Friday, June 13, 2008

Paraskevidekatriaphobia

Okay, I almost have to be a believer now.

Friday the 13th is BAD luck!

Either that, or my former "white cloud" for call nights has turned into a decidedly black one (in medicine we often describe people who always have quiet calls as having a white cloud and those who are constantly hammered on call as having a black cloud).

Actually, I haven't believed in "good luck" or "bad luck" since childhood; I believe we create our own "luck." But this was not only another one of those up-all-night calls but also a call during which there seemed to be more equipment mishaps, paperwork losses, and communication flubs than usual!

My colleague Maddog (moniker his choice) once had a memorable Friday the 13th case: a midnight penile fracture in a 280-pound patient incarcerated for some scary crime or other. Maddog was calling him "Hannibal Lecter" and said anyone near him would have felt like potential snack food. [Photo credit: Geneva Foundation for Medical Education and Research.] It just went downhill from there for Maddog. [Click here for a urologist's tidbit about penile fracture.]

During the day today I was in the O.R. off and on for about 12 hours.

Then there was a call from the E.R. doc who called to ask if I could stand by and assist while he tried to intubate a near-300-pound patient with a suspected medication reaction. The patient was so large she appeared to take up the entire exam room. Already this sets off alarm bells in an anesthesiologist's mind: obesity triggers concerns about difficult airway management, difficult IV access, difficult spinals and epidurals, and potentially difficult managemet of various medical problems. When we anesthetized the patient and placed her supine on the stretcher the middle of her belly was a spherical mound that practically obscured my view of the nurse on the other side of the stretcher. When I saw how much soft tissue there was around the neck I began to dread hearing the E.R. doc say he couldn't see the vocal cords, but he did a nice job with the intubation. Whew! [Some descriptive elements of this case have been altered. This photo and the next are from http://commons.wikimedia.org]

Then there was the mother whose premature fetus was presenting a nerve-wracking fetal heart tracing. We watched over her for hours, prepared to do a crash C-section but dreading the delivery of a premature infant at a hospital with neither a neonatologist nor a neonatal ICU. Fortunately she stabilized enough to be transported to the closest tertiary care center.

Then there was the last epidural I placed. Usually I can place epidurals reasonably quickly. That last epidural, though, was CURSED. The procedure itself wasn't the problem; the problem was unforeseeable, uncontrollable equipment issues. The first epidural catheter I passed developed a kink that prevented me from injecting medication through it. The second one hit a blood vessel and was thereby rendered un-usable as well. I went through three catheters before breaking this streak of misfortune. This is almost UNHEARD-of.

Then I was up till 3:30 in the morning doing ob/gyn cases - for a patient who had had a miscarriage, and another woman whose labor had stalled and needed her child delivered by caesarian. I went to bed at 4 a.m. thinking, thank the Lord, I can get at last get a little sleep before I switch to being on call for the other hospital...but at 4:30 the beeper jolted me out of a just-acquired, much-desired sleep with the most annoying page in recent memory.

Nurse: Hello? Is this Dr. Z?

Me: No, it's Dr. T from anesthesia.

Nurse: Oh...um...I'm just calling because Dr. G from your department changed an epidural order to a rate of 10 mls per hour.

Me: Ok.

Nurse: I just wasn't sure if that meant the infusion rate or what.

Me (crazed with sleeplessness): I would assume so - it does say "rate," right?

Nurse: Um...right. Actually the problem is the order was written at 3 p.m. but the nurse from the afternoon shift never picked it up.

Me (confused): Ok. And?

Nurse: Well, the nursing supervisor told me to call Dr. Z.

Me: I thought the order was written by Dr. G?

Nurse: It was, but she said to call Dr. Z.

Me: Dr. Z's not here. She's not on call. What does the nursing supervisor want, exactly?

Nurse: Well, we have a policy that any time there's a medication error, the doctor has to be notified.

Me: I look again at the clock. Quarter to five. So, the order was written during the previous shift?

Nurse: The 3 to 11. I'm on the 11 to 7.

Me: That's almost over.

Nurse: Well, it took us a while just to figure out what happened. When we finally sorted it all out my supervisor said to call you.

Me: Why? I'm sorry. I know I'm sounding a little frustrated. Please don't take it personally. It's just that I've been up since 6 o'clock yesterday morning, and I'm not fully understanding the situation. I'm just trying to understand what you need from me.

Nurse: According to the rules we have to make sure the doctor is aware of all medication errors.

Me: I see - "M.D. aware." So, a NURSING error was made - one of the nurses failed to carry out a written order - and now thirteen hours after the order was written, which means the NEXT DAY, you're calling a doctor who has never seen the patient, heard of the case, or been involved with any of the orders? I'm still a little unclear as to what exactly you want me to do.

Nurse: Well...Do we still carry the order out now?

Me: Is the patient in pain?

Nurse: Yes.

Me: Then I don't see any reason why Dr. G's written order shouldn't be carried out, as written, the way it should have been YESTERDAY.

Nurse: Um...Can I write a note that I talked to you about it?

Me: Close eyes. Count to three. You could certainly document it this way: Attending physician aware of egregious nursing error made by day shift nurse and recommends now following-through with the order.

Nurse: Actually, Dr. Surgeon is the attending.

Me: Four. Five. Six. Well, you could word it like this: attending ANESTHESIOLOGIST aware of blatant negligence of day shift nurse and approves of following other attending anesthesiologist's orders. Has Dr. Surgeon, the attending surgeon, been notified that HIS patient hasn't been given her pain medicine?

Nurse: Um, yes, he's aware. I told him when we had to notify him that the post-op antibiotics he ordered weren't given either. But he's not in charge of the epidural orders. I'm supposed to notify the doctor in charge of the epidural orders.

Me: Taking a deep breath. Trying not to burst into tears with exhaustion and frustration. Would it make it easier for you if I came to re-write the entire order set from scratch? Maybe I'll just do that, since I've given up all hope of ever going to sleep tonight.

Nurse: Oh, that would be great. Thanks! Sorry, we just have to follow the policy.

I restrained myself from muttering, Oh, of course - God forbid there should actually be any THOUGHT going on.

Once again, I am unable to maintain complete outward sweetness when totally exhausted and suffering from a pounding headache. *Sigh.*

To her credit, the night nurse didn't take my crabby mood personally after I apologized if I was coming across as a little curt or frustrated. Actually, we even shared a good laugh over the absurdity of the whole situation, and she gave me some Tylenol for my head.

2 comments:

katy (aka funny girl) said...

Damn nurses. :-)

T. said...

When they're good, they're wonderful, you gotta admit...but when not...then, NOT...just like doctors!! :)