buried

My service got hit by an avalanche today. We halfway saw it coming, knowing what the OR schedule was, but half of it was through the ER. The only good thing is that almost everyone was genuinely sick. It’s much more fun to take care of sick people who get thrown into your lap, than not-sick people who have to have the paperwork done anyway.

I got to spend a fair amount of time in the OR, with one case which was at my level, and one senior-level case which I was thrilled to land in because there were simply no other residents free in the entire hospital. Of course, I paid for it by drowning in floor work whenever I left the OR. I was pleased beyond words to be operating, but it was frustrating not to be able to take care of my patients as carefully as I usually like to.

We got a few disasters dumped on us from outside hospitals. Another patient with truly peritoneal signs. I love getting called by the floor secretaries: “Your attending accepted this patient in transfer from Hospital X. I don’t know why he’s here. Oh, I guess he has abdominal pain. No, I don’t have any idea what they diagnosed him with. He has no papers with him. Oh wait, there are some CT scans. No labs. Oh wait, here are some labs. Yeah, he looks great.” That didn’t sound very reassuring. I went up to see, and found the poor guy literally fulfilling the cliche description of peritonitis: jumping off the bed, hitting the ceiling if you touched him. The front page on his records from the other hospital said, “perforated bowel.” Clearly the people who arranged his transfer with my attending hadn’t mentioned that, otherwise the attending wouldn’t have been content to let him drift around on the floor like that, trusting to chance that he would get noticed. The OR scheduling staff started to cringe when they saw me coming, because of the number of cases we added on today.

Beyond that, half my patients on the floor developed surprising new conditions requiring urgent attention, and nearly all of the postop patients deviated in some way from the proper course, ranging from low blood counts requiring transfusion to aspiration requiring stat reintubation.

Under these circumstances, when the nurses called to tell me about a patient with panic attacks who was clearly inventing wilder and wilder symptoms because I wasn’t coming to hold his hand, I felt justified in ordering a simple rule-out test, and then proceeding to ativan. I trusted the nurses to let me know if it was anything more than a panic attack, and they didn’t mind me ignoring them, because they could see all the other real disasters on that floor.

Just to add to the fun, most of the other surgery services were getting similarly slammed. Some of my urgent add-on cases got bumped by even more emergent add-ons from other attendings, and as late as I left, half the residents were still working in the OR, or picking up consults in the ER. It’s funny how different patients respond to having me check on them at 8pm and promise to return early the next day, from “you’ll be here in the morning? oh good, I trust you” to “you’ll be here in the morning? do you ever sleep?” To both of which the answer is a smile and a quick escape out the door.

Tomorrow is going to be a bad day, mopping up, even if nothing more hits the ER tonight. And with my attending’s luck so far today, I fully expect to find three more seriously ill patients on my list tomorrow.

 

deciphery

Everyone talks a lot about communication among members of the healthcare team, but usually they’re referring to communication between doctors and nurses. In my experience, most doctors do a decent – or at least a passable job – at this, since you usually have to tell the nurse what needs to be done in order for it to happen. Also, as in the old military paradigm, the troops do a better job if they know what the plan is, so they can make intelligent adjustments to unexpected circumstances.

I’m a little more puzzled by the communication between different groups of doctors – or lack of communication. It’s not at all uncommon for an ICU patient to have anywhere from three to six different specialists “following” him (I always cringe when I write that – it sounds like a stalker is loose in the hospital), and floor patients, if complicated, will have their own small entourage. These specialists rarely talk to each other, or even to the primary (ie, admitting) service. They all round at random hours of the day, and leave notes in the chart, and expect these notes to enlighten everyone else as to their thoughts.

