I guess I ought to be grateful for the nurses who call to inform that the patient does not have a fever (who have, wonderfully, been fewer in number as the month progresses; not because of anything I do, because my standard response to annoying calls is to say, Thank you very much for telling me; I’m not sure whether it comes out sounding pleasant or annoyed), in light of this recent exchange:

Nurse: Do any of this list of patients belong to you?
Alice: Well, I cover the general surgery services. Are any of your patients on those?
Nurse: Not this one, or this one, or this one. But this guy would like something for sleep.
Alice: Okaay.
Nurse: And this lady here has had slightly low urine output all day; but it’s picking up now.
Alice: That’s nice.
Nurse (coming back from the other end of the hall): She also has been pretty drowsy all day. But we had her slow down with the pca (patient-controlled analgesia: continuous small doses of narcotics tend to work better for real pain than waiting till it’s unbearable to ask the nurse for help) around lunch, and she’s been more awake since then.
Alice: Sounds good to me.
Nurse (coming back from the station 30 seconds later): She does complain that it hurts to take a deep breath.
Alice (now mildly interested): Has she been using her incentive spirometer much?
Nurse: I’m encouraging her. And oh, by the way, her heart rate is now 140.
Alice: Thanks for telling me! (running down the hall to the patient’s room)

Where I discover, after some hunting and with help from the medical student, that her pulse ox is somewhere around 80%; which leads to spending the next two hours investigating the cause of this, and making sure that it improves. Illogically, this makes me avoid that floor even more. I spend most of the night now, when not actively wanted elsewhere, on my favorite surgical floor, where most of the nurses will tell you soon enough, but not too soon. I like their estimate of how low a urine output is worth calling about, how high a fever is worth mentioning, and how fast a heart rate is worth looking for an EKG on.

Tonight was mildly interesting in that I spent about five hours aggressively investigating exactly how the lab system functions: who draws blood, where they take it to get it to the lab, and how it moves through the lab’s cubbyholes to come up with the desired answers. This investigation was spurred by the lab taking blood drawn for a stat potassium level on a patient with some interesting arrhythmias, and losing it for three hours. My interest being piqued by this, I went on to discover a couple other egregious instances of neglect by the lab/blood team (it’s very hard to pin a missing vial down on either the tech who drew it, or the tech who should process it; there seems to be a black hole in between; since the night nurses like the night blood techs, I tended towards blaming the lab techs), and learned how to file incident reports. I also learned that stat labs happen three times as fast when you walk down to the lab personally and inquire what they’re doing with your specimen. Calling speeds things up, but walking down produces lightning results. So, I may not be able to keep track of every fever or decreased urine output overnight as closely as I’d like, but I’m learning how to get the necessary labs done. I figure a couple more incident reports every night for the rest of the month, and they might even stop losing the blood. (Which especially bugs me when they do it to little old ladies who are hard sticks; it hurt them enough to get that blood in the first place that, in addition to the waste of time, it seems downright cruel to go drawing more blood just because somebody doesn’t care to look in all their corners carefully.)

Although I still think Brad is a rather pompous fellow, I must admit that I’m starting to copy a lot of his interpersonal tactics. He, of course, being a young man, can pull off the whole stereotypical handsome resident/pretty nurse deal with all the women; but he knows everyone’s name, and when he wants something done, he doesn’t hesitate to call, explain the clinical situation in a way that makes the nurse or tech feel included and important, and cajole a faster response. This is rather the opposite of my instinctive belief that if the paperwork is in order, the correct response will necessarily occur. (When I was on a proper service, I had my computer so organized that I could find consults to my attendings before the chief knew about them, and would go and see them regardless of whether the resident or secretary called to notify us of the consult.) It’s rather a paradigm shift for me to recognize that there are much stronger forces for getting things done than simply following the rules; personal friendliness will go a lot faster. If you want labs now, call and talk to the iv tech; if you want a CT, call the radiology tech and explain why it’s important. But this goes with the culture I’ve admired here since the beginning of the year: the residents and many of the attendings go by their first names with everyone. Loyalty is stronger than protocol.

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