medicine


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.

No doubt this is extremely lame, and I ought not to be confessing it in public. But as a result of studying for the inservice exam, I have finally grasped the significance of FeNa (the fractional excretion of sodium in the urine, calculated as (urine sodium/creatinine)/(plasma sodium/creatinine) ), and urine sodium, and urine electrolytes, relative to acute renal failure. This is one of those topics that people have been asking me about for the last three years, and I always gave them a blank stare and some kind of mumble. (The answer to the equation is either more or less than 1%, so you have a 50% chance of guessing the right one in a yes/no question.) Then they would give me some rapid and forceful explanation about its extreme and vital importance, which I of course didn’t understand. Back at the beginning I used to look it up in huge textbooks, and by the time I got to the end of the five-page section on the subject, I’d forgotten the beginning, and didn’t get anything out of it.

Now, having had more patients than I can remember suddenly develop oliguria (low urine output), and having stood there staring at their ins-and-outs sheet, and trying to correlate it with the latest electrolyte panel, and being still at a loss to figure out whether they were dehydrated, and needed a lot more fluid, or were well hydrated, and had acute tubular necrosis for some other, possibly reversible, reason, I am very interested to discover that the FeNa will help me figure this out. They told me this many times in the last six months, but now I get it; and you will find me checking urine electrolytes without having to be reminded, because I finally want to know what they show.

I know; I should have figured it out a long time ago. But the relationship between the esoteric calculation and the patient’s problem never clicked for me before. Better late than never, hmm?

The attendings I’m with this month do some amazing surgeries. Shocking, actually. The procedures are necessary and lifesaving – but also brutal and mutilatory in a way I’ve never seen before, somehow even worse than burn surgery. The med students are standing there looking horrified, and I try to act cool, as though I have any idea what’s going on; but I don’t even know what the next general step is, and I can’t quite believe it when I see it happening.

They gave me the weekend off, and I don’t know what to do with myself. It would really be less boring to be back in the hospital. I want to know whether Mr. A will be any less depressed this morning, how Mr. D’s PE is coming, whether Mrs. R’s mysterious fever continues, and where it’s coming from. I suppose I should clean the house, but that won’t take long. I suppose I should study. That ought to occupy the rest of my time. The surgery intraining exam is in three weeks, and since the senior residents are scared of it, I can only imagine how much trouble the interns are going to be in. At least I get to go to church tomorrow, maybe for the only time this month.

The other day, being at loose ends at lunch time, I fell in with some medicine interns, whom I’ve been friends with since we suffered through ACLS and orientation together, and we sat down to eat in the cafeteria. I was enjoying talking about nonsurgical subjects (such as medical ICU patients – one of the interns was excitedly relating how he had finally gotten to do a central line – and the other interns’ children, and the nonexistence of global warming) when my least favorite surgery chief resident came in, with some other surgery residents. He sat down a couple tables over, and started taunting me for being on the dark side and having forgotten who I was. I said I was being friendly. “Well, don’t be too friendly, or they’ll start calling you to help with central lines.” “They already did,” I said flatly, and he finally left me alone. (I didn’t think it was necessary to add that the last time medicine had asked me for a friendly central line, I failed miserably, and had to be fished out by my senior.)

Why does a drug go and be a controlled substance, when there are absolutely no narcotics in it? Just to trip up poor interns, and make them get paged by angry patients and pharmacists at night. It’s very difficult to either apologize or be authoritative about one’s lack of a DEA number when your cell phone connection is breaking up. . .

Chief’s advice: don’t write scripts. Let the interns do that. Ha.

My hospital has, among other distinctions, a pediatric psych unit. You may well ask, what on earth is a pediatric psych unit? Now that it’s fashionable to diagnose not only 15-year-olds, not only 10-year-olds, but even 7 and 5-year-olds with psychiatric diseases, sooner or later children will turn up who are “not doing well on medications,” and by somebody’s standard need to be admitted to the hospital.

It makes me sick to see these poor children in the ER with this diagnosis on their charts. To my mind, drugging your 7-year-old with high-powered anti-schizophrenic medications like abilify and zyprexa (remember the horrible side effect profile of most of these drugs: zyprexa is well-proven to cause diabetes, for instance) is downright child abuse; not to mention then allowing strangers to incarcerate them in a “hospital” because they’re not behaving the way you want them to.

The usual story is that they’re being violent at school: kicking, hitting, maybe even biting the staff. Folks, since when is a 50-pound child a threat to anyone? Are you really telling me you can’t control a normal-sized first grader? You have to admit him to the hospital for this? The problem with these children is that their parents are too lazy to discipline them properly. I support corporal punishment; which these children clearly haven’t had enough of. Now, once they’re this violent, I could see an argument that more violence of any kind in response won’t help. Ok, fine. But I guarantee you that anyone, if put in an empty room and left strictly alone, will quiet down sooner or later. Maybe two hours later. But far better that their parents or teachers should spend that time watching out of the corner of their eye (rather than giving the child a wrestling match and a shouting match, the way he wants), than that these little children should be institutionalized at this age.

