Back from a ID theft imposed digital holiday and stuck with a raging case of insomnia. I mean, what did I do to sleep for 4 hours voluntarily? I wanted to sleep, just couldn’t, so here I am.
Nothing puts experience in perspective like having a doc ask you for advice. It’s humbling and kind of scary all at the same time. Really? You’re the doc. Y’know, medical school? At least 1 year as a full fledged doc, writing orders, telling us lowly peons what to do? Any of this ring a bell?
The conversation went along these lines…
“So I have a patient I want on tele, but they’re bradycardic. I mean, you do that right?” Dr. Obvious.
“Um, yeah. We have brady folks all the time. Not really a big deal.” says perplexed charge nurse (PCN).
“OK, can you guys do pacing on the floor or do I need to send them to ICU?” Dr. Obvious.
“Uh, if you’re thinking they need to be paced odds are pretty good they need to be in the Unit.” PCN.
“Right.” Obvious is thinking here. “They’ve been brady and slightly hypotensive. You guys can handle that right?”
“Uh-huh.” starting to look around for Peter Funt and a camera crew. “I mean, brady is fine. If he drops too low we’ll just drop into ACLS and do our thing. How low is he anyway?”
“He’s been holding steady in the 40’s. Last BP was 100s over 60s”
face palm… “Look as long as he’s not doing any kind of funny block, I’m cool with them in the 30s with a pressure that good. He’ll be fine. If you want, you can write orders for atropine prn and we’ll put pacer pads on…”
I’m trying not to laugh here. Really 40-50s with pressures in the 100s? I thought it was a real issue, like they’re runnning 30-40’s in a Mobitz II block or something funky. Really? Sure, I appreciate being asked what our comfort level was, but you’re the doc. You get the special white coat and all that to make these hard decisions. You want tele, fine. We’ll deal with the the issues, and if the fecal matter hits the air oscillator, we know what to do.
Had a patient the other week that ran consistently in the low 30’s post-Sotalol. I’m OK with that. BP of 86/40 in a CHFer who’s talking to me coherently and making urine? I’m good. Now the guy who we were getting pressures of 70/palp with a heart rate in the 120’s and was minimally responsive, that made my sphincter pucker a little. But that’s why I love telemetry, we take relatively unstable patients (even those that probably need to be in ICU) monitor them and do interventions to fix them. Part of me appreciates the call, but part of me views it as an insult, in the implication we can’t take care of the (not)unstable patient. Make your decision, you’re the doctor, right?