Puella cum Cultello

girl with a knife – the tired ramblings of a female surgeon-in-training

Tag: learning

Outside hospital – ain’t so funny in real life

The Outside Hospital video is great satire – and like all good satire, it shines a very bright light on some uncomfortable truths.  In this case, we’re given some examples of medical hot potato: the patients who do poorly in some God-forsaken outpost before being transferred, with very little useful documentation, to a tertiary care hospital in the Big City.  Sadly, most of us in the trenches of these hospitals have our own memories of being handed a trainwreck with very little back story to help us out.

Mr B was my hot potato.  I was the surgical ICU nights/consults resident, and I got a quick phonecall from the chief resident a couple of hours into my Friday night shift.

“We’ve got a transfer coming in from Outside Hospital, it’s a 78 year old guy who had surgery 3 days ago for gallstones.  Sounds like there might have been some kind of intra-op injury, he’s had a rising white blood cell count and hasn’t gotten better despite antibiotics.  I don’t really know too much else, Dr J [our attending] accepted him and said they sounded like they just gave up.  We’ve requested their scans and notes, but do a history and physical and get some labs when he arrives and give me a call, he should be there around 10pm.”

Phew.  So a potentially very sick old man, and it seemed like we were didn’t have the full story yet.  I’d have to wait it out and piece it together once he arrived.

Sure enough, around 10:30pm, my pager went off. “Mr B is in room 525.”  *groan*  Great.  I had no idea how sick he might be, but he’d scored a bed on a floor that wasn’t used to taking care of anything but the most stable of patients.  I trudged up the stairs, complaining under my breath about this case already.  And that was the last peace I had that night.

I walked into the room, and introduced myself to Mr B’s daughter and wife before turning to say hello to the patient himself.  One look told me all I needed to know at this point.  He was sick, really, really sick, and he didn’t belong on a regular floor – certainly not a floor with no cardiac monitoring.  After saying hello to Mr B and his family, I excused myself and marched right over to the telephone to wrangle with the admissions people.

Me:  Mr B needs to be in a bed with cardiac monitoring.

Admissions:  We only have one regular monitored bed left, and that has to be saved for ER admissions.

Me:  Well, I don’t care where you put him physically, he just needs to be on a cardiac monitor, he’s too sick to be left on level 5.

It went back and forth like this for a few moments, until they agreed to let him have an ICU bed with basic monitoring status.  This was a decision that would serve me well later on.

I went back to the room and finally performed my full history and physical.  I began to have sympathy for vets and pediatricians.  The patient and his family were vague about the details.

Mr B had abdominal pain a few days ago, they went to Outside Hospital and the surgeons told them he needed emergency surgery.  He woke up feeling a little better after the surgery but still had fevers, jaundice, nausea and vomiting 3 days later and then the doctors at Outside Hospital said he needed to come here.  Oh, and his incision was still hurting a little bit.

That was it.  They had no idea which surgery he’d had, no idea why he had it, no idea why the other surgeons thought he wasn’t getting better.  Nada.

I took a deep breath before telling them my plan.  Get labs, start antibiotics, transfer to the ICU, ASAP.  Then I can figure out what the hell’s going on, I thought to myself as walked back to the nurses’ station.  I hoped the notes that came from Outside Hospital would help me.

Ha!  Wishful thinking.  Two hours later in the ICU, I was still sifting through them.  From the reams they’d sent, I had managed to pull out a handful of potentially useful pieces of paper:  two pages of labs (one pre-op and one from that day – stratospheric white count and liver function tests on both); a short typed up history and physical from the ER visit; a barely legible post-op note, from which I could just about tell their diagnosis and operation; and scrawled, completely un-readable notes from the day after surgery.

No operative note to tell us what they’d found or their operative technique, no interval labs or other tests, no discharge summary.  Just a big stack of nursing notes.

At this point, I texted the chief resident with our lab results (high white blood cell count, elevated liver enzymes), and my antibiotic plan, just to keep her in the confused loop.