Of course, since the notes are illegible, no one is very enlightened. I’ve decided that it saves time not to try to read the subjective part, or the physical exam, or the labs. If I can just sort out a few key phrases in the plan section of the note – continue, stop, start some medication or other – I’ve got enough to report on. Then, if I can figure out the signature, I can even tell whom I might page if I have urgent questions. It’s gotten so I recognize the handwriting of all the ID specialists (I think the whole group buys special pens), the critical care attendings we see most often, and the endocrinology and urology PAs. For the rest, if I recognize what their plan is, it might give me a clue as to which specialist would be interested in that subject, and then I see if the operator knows which resident is involved with that specialist.

The only times we actually talk to each other are as follows: 1) Two attendings meet each other at lunch; in this case they will discuss the patient in detail, and mysteriously produce a plan, and then blame their residents for not acting on it, already. 2) An attending decides to round so early that his path and mine actually cross, in which case I’ll ask a great many questions, for my education, and to figure out the plan. This is indeed very informative, but if I don’t time it just right, I won’t see him the next morning, and so will lose track of his plans. 3) There’s something so critical going on that I play tag via the operator, paging every resident and fellow who seems connected to the attending we originally consulted, until I track down someone who knows what the plan is. 4) The consulting service has such an important idea that they page me to tell me to act on it. This is fairly rare, and usually annoying when it happens: is it really that much simpler to page the intern to tell me to write orders, than to just write the orders yourself? But I’m glad to hear from them, so I don’t complain.

My approach is: 1) To write very neatly. I actually scare myself because mine are almost the only legible notes in the chart, so everyone always reads mine for information, and I can only hope that I’ve correctly interpreted and quoted everyone else’s chicken scratch. I would hate to be the only person the lawyers can pin down as saying xyz. But at least no one is in doubt as to what I thought; my attending may have thought something different, and his note below mine may be a beautiful arabesque of loops and squiggles; but my plan is what counts, since that’s what everyone reads. 2) To call other services quickly when I have questions, and especially when we have any plans for patients who are admitted to a medicine service. I can only imagine how frustrating it would be to come in and find that the surgeons have kidnapped your patient into the OR, so I try to let them know what our plans are. 3) To hang around the patients’ rooms whenever feasible, since this makes it more likely that I will actually catch the other services as they round.

I’m not sure what better approach there could be. Legibility is the holy grail of medical records – desirable, and unattainable. But at least one’s pager number should be written legibly, so it’s not such a daunting task to track the writer down and ask what he was thinking – or some other diplomatically worded question which doesn’t imply that the time spent writing in the chart was worthless. (Also, this is where talking to the nurses comes in handy. If everyone talks to the nurse, she (or he) then serves as a repository of easily accessible information – if you can find the nurse. Sometimes this is easier than finding the chart, other times vice versa.)

Oh yes. And everyone politely writes at the end of their note, “appreciate consult,” or “appreciate cardiology input,” or “will follow endocrine’s recommendations.” At least we’re courteous in our illegibility. (Sometimes this helps because you know what letters have to be involved there, so, like the old codes, you can extrapolate back to the main body of the note.)

 

responsibility

A friend at church gave me a copy of Atul Gawande’s new book, Better: A Surgeon’s Notes on Performance.

I don’t enjoy reading Gawande’s writing, I think for two reasons: he writes so well it makes me depressed about my inelegant efforts here, and he takes his work so seriously that it makes me feel inadequate and guilty about all kinds of things I remember doing, or not doing. He is not a comfortable author for doctors to read.

For instance: responsibility. When I was a medical student and something was missed, I could always tell myself, “You should have noticed that, you should have taken care of that, you should have drawn attention to that – but it’s ok, that’s what the residents are for. In the end, it was their responsibility, not yours.”

Now there’s no more such comfort. Occasionally the thought occurs to me, “I really should have caught that – but then, the chief and the attending should have, too.” I don’t let myself believe that, though. Interns really are there for the details. The others spend so much time in the OR, have so much more of the big picture to look at, that they rely on the interns to catch a lot of details. Yes, they often do find things that I overlook. But that doesn’t change the fact that, at baseline, they’ve told me that it’s my job to be the team’s eyes and ears, and so if a detail slips past us, it’s my fault.

