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.