04 January 2007

Kicking ass and taking names

I did something to my back at Karate the other day. Nothing serious, but a painful lumbar muscle strain. I took enough ibuprofen to kill the proverbial horse, but it was still really hurting when I went in to the swing shift, 7pm-3am, and it was with the grumpy thought that "nobody gets narcotics tonight unless they're in more pain than the doctor," that I began my shift.

The department was absolutely out of control on my arrival. The PAs were doing well keeping the "Greens" taken care of, but there were probably 20 "Yellow" and "Orange" patients
in beds and in the hallways waiting to be seen, some of whom had been waiting four hours or more.* And that's not even to mention the waiting room. Ugly.

So I put my head down and got to work. What else can you do? The nice thing was that according to the day's assignment, I had my own eight-bed area, which for once was fully staffed with nurses and a tech, and I had some of the best nurses on my team. And it was amazing. Things just happened like they are supposed to -- meds were given, beds were emptied, every patient I touched just got dispositioned as soon as I walked out of the room. Truly, I was in The Zone. And some of the folks were sick. One dude with a hemoglobin of 2.5 (which is about 15% of the normal red blood cell count), another with a severe pneumonia, a couple of septic octogenerians, a ruptured ectopic (diagnosed, I might add, on bedside ultrasound), etc. My partners in their areas were doing the Lord's work, as well. Six hours into the shift, I finally looked up. All patients had been seen, and the waiting room was empty. At that point, I had seen twenty-four patients, of which eight were admitted.

Now, I don't mean to brag. Well, yes, I do mean to brag a bit, but I should supply a little perspective. At our facility, the acuity is high, operations are not too efficient, and if you can see two patients an hour, you are doing well. I had seen four patients an hour. It was, as far I can recall, my all-time personal best. And even better, all my patients were done, the documentation was done, and I walked out the door an hour early. Unheard of -- all the stars aligned for me. I had also been able to do this without short-changing the patients in terms of face time. I got to sit down and talk to each at the beginning, and check in once or twice each. I can't credit the nurses enough. I ran them hard, to be sure, but they rose to the challenge. I wish I could work with that group every night.

And as I got into the car to drive home, it occurred to me that I had not thought about my back in hours.

You know, one of the interesting thing about my job is that it is always challenging. The medicine is challenging -- sometimes. But honestly, after a while, you can tell the diagnosis even before you walk into the room. You just know, somehow. The mental gymnastics in figuring out the diagnosis on 90% of the patients becomes reflex. But the real challenge -- to be efficient, to Move the Meat, to manage the limited resources in your department in the most effective manner -- that is always different and never gets old and, strangely, sometimes offers more satisfaction than does the actual patient care.

I can't wait to see what tomorrow is like.

*We use a "Five Tier Triage System"
Red -- About to die
Orange -- Very serious complaint/problem; should not wait
Yellow -- Potentially serious problem; wait should be short
Green -- Stable, minor problem; not urgent
Blue -- Not urgent at all (med refill, etc)


  1. how anti-climactic. i thought you were gonna get done with your perfect shift, you were gonna get into your car early with a huge smile on your face, and a nurse was gonna run out to your car, get in your way, and tell you a bus full of hemophiliacs was just hit by a bus full of narcotic pain medication addicts and they were all on their way to your ER.

  2. "But the real challenge -- to be efficient, to Move the Meat, to manage the limited resources in your department in the most effective manner -- that is always different and never gets old and, strangely, sometimes offers more satisfaction than does the actual patient care."

    Even that is a satisfaction that is often taken for granted. Thanks for the reminder.

  3. Well, last night absolutely sucked for me, however. I saw 41 patients from midnight on until 7AM by my lonesome self. And all needed to be in the ED, too. Not the BS toothache, sorethroat crap either. I stayed afterward to dispo my own patients because it's my policy never to turn over to anyone. I didn't get out of there until 10:20 this morning. Let's see...stab wound to flank, got the liver, stab wound to chest (these two dudes stabbed each other) PTX, ventricular lac with tamponade, aortic dissection all the way from the ascending, involving brachiocephalic, bilateral common carotid, arch, descending aorta, all the way down to the iliacs. Renal arteries were involved, too. The motherload of all dissection! Acute anterior MI, thank goodness no cardiogenic shock, Pulmonary Embolus, 1 appy (what's a shift without at least 1 appy?), 2 SBO's, dialysis pt. with flash pulmonary edema, 2 pnemonia cases, a 4 wk'er with pyloric stenosis, a GHB overdose who got intubated then extubated, Tylenol PM overdose, post op wound infection and dehis in a lady 4 days s/p incisional hernia repair....Pancytopenic pt with lung ca receiving chemo, he was in septic shock...my head is completely numb at this point. I'm gonna go to bed now. There were too many sick people to remember them all. I left 2 charts undictated and will have to dictate them later this evening when I return.

  4. Charity, I'd say that roster of pathology defies credulity, but I've seen the photos of your trauma bay and the CT scans you post. However, I have said this before -- that sort of volume plus that sort of acuity is unsafe. It's just wrong, on so many levels. Five patients an hour? With 20% or more critical care cases? Come on. I'm impressed that you are able to do it, but I am angry on your behalf that you have to. Where is your medical director? ER docs aren't that hard to come by -- get another doc for the overnights. If you don't, it's only a matter of time before the volume overwhelms you and you kill someone -- and then you'll have a malpractice case that you *can't* defend. I'm no wimp -- I'll see 2+pph at a shop where we admit 30-40% with 10-15% critical care, but that's busting my ass, with a lot of nursing help. 5 pph -- that's dangerous.

    Let me know if you want me to come out as a "consultant" and tell your administration how badly they need more help. :)

  5. Shadow,

    I'm not shietin' you about the volume, I'm really not. Last night was just one of those bat shit crazy night. I went straight home and dropped into my bed and slept without breakfast. I just woke up after 6 straight hours of uninterrupted sleep, which I rarely ever get. Ah, that reminds me to thank my lovely wife for taking the kids out of the house and occupying them for that long so I can sleep in total silence. I'll post the dissection patient's CT when I get a chance tomorrow. Yes, it's completely unsafe and dangerous. No one is more keenly aware of the situation than I. We're down 2 docs at this time and have already interviewed several candidates. Since our census have jumped up dramatically this past year, the hospital have agreed to shell out the bucks so we can hire 2 more docs. So in total, we're interviewing for 4 positions. To be honest though, the area leaves little desire for anyone to move here and raise a family. There is absolutely nothing here to attract any decent candidate to come and live.

    I've actually met with our state representative (he's a high school classmate of mine) as well as our state senator. They're both interested in turning our medical center into an academic institution because it's state chartered hospital since the 1930's, which means that they can actually offer sovereign immunity to all the staffs. Our volume and diversity of pathology can certainly accomodate for medical students and residents from the state universities to rotate through. I'm negotiating with the new CEO of the hospital to extend sovereign immunity to our group since it's certainly within his power to do so. But the asshole wants us to be hospital employees first and not an independent contracting group. Bullshit, because there should be no problem for a state chartered institution to extend sovereign immunity to it's independent contractors. The wheels are turning.


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