The Agony and...More Agony
Monday, Columbus Day 2005, the day after Long Call. I get in about 7am and "pre-round" on my patients. The idea behind pre-rounding is to get a picture on any significant events during the night - the primary source is the patient, and other sources include any nursing notes or any vital signs or lab results that have just been reported. I get to JJ's room about 7:30 - the first thing I always ask is "How was your night? Did you sleep well?" Apparently he didn't - JJ is a light sleeper - would benefit from sleeping pills, but I sell him on the idea of trying ear plugs. Sounds like JJ is stable, though.
Mikey: Is there anything you'd like to ask me?
JJ: Yes. One of the nurses gave me some medicine - it was a powder mixed in water - and when I took it, I felt a burning in sensation all over my chest and then I felt it in my neck and shoulders and I had a headache for an hour.
Mikey: When did this happen?
JJ: About an hour ago.
Mikey: Are you having any pain now?
JJ: It ended about ten minutes before you came in.
Mikey: So the pain lasted about an hour?
JJ: Yes.
Mikey: Did you tell anyone?
JJ: Well, the nurse left before I actually took the medicine.
Mikey: Did you press the alarm button?
JJ: Well, I know the nurses are really busy...
Two things to note here:
The team enters JJ's room to see how he's doing - he looks a little more sick than yesterday - he's sweating and becomes short of breath when he sits up. When we listen to his lungs, we can hear fine crackles whenever he inhales and exhales. His urine is a really dark coca-cola color. We quickly bring in instruments to measure his blood pressure, O2 saturation, and get an ECG. His blood pressure is up, his O2 saturation is down, and we see ST depression in a couple leads on his ECG. This probably isn't due only to his pneumonia. One of the first things we can do is decrease the workload on his heart, so we order 20 milligrams of furosemide to be administered immediately. Furosemide is a potent diuretic and will prevent water resorption in the kidney, leading to a profound increase in urine output. Simply, this will decrease the amount of resistance that the heart has to work against with each contraction. Within several minutes, JJ has put out a couple hundred milliliters of 'Furosemide urine'. Stacey calls it that because of the color - before furosemide, JJ's urine was the color of Guinness - after furosemide, it's more the color of Bud Light. This is good - it means the drug is doing its job.
Stacey, Sally, Reva, and I huddle to discuss the case. I'm already feeling guilty about not alerting anyone about JJ's chest pain, previously. It gets worse. If you recall, the previous day we thought that JJ was dehydrated, so he was given one liter of normal saline. The evidence points strongly to the idea that we overloaded him with fluid. The increased blood volume could explain the increased blood pressure. The increased blood volume could cause leakage of fluid into his lungs, explaining the crackles we heard on exam, his shortness of breath, and his decreased O2 saturation. We wondered why we hadn't noticed it earlier. I get flustered. I had visited JJ later in the evening to ask some more questions, and the nurse had mentioned that his O2 requirement had increased to 6 liters of O2 per minute, up from 3 liters earlier. I'd mentioned it to Rahul, who said not to worry about it.
When I report this in the huddle, it comes out in the following manner:
Stacey: This was sudden. He was only on 3 liters of O2 yesterday.
Mikey: I noticed that his O2 requirement was increased last night.
Sally: Did you tell anyone?
Mikey: I did - it didn't seem like anyone (and I was desperately searching for the correct words here) was concerned.
Already my day has turned upside-down, but I quickly realize that I've violated a cardinal rule in Medicine: don't correct your resident in front of your attending physician. To be honest, I was putting out information because I'd neglected to put it in my presentation beforehand, and now it looked like I was humiliating Stacey. I've never wanted so much for a hole to open up and swallow me whole. We have to finish rounding on the rest of our patients, which takes about an hour. I have a hard time paying attention - all I can think of is how much I've screwed up, how much of an asshole I am, and how I'm going to apologize to the team. This is the Longest. Hour. EVAR.
I take Stacey aside and privately apologize to her. I don't know what embarrasses me more - my failure to alert the team immediately concerning JJ's condition, or my correction of Stacey in front of our attending. She's baffled:
I spend the rest of the day alone with my thoughts, wishing this pain would end.
Mikey: Is there anything you'd like to ask me?
JJ: Yes. One of the nurses gave me some medicine - it was a powder mixed in water - and when I took it, I felt a burning in sensation all over my chest and then I felt it in my neck and shoulders and I had a headache for an hour.
Mikey: When did this happen?
JJ: About an hour ago.
Mikey: Are you having any pain now?
JJ: It ended about ten minutes before you came in.
Mikey: So the pain lasted about an hour?
JJ: Yes.
Mikey: Did you tell anyone?
JJ: Well, the nurse left before I actually took the medicine.
Mikey: Did you press the alarm button?
JJ: Well, I know the nurses are really busy...
Two things to note here:
- JJ is an amazingly nice guy. Nicer than nice. Even knows how his hospital roommate is doing, he politely notifies a therapist the best way to wake his roommate up. Point being: there are patients who complain too much, and there are those that complain way too little.
