Back to work, back to work. Triage let me sleep 'til 8am, ahhhhh. I get to go to an only semi-crappy hospital. 25 year old intercranial bleed. I arrive around 09:30, with visions of getting a first clinical done early, maybe have the second one done by this evening. My optimism is bolstered when the intensivist does the first clinical right after my arrival. Oh, what a naive, little TC am I. The intensivist decides to stop that exam, let neuro do the first one, then she'll do the second exam 6 hours later. Perfect. Except that neuro never shows. Did anyone call him? I asked for lab results....oops, tube of blood still sitting on the counter for 3 hours. Intensivist tells me patient is breathing over vent, somewhat miraculously considering he's BRAIN DEAD. I can't piss her off-I still need her to write orders, after all. "Excuse me, doc,"I say" I don't mean to insult your intelligence, but are you sure he's breathing above the vent?" Because I'm not naming names, but I've seen people who oughta know better look at a vent and not the patient and tell me the patient's breathing on his own-cause the machine said so! She's sure.
But wait! A few minutes later she comes out of his room and allows that maybe it was his enlarged heart beating that made his chestwall move and not his lungs. I say why not do an apnea test to be sure. No, no. Several minutes later she says, "I think I'll do an apnea test." Good idea, doc. Why didn't I think of that? Repeat this for 10 hours and you have my day. Hospital services tells me that she is not only the ONLY intensivist attending at the hospital, but she's the director of ICU. And she doesn't like being told what to do, so make nicey. Oh, I'm nice.
They do an apnea test without blood gases. Don't ask her for blood gases, I'm warned. She'll give you a big, long story about why they're unnecessary. So I bite and ask her why, thinking she's going to quote some research or something. No, it's because neuro will order the baseline ABG and not correct it and still do the apnea test. So the hospital's solution(because this is an actual policy) is not to do the ABG's. The irony is that when I gouge out my own eyes with frustration, I won't get preferential treatment for an eye transplant. AAAAAaaaaaarrrrrrhhhhhgggga, ga, ga.
post script:I left a stable patient with plans to return in the am, but went back in the middle of the night as he became unstable. The nurse busted her butt trying to keep him going while I tried to think of things to try. In addition to dropping his BP and oxygen sat's, it looks like he had an MI and went into atrial fibrillation. We coded him at 7am, 7:30am and 8am. Then they finally called it. I got someone from the OR to translate for mom as all this was going on. No fun was had by all.
Alright, class, let's review:
- Change of shift codes are no fun.
- If neuro had arrived at 12noon, instead of 8pm, we might have had 2 clinicals and I could have gotten consent and managed this patient instead of putzing around all day while he slowly detiorated. The earlier you can manage the patient for donation, the better the outcome will be.
- Dr Intensivist, who by her own admission is against donation, should have communicated with the neurologist about who was doing what clinical when(she delegated this to the resident.) If they really wanted to make this donation happen, they would have. Now they can say, "well, we try, but this donation process never works." or "that mom was never going to go for it anyway."
- And what's up with doctors being against organ donation? I imagine having this conversation with her:
Her: Well, I don't really believe in donation.
Me: Alright, then, we'll add you to the list.
Her: What list?
Me: Why, the National No Organ Donation List, of course.
If you don't believe in donation, you can't be a recipient.
Her: Is there really such a list?
Me: What if there were? Hmmmmmmmmmmm.