So once upon a time, in my ICU, we did not have intensivists 24/7. Day before yesterday, as a matter of fact. We'd spent two years begging, pleading, petitioning for them.
This is the way it used to be:
Several weeks ago, I had a patient whose breathing was deteriorating, as was her mental status. She went from 2L nasal cannula to 15L nonrebreather in a matter of four hours. I called for a chest xray that I did not get an order for first (because, duh). Dr. D happened to be in house late and this individual is nobody's favorite doc. Magnanimously, he addressed the unit, "Is there anything I can do for you before I go home?"
"Yes." I said. "You can look at my patient who's not breathing and I'm thinkin we'll be intubating very soon." He pokes his head in to see the patient. He looks at the chest Xray. "Well, look, she's improving," he says.
I look at the chest Xray. (Insert that cartoon head-shaking noise here...that yadayadayada noise.) Now, I'm not a Medical Doctor, and I do not have your salary or swagger, but when I look at chest Xray A from yesterday and it shows mostly black lungs, and chest Xray B from now and it shows mostly white lungs....THIS IS BAD. When the patient's O2 needs go up by 750%...THIS IS BAD. When a patient's work of breathing increases and the patient feels short of breath...THIS IS BAD.
"Oh no, she's getting better." I am so struck stupid by this beyond-stupid stupid stupidity I don't know what to say. I have no poker face, and I'm sure my expression is a mixture of genuine bafflement and creeping horror. "You don't agree...." he says. Insightful, that one. "No," I say, pinching off the snappy one-liners, "Not even a little bit. She will be intubated before noon." He shrugs, "Well... Not by me. She's getting better."
Not by him.
But she was intubated before noon by a competent doctor who knows that 750% is A BIG number.
Not only did she not get better, she was formally diagnosed with ARDS, spent two weeks on the vent, extubated, reintubated and died this past weekend.
I admitted a eighty-something year old lady who was 90 lbs soaking wet....she had two peripheral IVs in her hands. In one IV, an MD had ordered me to infuse vancomycin. In the other, I was to give Levophed. "But Dr. So-N-So, don't you want to come upstairs and put in a central line? Or call someone to do it for you?" He was busy seeing other patients. I get that he's busy. So am I. I don't want to shred my patient's veins and if he's overloaded, ask for help. I can even get it for you. It's about best practice for the patient, and you know what I'm asking for is the right way to do it. Your hands are tied? Cool. I can find somebody who can do it.
Instead, ego got in the way and he gave me an order to specifically call nobody else. Which is just silly.
Because when you told the nurse of 25 years down the hall that you weren't gonna come look at her active GI bleed, that you were too busy, that you weren't worried right now about her dropping hematocrit, that she didn't need a central line for the pressors she was starting to require secondary to her active bleed or the NG tube right now, and that she shouldn't "bother" the other docs...? She got the charge nurse to call the medical director, your boss.
As a side effect, I also got my central line for my patient before change of shift was out. Kinda that MD, the medical director and the PharmD were kinda on my side on the centrally-given Levophed issue. No reason to give it peripherally if there are MD hands available to do it right. The medical director was at the nursing station at 0400. She earned some big points from me that night by doing so, as did the doc who came in to place my line....the guy I wanted to call to begin with.
Night shift does have a favorite doc, and we want him to own all our patients. The problem is, he's just one guy, and he deserves more time away from the hospital than he tends to take. He takes ownership of patients, and he is thorough and reasonable. We know what good care looks like. Our CV surgeons can be very unprofessional in tone and manner to us, but they completely own their patients' care. They never let you wonder who's driving, or if anybody IS driving. Nobody feels like their heart patient is being ignored, or that stuff falls through the cracks.
Which is what we feel sometimes happens with every patient who isn't under the direct care of one of those handful of good docs we work with. Particularly, this seems to be a nighttime problem.
So we got our intensivists that many nurses I respect fought so hard for. A year of documentation proved that the nurses were right: patients were often receiving inferior care at night because of a lack of in-house MDs. I don't think there's a doc or a nurse out there that thinks having no MD in an ICU for 12 hours is a good thing.
It's not just for the patient who suddenly develops respiratory distress and who only has one side of her chest moving when she's gasping for air. Though that happens.
It's also that nurses hate that feeling of watching a patient carefully, and seeing subtle signs that Bad Things Are About To Happen and no one single thing, or possibly even all things are "callworthy." Here we got MDs right there, so we can say, "Hey, are you seein this trend, too? Can we do something to avert the train wreck that's probably coming?" Maybe even avert it so that dayshift people don't have a daily crisis at 0900 from stuff that could've been handled all night.
Last week, I had a patient with a bp of 240/114 and I paged one of the intensivists who was at our sister hospital. He was a good MD, awake, and followed my patient with me as we tried every foogin drug we could think of (patient had no kidneys), until high-dose Labetolol drip finally worked at about 0700. I went into RN report feeling like I had done my best for this patient. I think the patient felt like I was working very hard for him, too, and that's a good feeling. I felt good, for a change, that I'd worked well with this doc, who I hadn't met before. That he was sharp, and thorough, and he was listening carefully to what I was telling him about this patient's condition.
The intensivist coming on shift for the day tore my head off for not paging the nephrologist first. Do you know why I didn't page the nephrologist? It isn't fair, but this is true: I've worked in that hospital for 2 years. This doc had been paged on dayshift FIVE TIMES and failed to call back...IN DAYLIGHT....same guy you want me to call, now sound asleep? You got two tools in your toolbox. One you've used before and it hasn't worked well for you before, it didn't work well at all today...and there's this other tool, a smart guy, professional to work with, who's awake at your sister hospital and returns pages quickly and is responsive to your patient's needs?
Again. Your patient's blood pressure is 240/114.
Which tool in your toolbox do you grab? It's not a tough choice.
The daytime doc TORE my head off. I stood my ground. "Your partner was extremely helpful to me. He helped my patient. I thought that since this patient is in the ICU, I can call you or your partners on any one of them with critical changes. Patient's blood pressure was dangerously high and your partner handled it." Daytime doc stomped off.
I don't get it: You round on my patient, who's in the ICU, you guys "own" the ICU....but not this patient? Have you seen a worse blood pressure today? The nephrologist was ignoring the sbp of 185 earlier today (which he might consider clinically okay with no kidney, but if so, why write for 20mg of Hydralazine for sbp > 160 when it is completely ineffective and has been all day?), and treating the intractable nausea with 12.5mg Phenegran...do you seriously think these are orders from an MD who feels ownership of this man's care?
I just want somebody to fix my patient. Don't get mad at me for doing my job. If I'm stepping on toes, it's cos I'm not gettin what I need. I mean no disrespect, but I don't care about your toes any more than you care about mine. This is about THE PATIENT, remember?
I get that the intensivists want to be there for support, not to fix every single patient's issue that a medical doc can fix. I don't think the doc that tore my head off was truly angry at me. (And his progress note, written after I left, strongly suggested who and what at whom he was angry...) I think they're just overloaded because, well, they are fixing everybody. Everybody who isn't a patient of night shift's favorite MD or one of the CV surgeons' patients.
I just don't know what to tell ya about that one.
The intensivists being here were supposed to fix this problem of ours.
More soon on how that's going.