Thursday, February 12, 2009


This morning we had a ninety year old woman who had newly diagnosed breast cancer. Rather than going through the risk of general anesthesia, we performed a lumpectomy under local anesthesia while she was wide awake, not getting so much as a drop of ativan. Immediately after, she went to the pharmacy to pick up some painkillers, then drove herself home (waiting until she got there to take anything, since one can't drive if taking narcotics). She didn't have anyone with her because she didn't tell her son and daughter she was having the surgery until last night so that they wouldn't be able to miss work for her. She takes care of her demented husband at home, so had to be back quickly.

Last night, one of my post-op patients, rather than waiting 5 minutes for the nurse to page me for more pain medication, called a rapid response from her room. What she thought it would accomplish I don't know, since it's composed of nurses who can't give narcotics without an order anyway. Then she called the operator and tried to bully her into calling my attending at home. Quite a contrast.

Saturday, February 07, 2009


This month I'm again at one of the local community hospitals. While in a lot of ways more relaxing than the academic hospital, we only have two residents this month so we've been pretty busy. I started out on Sunday, thinking that I could round early, take care of a couple minor issues, then go to church for the first time in a month (we take home call there, so don't have to stay in the hospital if nothing's going on--we just come back if there's a new patient or one of the current patients crashes). That dream ended when I was paged at 5:30 AM by the intern who had been on call Saturday night, to let me know that one of the patients had to be transferred to the ICU overnight, and was doing very poorly. Additionally, a nurse just called him to let him know that one of the vascular surgery patients had a cold and pulseless foot (which, if true, would be a surgical emergency).

So, hopes of a quiet Sunday crashing, I went in to the hospital, stopping at security to get my ID badge and keys, that should have been left there Friday. Only none of the three security guards could find them. I got them to give me a student ID though, so I had access everywhere. I then proceeded to the ICU, first stopping to see the "cold, pulseless foot". It was actually quite warm, and I could palpate a posterior tibialis pulse though not a dorsalis pedis. I looked through his chart, and there was no mention of anyone ever being able to palpate a dorsalis pedis, so I was not terribly worried. I went to see the next patient, and found that she had been made DNR/DNI (no resuscitation or intubation if she crashed) by her family. She barely had a measurable blood pressure despite being on a high dose of vasopressors, was completely unarousable, and had dilated, nonreactive pupils. There wasn't really anything to do, but I called my senior to let her know what was going on. Then I called the family, and confirmed she was really DNR/DNI. They eventually chose to pursue only comfort care, so we stopped the vasopressors and she died within 20 minutes. It was the first time that I had to pronounce someone dead and call the family--fortunately they knew she was doing poorly, so it wasn't a shock. In between dealing with these issues, I was also trying to round on all the floor patients whom I had never met before--thankfully there weren't too many of them.

Once that was done with, we ended up having one OR case that had been added on, a pilonidal cyst excision. I got to do the procedure, which was nice. By that time it was 3:00, and I went home. Nothing else happened, so I slept most of the night.

I do have to give a little note about pager etiquette--when you page someone, you are essentially asking that person to stop whatever he or she is doing and call you back. To be courteous, you need to be at the telephone when that person does call back, and you need to wait by the telephone for a minimum of 5 minutes, in case they're doing something else and can't get to a phone. After 5 minutes, you can leave and let the clerk call you back when the person calls back. It is completely unacceptable, and actually very rude to page someone then leave the phone. I mention this, because there is one particular hospital we rotate through that every single nurse does this every time, so that when I call back seconds after being paged, I am then put on hold for five minutes waiting for her to finish whatever task she has left to go do and actually come back to the phone. It is incredibly infuriating, and essentially is telling whoever you paged that your time is worth more than theirs. Now I wait on hold for a maximum of one minute then call the secretary back and tell her to tell the nurse to re-page me when she has time to talk. It's gotten me a couple of apologies, but they continue to page and leave the phone. This doesn't happen at any other hospital I've been to, so it shouldn't be asking too much. All right, end of rant.