This last month, there’ve been several times I’ve found myself looking at the chart and kicking myself. A lab value overlooked till the next day, a dose of medication not ordered or not given, a pathology report not noticed, a radiology report missed. I am now the generic “resident” in Gawande’s stories who is the first person to miss a detail which eventually becomes a major problem. There is no longer anyone else to take the blame for me. Now and forever, the details are my responsibility. When I’m a chief, I’ll have interns, and if they miss something, I’ll still hold myself responsible. It is no longer permissible to share.

It doesn’t help that, as I finally realized at the end of the month, my resident last month was not the greatest. He seemed friendly and helpful enough, so at first I didn’t notice a problem. Later it became clear that, although he was supposed to be there to catch my mistakes, I seemed to spend a lot of time catching his. There were times when he said, I’ll take care of that patient’s results; I’ll look at those reports; I’ll put in those orders – and a day or two later I’d realize he’d missed something. Nothing horrible or deadly, so I didn’t say anything. There were enough other incidents that the chief and attendings knew about that I didn’t feel a need to point out his failings. But I’m developing the surgeon’s paranoia. Never trust anyone, they tell you. Students lie. Interns lie. Chiefs lie. Even attendings lie. Check everything yourself. Never believe anyone. You’re responsible – so don’t leave yourself open to the mistakes of others. Doublecheck everything.

In five months, not only will they let me do surgery – but I’ll be a junior resident, supervising the interns, and the very last vestiges of non-responsibility, of having somebody else to share the blame with, will disappear.

They didn’t explain this part in the med school brochures, how heavy this is, how you can’t stop thinking about the details you missed, the ones you can’t remember if you checked on before leaving.

 

priority check

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.

 

covering up

Today one of the attendings, bless her heart, took pity on me standing around the OR, and let me do the minorest, dirtiest part of a dirty case. But I was happy. I’d never done that particular procedure before, and she let me fumble around with things and take my time.

Then I got paged from the ICU (which I’m not responsible for): “Please, are you taking care of Mr. Jones?” I used to just refer those calls to the senior resident, to whom they belong. But I’ve learned to ask first: “What’s the problem?” If they want an order to continue the current iv fluids, I can do that; or if the patient is crashing, I want to know it. “His blood pressure is dropping, and he’s tachycardic and anuric, and I’ve paged the senior five times and he’s not answering.” Ok, great. I ran over, trying to figure out, with a lost senior and the chief scrubbed in, who I would call if there was a real problem.

Mr. Jones was fine. He was sitting up, not having much pain, looking a little worried by the nurse’s concern and my sudden appearance, but not looking like someone who’s actively trying to die. He wasn’t truly tachycardic, with a heart rate in the 90s. (Tachycardia is defined as a heart rate greater than 100, and medical students are taught early on that 100 Fahrenheit is not a low fever, and a rate of 95 is not a little tachycardic. Temp of 100.8 is a little fever, rate of 110 is a little tachy.) So airway, breathing, circulation were under control. Abdomen was soft; JP drains looked fine, just a little serosanguinous fluid, so no hemorrhage into the belly. His urine output, on the other hand, was not pleasing: it had been dropping markedly for the last five hours, and was now precisely zero. That was easy: hang fluids.

Then I started asking questions: this ICU has both a trauma team and surgical intensive care team, whose members practically live in the ICU. If the nurse was that concerned about this patient, to start asking the operator to page anyone remotely connected to the attending, why hadn’t she called the surg-ICU resident? “Oh, I did, but he said to find someone from the primary team.” “And you paged my senior?” “Four times, but he never answered.” That was puzzling, because I had thought better of both those residents, than to ignore a patient who by report was tanking, or to ignore four pages.