- The second that a patient reports the slightest bit of chest pain or pressure, you tell someone. Anyone - nurse, resident, attending physician. Anyone. Because as soon as you do, there's a set of events that occur to ensure that the patient isn't going into cardiac arrest.
The team enters JJ's room to see how he's doing - he looks a little more sick than yesterday - he's sweating and becomes short of breath when he sits up. When we listen to his lungs, we can hear fine crackles whenever he inhales and exhales. His urine is a really dark coca-cola color. We quickly bring in instruments to measure his blood pressure, O2 saturation, and get an ECG. His blood pressure is up, his O2 saturation is down, and we see ST depression in a couple leads on his ECG. This probably isn't due only to his pneumonia. One of the first things we can do is decrease the workload on his heart, so we order 20 milligrams of furosemide to be administered immediately. Furosemide is a potent diuretic and will prevent water resorption in the kidney, leading to a profound increase in urine output. Simply, this will decrease the amount of resistance that the heart has to work against with each contraction. Within several minutes, JJ has put out a couple hundred milliliters of 'Furosemide urine'. Stacey calls it that because of the color - before furosemide, JJ's urine was the color of Guinness - after furosemide, it's more the color of Bud Light. This is good - it means the drug is doing its job.
Stacey, Sally, Reva, and I huddle to discuss the case. I'm already feeling guilty about not alerting anyone about JJ's chest pain, previously. It gets worse. If you recall, the previous day we thought that JJ was dehydrated, so he was given one liter of normal saline. The evidence points strongly to the idea that we overloaded him with fluid. The increased blood volume could explain the increased blood pressure. The increased blood volume could cause leakage of fluid into his lungs, explaining the crackles we heard on exam, his shortness of breath, and his decreased O2 saturation. We wondered why we hadn't noticed it earlier. I get flustered. I had visited JJ later in the evening to ask some more questions, and the nurse had mentioned that his O2 requirement had increased to 6 liters of O2 per minute, up from 3 liters earlier. I'd mentioned it to Rahul, who said not to worry about it.
When I report this in the huddle, it comes out in the following manner:
Stacey: This was sudden. He was only on 3 liters of O2 yesterday.
Mikey: I noticed that his O2 requirement was increased last night.
Sally: Did you tell anyone?
Mikey: I did - it didn't seem like anyone (and I was desperately searching for the correct words here) was concerned.
Already my day has turned upside-down, but I quickly realize that I've violated a cardinal rule in Medicine: don't correct your resident in front of your attending physician. To be honest, I was putting out information because I'd neglected to put it in my presentation beforehand, and now it looked like I was humiliating Stacey. I've never wanted so much for a hole to open up and swallow me whole. We have to finish rounding on the rest of our patients, which takes about an hour. I have a hard time paying attention - all I can think of is how much I've screwed up, how much of an asshole I am, and how I'm going to apologize to the team. This is the Longest. Hour. EVAR.
I take Stacey aside and privately apologize to her. I don't know what embarrasses me more - my failure to alert the team immediately concerning JJ's condition, or my correction of Stacey in front of our attending. She's baffled:
- First, JJ's condition is not my fault - she makes the point that numerous other people are involved in his care: nurses, interns, residents, and the attending - any one of these people should also have recognized the warning signs. Small comfort, really - I'm on the front line now, and because I wasn't more forthcoming with the information, JJ has now been transferred to the Telemetry Unit (where they can keep a constant eye on his vital signs) and perhaps faces a prolonged stay in the hospital.
- Second, being corrected in front of our attending doesn't matter to her. "We've all been where you are, so don't worry about it any further." I'm lucky. A lesser person could've have made sure that I paid for such an insult dearly. I expect better of myself. Medical knowledge will come with experience. Professional behavior is something that I should be able to handle right now, and I blew it.
I spend the rest of the day alone with my thoughts, wishing this pain would end.
posted by Mikey at 11:07 PM
2 Comments:
Look, dude, you're harder on yourself than I am on myself, and that's pretty impressive. I know it's a BIG DEAL thing we're talking about here, and there are so many things that you can always look back on in retrospect. But there's a big difference between taking all of these things, putting them in the catalogue, and making sure you add in a quick reference key so that it gets easier and easier to keep everything in mental order in the future, and beating the shit out of yourself. Especially the second part of correcting your resident. I know that professional behavior dictates alot of things, but there are only 2 people in that equation - Her and you. Apparently she took no slight from it, so there's no reason for you to be so hard on yourself. Just my opinion, of course, but I just hate to see how hard you are on yourself sometimes. Mistakes happen, and though there's going to be alot of times when you can't, I personally think that easing up on yourself is allowed in this case, and better for your health.
I reccomend taking OFF the boxing gloves and giving your face a break lol....
I agree with davey here.
buck up ol boy, she didn't seem to give a rat's arse - cool! now you can look forward to something else to beat yourself up over :)
can't imagine doing what you're doing ... but, thought I'd let ya know I'm in your corner of the rin (where the hell did this boxing euphamism come into my life? I don't watch boxing?)
ciao bella,
who you become will catch who you are
(right, is that how you say it?)
kat
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