A couple of hours later, in between taking care of other patients, Mr B’s story was finally beginning to make sense to me.  Then his nurse came over to tell me that he was having some respiratory trouble.  We got some x-rays to make sure he didn’t have a raging pneumonia or heart failure and he perked up for a little while after breathing treatments.  My note was almost done (finally!) when she asked me to take another look.

This time, Mr B had taken a definite turn for the worse, and even from the doorway, I began wondering whether we should intubate him.  After telling the nurse to begin another breathing treatment immediately, I left to ask for a quick second opinion from the medical intensive care attending on call.  Less than 30 seconds later, Mr B went into cardiac arrest.

The usual chaos ensued, and in the midst of the code blue, my mind was racing.  Had I missed something in his history?  Given how little I had to work with, it was possible, but there wasn’t much more I could have done differently that night.  Did I under-treat his respiratory issues?  No, my treatment when he first had breathing trouble had been appropriate.

Did I delay intubation too long?  Well, less than a minute had elapsed between the time I learned of his new breathing trouble and his cardiac arrest.  There was no way that we could have called anesthesia and had him intubated in that time.  But there’s a saying in medicine: if you’re thinking about intubating, you probably should.

By now, I could hear his family wailing in the hallway outside his room.  And in between her sobs, I heard his daughter say something that made me want to punch a wall.

This didn’t happen at the other hospital!

I don’t think I’d ever been that angry with a patient’s family before.

No, no it didn’t.  Of course not.  Because Outside Hospital passed the buck before it could happen.


Words (not) to live by

See one, do one, teach one.

It’s an old phrase in medicine, and it embodies a teaching philosophy that has been passed on for decades – observe, practice, then pass on the skill.  During my third year medicine rotation, that expression was turned on its head once or twice.

Do one, see one, teach one.

I was asked to access a chemotherapy portacath – despite not having seen a port or the needles inserted into them.  The intern dictated a list of supplies and told me the requisite steps, along with a couple of technical tips (namely, “it’s a big-ass needle, don’t stick yourself!”).  I scurried off to the supply closet, eager to get started.

In many institutions, physicians are responsible only for placing central access catheters, which go into the large vessels of the neck and chest.  Specialized nurses will place difficult IVs or peripherally inserted central catheters, and they also access ports.  This allows these nurses to gain experience and develop immense skill in a small range of tasks.  They truly become specialists, and they are far more proficient with those tasks than most physicians.  However, this hospital didn’t have an IV therapy team, union contracts prevented nurses from dealing with most vascular access in a timely fashion, and these issues fell to the already overworked house-staff.

So, here I was, a medical student with less than a year of clinical experience.  I was about to stick a large bore needle into a patient’s chest, aiming for a small device that carried silicone tubing straight into the heart.  I had no frame of reference, no prior experience, for what I was doing.  I had some understanding of the potential complications (infection, thrombosis, air embolism), but the intern didn’t review them formally with me.

Yet no one questioned the appropriateness of this situation.

My intern was happy to have another task checked off his seemingly endless to-do list.  The nurse was glad to have vascular access in her patient without doing it herself.  I was excited to actually be allowed to do something, anything (“I get to touch patients!”), though I definitely had some trepidation about the matter.  And the patient was eager to just have the whole ordeal over with.

Of course, I struggled a little.  I improvised a lot.  I kept hearing a voice in the back of my head – “fake it till you make it”.  And, eventually, both the patient and I survived the procedure relatively unscathed.

But would this situation be acceptable to me as a patient?  Absolutely not.  However, the hierarchy of medicine and my eagerness to be helpful prevented me from insisting on more appropriate conditions.  I was too chicken to refuse, for fear of stirring up trouble, delaying patient care, and losing future opportunities.

Every doctor has to learn, and we all start with very little knowledge.  We slowly gain knowledge and experience under supervision, an apprenticeship if you will, before we’re left to our own devices.  But this should happen in a stepwise fashion, with incremental increases in latitude and responsibility.  Instead, all too often, it’s haphazard, and junior trainees are left to sink or swim – along with their patients.