Ok, that was slightly better. No nasty jobs from the floor or the ER. Fewer undesirable consults from the ER. (I fail, I really fail to understand, why an ER attending and senior resident would call me, show me a CT scan and an EKG, and ask me what we ought to do about it. Dude, I don’t know! I can see that there are QRS complexes, and that we don’t need to initiate the ACLS protocol. Beyond that, why are you standing there looking at me like I ought to solve the problem? The patient is in your ER! Doesn’t matter that a surgical service discharged him a few days ago; he and his ekg are in your ER now.) (I mean, I appreciate the vote of confidence, but my head isn’t that big; I know this is out of my depth.)

I’m beginning to fantasize about adding a lecture to the series of “basic medical things you really ought to know, in case you weren’t paying attention to this part in medical school” that the hospital sets up for the interns during July. In addition to the [valuable] medical things like, when it’s time to intubate, how to think about renal failure (since thinking seems to be the only thing you can really do about it), management of acute coronary syndrome, and so on, I would like there to be a lecture on, “how to consult surgery appropriately.” It would include such basic concepts as

1) don’t call it a rigid abdomen unless it is
2) on the other hand, if you think it is a rigid abdomen, please call us now and not six to twelve hours later
3) please don’t consult us about the possibility of bariatric surgery for a morbidly obese patient during his hospital stay for another medical issue! this requires six months of outpatient preparation, and does not require an urgent in-house consult
4) please don’t mention the words “elevated lactic acid” if you want to be taken seriously; in fact, just don’t check it at all
(sorry, non medical readers; it is the fond belief of medical people that elevated lactic acid is a sign of infarcted bowel, which if true would require immediate laparotomy; however, it is the firm opinion of surgeons, at least at this hospital, that lactic acid can be elevated for many reasons, including renal insufficiency and general low-flow state, and is of no value compared to the clinical exam and, ok, the CT scan; nevertheless, people persist in checking it, and then stat-paging us because the patient, who is sitting up eating, needs to go to the OR now)
5) try to strike a happy medium between consulting us the second you get a positive c diff test, and waiting until the patient is septic on multiple pressors to ask us about a possible colectomy

As you can tell, the main problem with my scheme is that it would be next to impossible to give this lecture without being incredibly arrogant and snarky. So perhaps it’s just as well that no one tries.

I need to stop reading The ICU Book, or at least stop quoting it to my fellow residents. The author has now demonstrated to his satisfaction (though not entirely to mine; I’m still lagging a couple equations behind) that blood gas measurements are entirely useless, and in fact detrimental to patient care, and that most medications used for acute onset atrial fibrillation have no value whatsoever. I think his next chapter is about how giving people oxygen is in fact bad for them.

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