I knew I was going to get in trouble. It involved a line that I couldn’t get in, and had to be fished out of by the chief. Ignominiously. It was the one line I’ve never yet succeeded in placing (radial arterial line, if you have to know), and a semi-unstable patient, and a medical ICU, whose nurses were more interested in standard operating procedure and paperwork than in taking care of the patient. The fact that the chief proceeded to explain to me loudly how and why he dislikes the MICU nursing staff didn’t really make things go any smoother.

(Here’s one example of why the surgeons here mistrust the MICU: There is a code called in the MICU every one to two days. There is a code called in the surgery ICU once a month, if that. Maybe the patients in the MICU have worse medical conditions, I don’t know. But maybe the SICU nurses do a better job of recognizing when their patients are going down, and then organizing the necessary resources early, rather than waiting till the patient actually arrests before calling for help. It would be good to study someday the relative comorbidities of the two populations.)

All the pages I didn’t get for the last week finally caught up with me. I spent a lot of the time on the phone having this kind of conversation:
Nurse: “You know Mrs. Smith, in room 324?”
Me: “What kind of surgery did she have done? Who was the surgeon?” [flipping wildly through my stack of lists, which somehow all turn upside down every time I put them down]
Nurse: “She had x procedure, and her blood pressure is now 85/40; her heart rate is 95, and her urine output is marginal.”
Me: “Um, any idea at all about her cardiac history? You don’t know. Have you been giving her any beta blockers? Just an ACE inhibitor. Is she having trouble breathing? What room did you say were in, again?”

And then I run over there as soon as I can, and spend a few minutes flipping through the chart (this is why H&Ps are important, why do the day people never see fit to remark on the cardiac status of the patient? can I afford to give her a liter of fluid, or would 250cc only be more prudent? is it time to send repeat labs, or not yet? somebody ought to write the pre-op hemoglobin down somewhere) Then, once I’m in the room, the patient is lying calmly in bed, rubbing her eyes upon being awoken, almost always more disturbed by my sudden entrance and concerning questions (“Any chest pain? Any difficulty breathing? Have you ever had a heart attack or heart surgery? Do you smoke?”) than by any previous symptoms.

Late in the night, I got called by an ER resident. “Would you come see Mr. Jones? His CT scan is done.”
Me: “Yes, but what did it show? Why are you calling me?”
ER: “The last guy signed out to me that you knew about him.”
Me: “I knew about him, as in, he exists, and he’s in the ER. All I did was tell your colleague not to call my attending directly, and certainly not to call him before the CT scan was done. What do you need surgery for, now?”
ER: “No fair. He told me, Call Alice, she’s nice, she’ll take care of this guy. Your attending’s name is in the records; come see him.”

Which is why you see it doesn’t pay to be nice to the ER. I had been down there earlier, being friendly, commiserating about how the ER was getting snowed, and in the middle of the week, joking about who needed to admit which patients, helping out with the discharge paperwork on the other consults I was seeing. I made friends with a lot of the ER interns during orientation and ATLS, and we’re still mostly on speaking terms. But you see what it gets me: dump this patient on Alice, she’s nice. And I know my senior will kill me for inviting consults like that; the rest of the surgery residents talk about “putting up a wall,” blocking ER admissions, turing every non-urgent surgical issue into a hospitalist admission. It’s not polite or collegial, but in the middle of the night, when you’re struggling with necessary admissions and ICU issues, having the ER think twice about calling you might be good.

Of course, because it was my bad night, it turned out that when I mentioned the patient’s existence to my senior (while the ER guy was still trying to think of exactly what surgical thing he wanted us to do, before calling me back), he was forced to admit that this particular attending would want him admitted, no matter that his problem was medical in nature and he didn’t need surgery any time in the foreseeable future. So I’m “nice,” and when I try to fight back, I pick the wrong patient to argue about. Tsk. No luck. (I’m such a pushover that the senior ER residents have taken to calling me before they have any lab or CT results; that, I really am not going to accept any more.)

It’s not so much a problem now, because I can always fall back on, “The senior resident won’t accept this.” But next year, when I’m responsible, if I let them give me too many silly admissions and consults, the chiefs and attendings whom I’ll have to call at night will really not appreciate my “weakness.” I like being able to joke around with the ER people; but if it’s going to get me so much grief from my own program, I’ll have to adjust the relationship.

I ought to add that this relates to the quality of patient care, as well. One of the main reasons the ER residents think I’m easy is because, if I agree that the patient needs to be in the hospital, I tend to find it simpler to just admit them immediately to the surgical service in question, rather than making them sit in the ER for hours while we argue back and forth – surgery, ER, hospitalist, medicine specialty – about who exactly needs to take the patient. Sometimes the patient is better served by being gotten up to a bed quickly. On the other hand, it’s probably even better for them to be on the correct service. After all, though I maintain that we can provide good care for patients with medical problems, that care will be as old as our med school diploma. We don’t read the recent medical literature; the surgical literature is quite enough for us. There may be a few cutting edge variations, or abstruse specialty tests, that we’ll miss. Moreover, I think most surgeons have an element of ADD in their personality. If we can’t play with it (cut it, sew it, poke needles in it), we lose interest pretty quickly. We’ll be polite and conscientious about it, but a patient who hasn’t had, doesn’t need, and won’t have surgery during this admission is very boring to a surgical service. The patient will simply get more thought and attention on a service which specializes in thinking rather than cutting (to adopt the stereotypes).

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