Friday, November 28, 2008

The Incident

It was bound to happen. I stepped on someone's toes. This someone just happened to be the teacher's pet. And it happened when I was only a couple of weeks on the new job. Great way to make an impression.

One evening I was in charge of the recovery room. The end of the morning shift and the beginning of the call is always a chaotic period. Recovery is full of patients and as the operations finish more are brought in. For the most part the nurses are very independent and recovery runs quite smoothly. But at this crucial time of day a physician is needed to help out.

A patient after a long operation was brought to recovery. The anesthesiologist briefed me on the patient's history and the operation. A few moments later, the nurse called me over to examine the patient who was not breathing well. In fact the patient was in respiratory distress and need to be intubated and ventilated. The anesthesiologist was still around and she didn't want the patient to be reintubated. A rather vocal argument erupted between the nurse and the doctor. I told the doctor that I'm working in recovery and she might as well go home for a well earned rest. She didn't take the hint and stayed. Against my better judgement I went to tend to other patients. But moments later, the nurse, this time more agitated than before, called me again to see the patient who was not doing better. At this point I told the anesthesiologist that I believe that this patient needs to be ventilated. She said that she wants to check the ABG (arterial blood gas). This blood test shows the oxygenation, ventilation and metabolic status of the patient. I said that the patient is clearly in respiratory distress and that even if the ABG is normal, she still needs to be ventilated. The nurse, again added her vociferous opinion and was very rude. To diffuse the situation I again suggested that the anesthesiologist go home that I would take care of the situation. Again, she did not take the hint, drew blood for the ABG and went to place the sample in the machine. While she was absent, I asked the nurse for the intubation tray.

The ABG showed normal oxygenation but PCO2 (a measure of ventilation) of 45 mmHg. This is the borderline normal, but a person with respiratory distress should be hyperventilating and one would expect the PCO2 to be much lower. This result shows that the patient is tiring and will eventually stop breathing. Even though the text books mention a PCO2 of 55 as the indication for ventilation, I never wait for the patient to breath so poorly before intubating, it's just plain cruel. I said as much to the anesthesiologist but she remained unconvinced. Again, the nurse rudely voiced her opinion. I was getting tired of this and proceeded with the intubation. Flustered, the anesthesiologist said she was going to tell the boss. I felt like I was in kindergarten.

With the patient safely intubated and ventilated, I was called to the phone, the boss was irate. I was raked over the coals for being insubordinate to a more senior physician. She (the boss), asked rhetorically, if I thought I was more familiar with the patient than the anesthesiologist who had spent the entire day with the patient in the OR.

Flashback to kindergarten, no, nursery school. The teacher asks why did you break the window?
Oh, I dunno, I decided to evolve into a teenage punk a bit early and vandalize. Holy crap, is there any right answer to such a stupid question?!!!

The next morning, I apologized to the other anesthesiologist, that I had no intention of insulting her, but I felt that the patient's condition warranted immediate action. She, surprisingly, thanked me! Holy cognitive dissonance Batman! Yes, she actually thanked me for distancing her from the rude nurse!

(BTW, I actually have great respect for the rude nurse's vast clinical experience. She was, well, just rude.)

Then we were called to the boss' office where again I was raked over the coals, albeit very charmingly (did I mention that the boss is normally a very charming woman?). The important thing was not the clinical question of whether to ventilate or not (silly me, I thought that was the point), but that we maintain a good working relationship among the staff. This was starting to play out like a Fellini film. (Did I mention that I'm a great fan of Fellini?)

After a long beautifully crafted speech, I said, "Boss, you've burst through an open door, because we've already kissed and made up, the wedding is in three months." For a moment she had no idea what I was talking about, then, the light bulb lit up. "So why did you let me go on and on?"
I said, "it was such a nice speech, and you obviously spent some time thinking about what you wanted to say, I just didn't have the heart to stop you."

I figure, if one is to be raked over the coals, do it with style.

Post Script #1: Since then, my reputation has only improved.
Post Script #2: A month later, I serendipitously anesthetized the same patient for a tracheostomy because she still hadn't been weaned off the ventilator.
Post Script #3: I want to announce to all involved: "I told you so!!!". But I won't, because I was brought up to know better. (Thanks Mom and Dad).


Gila said...

Smooth response!

Did the anesthesiologist ever acknowledge that your call was correct?

Unknown said...

Nope, she hasn't.

rlbates said...

Never a good answer, is there? Has the patient improved since the second postscript?

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