You want what?

“Hi, Dr. Heart, I’m calling you about Mr. I’ve-gone-crazy who your partner did a pacer generator change on today.  He’s become very agitated and combative since the start of our shift.  I need something now to calm him down as nothing else has worked.  Would something like Depakote sprinkles or Zyprexa, maybe even Haldol be OK with you?  said the nurse into the phone.

Seriously, the guy was freaking out.  Every non-pharmacological method we have in the arsenal had been thrown at him.  He was confused and rightfully so.  It’s not nice to put folks with dementia through surgery, it leads to some very funky things.  He went from perseverating over his pants to perseverating over his wheel chair, then he wanted to be in bed, now in the chair and wherever you put him he wanted out of it.  Did I mention he could not stand and bear his own weight?

The other nurses looked at me imploringly to help his nurse out.  “You’ve got to do something!” they said to me.

“She’s his nurse, and yes, we’re doing all of her work for her, but I cannot call the doc for her.  I don’t know the details, I don’t know enough about his history to state my case for what I think is needed.  But I will talk with her.” I said.

The nurse came up to me minutes later and asked what to do.  I reeled off the things that might help, meds that we have used time and time again in these situations.  She agreed and went to call the doc.  Above is how I pictured the conversation (she likes to hide in the med room or pharmacy office to call).

I can surmise how the rest of the above conversation went.  “You want what?  I have no idea about any of those meds.  He’s agitated?  Um, not really used to dealing with this, is he covered by Medicine?  No?  Really?  I don’t even know what the doses would be for those meds in this situation.  Uhhh…how about some Ativan?”

To which the nurse readily agreed.  Really we would have taken anything at that point.  This is not to say that our cardiologists don’t know what they are doing, they’re just not as adept at helping us handle the agitated and combative elder as say our medicine interns or geriatrics service.  It’s a level of comfort.  Our geri docs would readily agree to something like Depakote far faster than Ativan, but it’s their milieu.  Would not want one of them dropping a stent in my patient.  It’s what you know.

And the Ativan?  It worked for a while but he ended up with a sitter by daybreak, still confused and combative, but staying safely in bed.  Lesson?  Avoid general anesthesia and things like Versed and Fentanyl on demented elders:  it makes them worse.

(Am not saying to not do procedures on folks of advanced age, make sure you give us the tools to manage them and ensure their safety post-operatively when you do!)
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Um, You’re the Doctor, Right?

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?

That’s Just Wrong

Not too long ago we had a patient on our obs unit who was dealing with some issues of constipation.  Unfortunately, they had 2 things working against them.  First, was being born with a congenital defect requiring surgery and leading them to a life of issues with their bowels.  Second, was being admitted to obs by Dr. Jackass.

Dr. Jackass wrote that the patient would be able to discharge after having a bowel movement.    After a phone call by the nurse for some pain medication, he decides to send things into overdrive and orders the following:

“continuous soap suds enema with rectal tube until clear”

“Say what?!” asked the nurse.

“Say what?!” asked the charge nurse.

“Fuck that!” said the patient who was young, alert, oriented and appropriate.

“He ordered what?!” asked Dr. I-have-a-clue who was the overnight cross-cover, “Yeah, nix that.  Go ahead and try a soap suds enema x1 – if they’ll let you.”

No enema.  Patient pooped, slept and went home.  Nice simple resolution.

original image here.

Mad as Hell

Finally someone is stepping up to force the maniacs in Washington to slow down, think things through and include everyone in the debate over health care reform.  Enter:  Mad as Hell Doctors.

Yes, doctors, mad as hell that the majority of the country has been left out in the cold while the privileged few run our system beyond ruin in a vain attempt to fix it.  Single payer?  I’m not sold on that idea, but my love of this idea lies here:

Let’s restart the effort and take Health Care legislation off the table until the Spring session of Congress. In the meantime, let’s use HR 676 as a starting point for a new health care conversation and empower MAHD physician-citizens to seek out the best minds from America’s vast resource of inspired health care professionals. We will then assemble these individuals into a working team that does not include anyone from the private Health Insurance Industry, the Pharmaceutical Industry, or anyone currently holding public office. Their assignment will be to craft a thoughtful, actionable single payer health care model, uniquely tailored for America, that the entire country can comprehend.

Who knows, maybe this is the method to shore up our failing system.  But what I love the most the drive for honest and open debate.  No back room deals inside committees, no one involved who has received money from the very places we’re trying to reform, no “death panels” (dumb-asses…read the fucking literature), the interests for once are left out in the cold with the goal of bringing everyone in, and leaving no one out.  Is that such a bad thing?  Really? I didn’t think so.

No, we need it now.

Somedays our hospital staff just baffles me.  Somedays they are über-ready to get something done, like the CT tech who calls 30 seconds after you put the order for a CT in.  Other days you call phlebotomy and three hours later they show up to draw a “now” lab.  There’s no consistency.  And when you need something like blood, it’s usually not just something that you can be “meh” about.  Case in point happened a couple of weeks ago.