Can you think of a worse thing to do to a child who’s already having trouble adjusting to the world, whose family situation is no doubt very fluid and unreliable, than to take him away from everything he knows and put him in the four walls of a hospital?

The crowning irony is that these children, here in the ER, seem well-behaved. They’re not bouncing off the walls, or yelling, or demanding anything. They sit quietly, smile at us, cooperate with everything. If there’s any point where they can be got to do this, then with proper encouragement, they can do it all the time. Most often, their family will say in bewilderment that the child is fairly cooperative at home; maybe annoying, but not completely out of hand. It’s only at school that they go completely wild. Maybe because they’re locked up all day with peers who are having just as much trouble as them?

These children are being abused. I hate to think of what their lives will be like in ten or fifteen years, when they become young adults who’ve never been given the chance to cope with the world except through the film of psychiatric drugs.

Further installments of the medicine/surgery disconnect: 

After a lengthy discussion in the OR about one of our patients who seems to be drifting along, securely not dead, but not making any noticeable progress towards getting out of the ICU, a few of the interns decided to talk to the medicine attending (who is very approachable; it’s not just any attending that interns could consider offering suggestions to). He listened very politely to our (perhaps wild) ideas about changing some of the medications around, and then answered (and I quote): “What he’s on certainly isn’t doing a whole lot of good. But it’s what’s classically indicated for his diagnosis, and I’m not excited about trying anything else. We’ll just leave things as they are.” Which was a very definite close to the conversation.

And we were left to meditate on the fact that almost any surgery attending, faced with three weeks of unsuccessful therapy, would be quite happy to start ignoring the book and branching out, on the grounds that since what we were doing wasn’t helping, some alternatives certainly couldn’t do much worse. Whatever the options might be, sitting still is not a popular one with surgeons.

 Who knows. Perhaps we’re just directing our frustration with the patient’s non-improvement towards the medicine attending. Perhaps we had no idea what we were talking about (where’s The ICU Book gotten to?). Or perhaps it’s another true indication of completely different ways of thinking about problems. I wonder whether men and women think more or less differently than surgeons and internists (which is stronger, learned or instinctive behavior – or are both of these differences inborn?). Opinions, anyone?

(But nothing could really spoil the delightful prospect of a whole weekend off – two days in which not to wake up to an alarm clock or get called in the middle of the night.)

Another example of how MICU doctors managing surgery patients doesn’t work well:
We get this man back from the OR after a long surgery, with blood loss of the type where it’s pouring onto the floor, the whole surgical team is wearing knee-high boots (which I hate, but you need them for this), the anesthesiologist starts the case running blood and crystalloid simultaneously, and at the end of the case you almost have to stop and give the patient a bath because everything is soaked in blood. (And the circulator stands there saying, “Who made this mess? I can’t walk over to the other side of the room, because I need to keep my shoes clean. When are you guys doing this again? Because I’m not going to be around.” I thought maybe she was joking, so I said, “Or you could just put shoe covers on.” She shook her head: “I’m not coming in this room again.” How she thinks she can work in an OR and keep her shoes clean, I don’t know.)

So here we are back in the unit, and the patient is oozing blood. We check coags (or rather, the nurses send coags, and ask us to sign). The INR is mildly elevated: enough to be of interest in a bleeding patient, but not disastrous. I and the MICU attending are notified at the same time. My answer: “Let’s give a few units of FFP (fresh frozen plasma, a blood component which contains the major clotting factors).” I figure there’s been so much blood and fluid lost and replaced that the clotting factors must be out of balance, and will benefit from immediate replacement. The MICU attending’s answer: “Let’s give 10mg of vitamin K iv.” (Vitamin K is the usual catalyst for the liver to make four clotting factors; this will begin to take effect in about three days, and is usually given to people who’ve been on coumadin, which inhibits the liver’s synthesis of clotting factors. This is a young patient with no liver dysfunction and no history of coumadin use.) I’m not saying he’s wrong, just that I am unable to comprehend his line of thought. We each ordered what we thought best, so I’m not unhappy, just puzzled.

Today was very satisfying because I seized the chance to do both an arterial line and a central line, largely unsupervised, by acting faster than the medicine team. I’m learning that when there are more than two nurses in a room, it’s time to head in, not keep sitting and chatting at the nurses’ station. The nurses may be beginning to respect me as a potential source of help when the patients are in trouble; and I was successful on my first independent lines.

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