My resident’s answer was simple: there was one page, which the circulator in the OR he was scrubbed in didn’t hear. If there had been even one more page, both he and she would have heard, and answered. And an hour later, the ICU resident found me: “You should always call me when you have a problem. I’m here to help.” “I would have called you if there’d been anything puzzling, beyond needing more fluids. But the nurse said she tried to get a hold of you.” He rolled his eyes. “That nurse? She never paged me at all. I was sitting on the other side of the nurses’ station.”

So the nurse was trying to cover up the fact that she’d ignored an ICU patient with dropping blood pressure and almost no urine for five hours, by flatly slandering the residents. I guess she figured the intern would be good enough to fix the problem, but too clueless to realize how much she’d messed up. As if I wouldn’t hear from the other residents. Just another lesson never to believe charges against someone without proof. I knew those residents were responsible; I should have known the nurse was lying (since I had no previous experience with her to show she was trustworthy) without having to hear their stories.

Mr. Jones is fine. He perked right up with one liter of saline.

As for the lady with the chest pain the other morning, I checked with that resident. He said I was doing just fine, except he knew that this lady is crazy, and every single morning between six and seven she starts yelling about something: one day her arm, one day her leg, one day her head – and today her chest. That’s why he would have been happy with a simple EKG.

The attending from yesterday found me in clinic, and inquired what strategy I had decided to pursue – as innocently as if I’d had any choice, or as if there’d been any question what I’d do, once he suggested something. But since he spoke like that, it establishes that next time I will have more of a choice – and more responsibility. Always more responsibility.

 

pile on

Things were going ok till this afternoon. Then, two attendings, the chief, and a fellow decided to educate me, in the usual surgical tradition; spurred on a little, I think, by having had a long and frustrating case in the OR. They asked what I wanted to do about a patient with a problem. I suggested a solution – the wrong one of course, and I realized it the minute the words were out of my mouth, but too late. The attending wanted to know why, so I gave him my best shot at a reason. He then in an ironical and speculative tone of voice mentioned several other very pertinent facts which pointed to a completely different course of action. Since he was right, I said that we should do his idea instead. And then he laid into me for changing my mind, and gave me a very nice lecture (but one which I’m afraid I didn’t appreciate at this juncture; about a year from now I’ll appreciate his phrases) about how in surgery one has to be decisive: pick the right thing to do, and follow through, because if you hesitate at every cut, you’ll never get through a surgery. (The fact that I’m currently extremely depressed about never getting to do surgery this year – and yes, that’s an exaggeration – didn’t make this meditation any more enjoyable.) We proceeded with rounds, and the fellow came along in the back, whispering to me quantities of evidence-based medicine demonstrating the fallacies of every single action I’d taken all day. All in great good humor and fellowship. Once the attendings had left, the chief and the fellow settled down to finish the lesson. They had me repeat every reason I could think of for my original idea, and then explained in detail why that was so wrong. So I said I’d do their thing, and suggested a medication dose, the usual one. Nope. Wrong answer. Another long inquiry into the mechanism of action of the drug, side effects, and why it’s dangerous for this patient. We settled on a tiny dose, which I’ve never seen used. I’m sure, after all that, it will work like a charm. (And that was, after all, the whole point of the fellow’s conversation: not to do something just because you’ve seen it, but because you’ve investigated, and know why you’re doing it, and how it will work.)

At the end of all that, they got to discussing another patient. I finally snapped, and made a smart-aleck remark about sexual anatomy, just to disagree with them about something – it was not dirty, quite a propos, and relevant to patient care. But since it was me making it, they knew I was angry, and they thought it was hilarious. And I feel guilty – for being angry, for saying that, for not taking better care of my patients, for letting myself care about not being in the OR.

On further consideration, that’s the most attention I’ve ever had paid to me by so many attendings and seniors. So I guess actually it means they think I’m worth teaching. I suppose that’s good.

