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.