had to agree that it wasn’t contrary to protocol if we did it). Eventually the patient stabilized and was moved to a monitored floor. I sent him with very specific transfer orders, and instructions via the nurse giving report, and the nurse who transferred the patient. I thought I could take a few minutes to catch up, and then go over to see what happened.

Half an hour later I called over to check. “How’s my little old guy doing?” The nurse answered, “Oh, I just called the nurses up there to check. Are you going to consult cardiology?” Me (thinking, why would we, we had the rate under control, no symptoms, give us a chance to try chemical cardioversion): “Not right now, no; what’s the rate?” “Oh, 180s.” Me (flying nearly off the handle; or maybe entirely off): “Were you planning to call and tell me that?” Nurse: “It’s ok, it was 160s till just now.” (It had been 90s when I sent the patient over to the cardiac monitoring floor; I thought they cared about cardiac rhythms there!) Me, sarcastically: “Honey, for your information, that’s the kind of thing you’re supposed to tell me about!” I hung up and ran over, to find the nurse blithely filling out useless forms on some other patient. I’m afraid I spoke rather sharply, and told her the forms could wait, but right now we needed to get this patient’s heart rate under control, and go start putting a drip together. He was 85 years old, and had been complaining of chest pain, vaguely, on and off. (And yes, we had done all the tests and medications for acute coronary syndrome.)

Of course, half an hour later, it did turn into a cardiology consult. Turns out the patient was not having a heart attack and is still quite happy and doing much better. Like most of my patients with new onset afib postoperatively, he was more distressed by our concern and rapid activity than by any actual symptoms.

Come to find out that nurse was very senior, and a rather important person on the cardiac floor, and on a first name basis with my attending. Bother, wrong person to snap at. But I don’t care how senior she was, calling another nurse to ask if a cardiology consult is planned is nowhere on the list of things to do when your octagenarian patient’s heart rate shoots up to 180 – or even 160. I would try to talk to her to smooth things over, but I don’t know what to say. I apologize to a lot of people these days; but I’m not going to apologize for that one. I wouldn’t mind if she had called my junior or my chief – but to call the other nurse, and not even mention the heart rate?? [ok, stopping the rant now]

Anyway, in between being concerned for my patient, I was also thrilled. This is the kind of situation that would have completely bowled me over a few months ago, but now I knew exactly what to do, and the senior residents agreed with my plans. (Not calling cardiology at first was their decision, back when the heart rate wasn’t so rapid.) It was still good to have them there checking on me, but it begins to feel as though, in five months, I might be ok to do this more on my own. It was almost like a test situation, there were so many variables, so many medications that we used and tests that we ran, and so many decision points based on the response to medications or results on tests. Now that the patient is ok, I’m almost glad it happened.

For the rest of the day, various other patients went downhill in more surgical and less easily reversible ways. On second thought, maybe there is something to be said for medicine. I know I’m going to offend my medicine friends again, but somehow it’s a different kind of stress to consider what medication to give, rather than whether the patient is going to die without you cutting him open, and committing him to all the risks that that entails. Or maybe it’s just that we weren’t giving enough weight to our consideration of which medication to use. I’m sure if I’d stayed around to ask cardiology, they could have told me a dozen frightening consequences to any wrong choice, that I just wasn’t particularly aware of.

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