Dr. Drackman must be the most irreverent writer extant in the blogosphere, and I know I am going to get in trouble with someone for saying this, but I can’t help linking admiringly to this story. Read it for yourself, I don’t want to give away the punchline.
. . . ok, got it?
That kind of thing (free air in a MICU patient diagnosed on chest xray taken for line placement) is the reason I’ve started to make a point of checking the abdomen and the feet of every patient I see, whether surgical or medical, regardless of the reason I’m there. Consultation for thyroid mass? We’ll include an abdominal exam to rule out masses or rigidity, and a pedal exam to make sure the pulses are palpable. I’ve seen too many patients with acute cholecystitis diagnosed after they spent three days in the hospital getting a negative cardiac workup, or calls from the MICU for “a cold foot that we just noticed this morning,” but no one, neither nurses nor residents, can certify when was the last time they actually looked at the feet and noticed them to be normal – maybe not even on admission. (And yes, we complain when the ER calls us for biliary symptoms in a patient with enough medical problems to make cardiac issues a consideration, or immediate surgery a bad option, but I wonder how well we’re serving the patients by teaching the ER to avoid calling us with strange upper abdominal pains that they decide to admit.)
Dr. Drackman mentions his indecision, when he first noticed the patient’s rigid abdomen, about how pointedly to bring it to the MICU team’s attention. It’s a touchy point of professional etiquette, in less dramatic cases, about how much to interfere when you feel certain the other doctors are mismanaging something, but it’s not technically your patient.
When called into the MICU, I do my version of a complete surgical examination, trying to make sure that there’s no surgical cause for the patient to be septic. (Similar to how, when the orthopods are consulted on a trauma patient, they admirably make it their business to examine the patient’s joints from head to toe, and to lookat every film we got, whether we pointed it out to them or not, to see whether there are any fractures the dumb general surgeons missed.) After all, I usually conclude my notes, “no role for surgical intervention,” so I better be sure it’s right.
When the medical patients are in the surgical ICUs, it’s more difficult to stay away. You can see them through the curtains, spending three hours trying to get a few lines into a critical patient, and it’s a great temptation to go offer to help, but I don’t. That would be insulting, and I would probably fail miserably, for my pains. (Though to be fair, I heard the nurses the other day praising a critical care fellow for putting in the fastest lines ever, subclavian and a-line in twenty minutes. My best, so far, is about fifteen minutes for a subclavian, ten for a radial a-line, if the supplies are all handy.) Besides, in the surgical ICUs, the nurses will do a good job of gossiping at the desk: “Did you hear about that MICU patient in the other room? He’s been getting septic, and no one’s sure why, but I think maybe he has C diff. Don’t you think I should just go ahead and check? Ok, I will.” (Stool for Clostridium difficile toxin being, like a urinalysis or tylenol for a headache, one of the handful of things a non-ER nurse usually feels free to order on the assumption that the residents won’t object too much when she tells them.)
This morning I was rounding in the MICU, and walked past a room where the patient was clearly not doing well. I heard the nurses discussing “maxed on all pressors,” and the monitors looked like they were about to flatline at any moment. The resident was standing outside the door, looking miserably perplexed. I didn’t stop, for several reasons: the resident was somewhat of a friend, and senior to me, so it would be silly for me to give advice; if all the pressors were maxed out, that says there’s really not much left to do (except throw fluids at it, which is what surgeons always do, and what the medicine people hate about us); and the patient had that peculiar shade of yellow-grey which says that nothing you do is going to have much effect, any way. He died within an hour, as I later discovered. I’m still questioning myself, though. Maybe if I’d recommended a fluid bolus that would have kept him going long enough for something else to be done. Maybe I should have stopped just because my acquaintance looked miserable, although due to her seniority, I don’t think I know more than her just because she’s an internist. Maybe they’d already tried fluids; I didn’t check what the iv rate was. Maybe I was right not to say anything about a patient neither I nor my attendings had ever been consulted on, and whom I knew nothing about, beyond the plain fact that he was dying.