Another part of my role as a junior resident, rather than an intern, is to handle consults from the medical ICUs. There is always a constant stream of these: mesenteric ischemia in patients who’ve been hypotensive for too long for whatever reason (MI, sepsis); toxic C diff; upper and lower GI bleeds which elude medical management.

The consults themselves are not so bad. The patients are usually intubated, which means one simply examines them, and then collects data from the chart, and calls the attending.

The part that’s driving me crazy are the MICU residents and nurses. The surgery residents have a saying: if you get paged with a stat consult from the MICU, it’s probably nothing important, and you can take your time getting there. If, on the other hand, you receive casual notification, through a string of secretaries, of a consult for which the original order was placed some 12 or 24 hours ago, you’d better run, because that patient needs to go to the OR already.

Partly it’s sarcasm, but there’s a lot of experience behind it: innumerable stat pages regarding bowel obstructions which are really ileuses (ilei?), as determined by an abdominal xray, or for uncontrollable GI bleeds which have after all only received two units of blood, and haven’t been scoped (or sometimes even seen) by GI yet (we have to have a scope, or some other study, showing where the bleeding is coming from; you can’t operate at random), or for mesenteric ischemia in which the patient has no abdominal pain, and is severely acidotic from urosepsis and lack of resuscitation; and so on.

Then there are all the times when a CT scan is done early in the evening for abdominal pain, and when radiology reads it around noon the next day, then we’re notified about the gross free air, the occluded superior mesenteric artery, the glaring small bowel obstruction in a toxic patient: all patients in whom 18 hours lost between the initial complaint and the OR time could mean, if not death, certainly a dramatic increase in morbidity. Why can’t they look at their CT scans? I’m not asking for detailed reads, just a glance: gross free air (as opposed to a microperforation) shouldn’t need an official radiology reading to be acted on. I know I’m no good at all at chest CTs, but I can see a saddle embolus, a lobar pneumonia, an aortic dissection. If I can stumble through the pulmonologists’ scans, can’t they look at the abdominal ones a bit?

And the nurses: I’ll stick to one chief complaint: NG tubes. It’s like a trap. No matter how many times I check on the NG (nasogastric) tube, by the time the chief comes to see, it will not be to suction. It may be buried under the pillow, or under the blanket, or down the side of the bed; it may be tied in a knot, or the connecting piece may have been artfully abstracted and lost. Somehow, the MICU nurses seem to believe it would be detrimental to the patient to actually leave the NG to suction. (For your information: an NG is a sump pump, meaning it has an air port, so there is no danger of damaging the stomach mucosa by leaving it to continuous low suction. On the other hand, it stents open the upper and lower esophageal sphincters, so having it in place increases the patient’s risk of aspiration, unless it is being used as intended, to suction.) If the MICU team sincerely believes that their patient has a bowel obstruction, why on earth do they insert an NG tube, and then not put it to suction? It’s not a surgical thing; it counts as medical management! Even three written orders to that effect will frequently not prevail on the nurses to put the thing to suction (I’ve tried).

Fortunately, every now and then I encounter the surgical ICU nurses moonlighting in the medical ICU – a breath of fresh air, although they sometimes look fairly frustrated too.

(And yes, ok, neither I nor the surgical ICU nurses have much knowledge of steroid drips or neutropenic precautions or the intricacies of hyponatremia. . . but an NG is not that complicated!)

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