PS. I remember when I was a medical student I used to feel really bad watching this happen to the interns and residents. So I’m glad the students weren’t around today. Because really, I’m most upset not because they taught me; that was good. I’m upset at myself for giving the wrong answer to start with, and for not knowing more about all of my patients and all of their problems. The fellow and the chief know so much because they study; they weren’t born that way – I think.

 

further tales of a dysfunctional OR

About a week after the events in my previous post, we had another big case to do at that hospital. I quickly discovered the reason that the surgeons at this hospital, more than at many others, dread having to schedule a case on the weekend. From the look on his face, Jim, the weekend circulating nurse, regarded the mere existence of our patient and us as a personal affront – let alone our insane desire to perform surgery in the OR which he was trying to keep neat, clean, and organized.

I consider myself rather tidy in the OR. I don’t drop blue towels (sterile, used to dry your hands after scrubbing) on the floor unless there’s absolutely no container within a sterile-arm’s reach. I try to put paper trash into the bins, unless we’re in too much of a hurry, it would compromise the sterile field to do so, or the only bin is heaped full and on the other side of the room. In which cases I will let things go on the floor. After all, the whole place is going to be covered in a mixture of blood and dripped chlorhexidine (disinfectant used to prep the patient) by the end of the case, as well as the inevitable bits of tissue and cloths which slipped off the table. Moreover, the whole place will have to be cleaned in detail before the next case. Jim gave me a personal glare every time anyone dropped something on the floor. Apparently I was more accessible than my attending to be glared at.

Another point on which Jim and the surgical team (of which he could by no stretch of the imagination be called a member) disagreed was the relative priority to be assigned to filling in paperwork. Jim clearly felt that checking off all his boxes was number one on the list of things to be done that morning. I, on the other hand, tended to share my attending’s belief that handing in pro-coagulant supplies was more important for a patient who was bleeding copiously, and for whom blood loss was one of the two riskiest aspects of the case. We also tended to feel that bringing in clean instruments (eg, when a scalpel had been contaminated) was perhaps of higher importance than picking up every scrap of plastic which had made its way to the floor. As for getting the suction actually hooked up and working, Jim maintained such a scowl whenever the subject was mentioned (and was always so far behind on other important tasks) that we were obliged to proceed through almost the entire case without one. When Jim was finally relieved for lunch, his replacement gave the machine one quick push, and voila, working suction. Thanks, Jim.

At one point, as Jim walked slowly out of the room to look for supplies, trailing a string of obscenities, I murmured a question to the scrub tech, why the three of us (including the attending, nominally more powerful than a circulating nurse) put up with such filthy language and obstructive behavior. The answer was obvious. He held us hostage, inside the sterile field. Unless we were willing to bet that the five minutes involved in re-scrubbing would be less than the time wasted by his nattering, there was simply nothing we could do about his behavior. (As for complaining to the supervisor, I believe it’s been done; but this is a union hospital.)

When it got to the point where Jim was standing in the corner answering work-related inquiries on a portable phone, rather than walking to look for some objects which were absolutely essential to taking even one more step in the case, our scrub tech finally gave up, broke scrub, and ran out, to return with the items before Jim had finished his phone conversation. This was after the attending had repeatedly, politely but firmly, suggested that our immediate needs (sterile supplies, etc) were more important than his paperwork, to be met with a literal cold shoulder: Jim simply turned his back and kept on with whatever he had been doing.

The only thing that made the day bearable was the scrub tech, who was a miracle of cheerfulness, enthusiasm, and determination to get the job done, in glaring contrast to Jim. She didn’t complain about me and the attending asking for several things at once, as we tried to move as fast as possible through a major surgery on a patient whose precarious condition was further imperilled by extra time in the OR. In spite of being near the end of an incredibly long shift, she remained alert and helpful. There were literally no words good enough to thank her in without sounding melodramatic; but I tried.

(The patient did well, despite the obstacles. Enough strong team members can balance out the rotten apples, but at some cost in energy and cheerfulness.)