We had a patient who needed blood.  Badly.  Unfortunately due to their specific disease and numerous antibodies, they needed special blood.  The Red Cross had to fly it in.  Yes, fly it to us and we’re fairly good-sized city.  It’s not like we’re in the middle of podunk backwoods-land.  The blood bank calls us at 1am and says the blood has arrived and we figure we’ll be getting a call soon that it will be ready.  2am, nothing.  3am, nothing.  The house doc comes up asking if the blood has started, he wants it done now.

So we call blood bank.

“Calling about the blood for us up here on 5.  Is it ready yet?”  asks the nurse.

“No, we’re having a problem with the computer and can’t get it ready.” replies blood bank.

“No, we really need it soon.  It’s kind of important.”  replies the nurse.

“Well, you see there’s a probelm with the computer generated tag and I can’t do anything about it.  Only my supervisor can has the right access…”  says blood bank.

“And when are they coming?”  angrily asks the nurse.

“Uh, I haven’t called them yet.  Don’t really want to wake them up, it’s 3am.”  they say.

“Maybe you don’t get it.”  says the nurse.  “My patient’s H/H has dropped to 5.0/16.3 in the last 4 hours that you’ve been stalling on getting the blood to us.  You need to call them.”

“Let me make a call.”  they reply.

30 minutes go by.  The house doc comes by again, still wondering if we’ve started, which we haven’t.  And then comes the cool part.  He calls them.

“Look, I don’t care if the supervisor has to override this or that.  My patient needs blood.  If they haven’t arrived in 10 minutes, I’ll come down there and sign the blood out myself, to hell with your computers.”

Guess  what?  The blood was ready in 7 minutes.  Sometimes having an MD to throw their weight around is a good thing!

Sleepy Head

One of the nephrologists is a  notoriously sound sleeper and wakes up very, very slowly.  So when he’s on-call you can pretty much ask for whatever you want and he’ll sleepily agree to it.  And when you’re having the conversation he requires constant stimulation to keep him awake.  There’ll be long silences puncuated by the nurse saying, “Dr. Nephro…you still with me?”  To which he’ll groggily assent that yes, he was still there, kind of.

A friend of mine had called him one night for a patient with out of control blood sugars figuring to start an insulin drip to get the patient better controlled.

As the nurse is on the phone “Uh, OK.” says Dr. Nephro, then  silence.

“Dr. Nephro?  Are you still there?”

“Huh?  Oh yeah.  Uhhh…let’s start a Vitamin K drip…” trails off as he falls back asleep.

“Dr. Nephro?  Don’t you mean insulin?”  asks the nurse.

“Uh yeah.  Sure.” he replies then proceeds to give relatively cogent orders for the insulin drip, with a little extra prodding from the nurse.

About 6am, we get a phone call at the nurses station.  It’s Dr. Nephro.

“Uh…” sheepishly he asks, “Did I order a Vitamin K drip on someone last night?  I seem to remember getting called, but I can’t recall if I actually ordered that.  Did I?”

Being the good charge nurse I replied, “Well, you started to…”

“Really?” he asked.

“Yeah, but the nurse re-clarified it with you and got the insulin drip the patient actually needed.”  I replied.

“Oh, OK.  Thanks for being on top of it.”  he said as he hung up.

I was talking to a nurse over on the renal floor and she said that they can pretty much get whateve they want out of him when he’s like that.  It does however, make for some interesting morning phone calls!

Just because you’re smart

Doesn’t mean you get to be a dick.  Case in point happened the other night.

My friend and co-worker pages the on-call doc and when he calls, the following conversation ensues:

Nurse: Yes, I’m calling about Mr. Jones, a 55 y/o male admitted today with hypertensive urgency related to changes in medication to his intra-thecal pain pump..

On-call Doc: interupting His what? already pissed off

Nurse: Intra-thecal pain pump.  They’ve been tweaking his clonidine dosing.  His blood pressures have been running anywhere from 200s over 110’s to 180’s over 90’s.  Right now, after 200mg of Toprol XL he’s still at 188/105.  He has a history of a AAA repair less than a year ago and I’m a little uncomfortable having him run so high.  All the Toprol did was drop his heart rate.  He’s also been having episodes of chest pressure that’s been relieved…

On-call Doc:  You’re uncomfortable?  I’m OK with that pressure.

Nurse:  Even with the AAA repair and his increasing episodes of chest pressure?

On-call Doc: smugly Well it sounds like we need to modulate his angiotensin system then.  Do you know what drugs do that?

Nurse:  Isn’t that your job?  It’s why I’m calling you…

On-call Doc: breaking in again It’s enalapril.  Do you need me to spell it for you? A-N-A-L-I-P-R-I-L. nurse repeats aloud 10mg, PO BID, 1st dose now.  Good night.  hangs up

Nurse: to me Don’t you mean E-N-A-L-A-P-R-I-L?  Dumbass.  Too bad he hung up.  That was fun, maybe he could have been a litle more condescening…

Ahhh, smug docs.  Always a favorite.  Especially when they do or say something truly stupid.

Hmm… patient got analipril (snerk), his pressure went down and his chest pressure magically went away.  I love it when you note you’re uncomfortable with a patient’s assessment/orders and the doc says, “I’m not.”  All I can ever think about, but never say is, “Of course you’re OK with that.  You’re not here to deal with it when they go south.”  But I guess when you’re “smart”…