Dumb and Dumber

Ah, yes.  The night float.  It's that special time of year when your only task is to keep-the-patient-alive-for-God's-sake.  The night float is what separates the men and women from the boys and girls, and this applies to both interns and nurses.  So, with great love for all of the amazing nurses who are truly super-competent (and save my ass generously and frequently), here is a list of the top five dumb and dangerous things I have observed the nursing staff doing.

1) Calling to find out about discharging a private patient, since the family was waiting to take him home. The nurse told me she couldn't find any of the paperwork, and that the family was getting very impatient.  When I came down to check, all of the paperwork was completed and paperclipped to the front of the chart, along with all of the prescriptions.  "Oh," was all she could say.

2) Calling to put an IV line in a patient with massive edema, who already had a working line.  When I went to the bedside, the nurse insisted that the line was gone because she couldn't draw back.  A reasonable point, except that 2 different IV solution bags were still dripping away without any issue.  The nurse then pointed to the arm being swollen as a sign that the line was infiltrated.  Except that the patient was swollen all over. As a bonus point, she had refused to try the line herself.

3) Calling to visit a patient who cut himself shaving, and had unstoppable bleeding.  I asked the nurse to tear off a piece of toilet paper and stick it onto the cut, and hold pressure while I walked over, imagining a massive torrent of blood gushing out of the patient's face.  When I got there, I discovered an extremely loose ball of toilet paper marginally taped to the patient's quizzical face.  I tore off a tiny corner and stuck it directly on the 1/2 mm wound, then held pressure for 2 min, and found the bleeding to have magically stopped.  I walked away wondering why the nurse hadn't thought of that, since how to stop a shaving cut is something I learned from my dad, not something I learned in the trauma bay.

4) Tapping me on the shoulder every two minutes to ask about how much insulin to give a patient whose blood sugar was 457.  This is a reasonable question, except that I was pushing on the chest of a patient who was coding at the moment.

5) Removing the saturation monitor from an acutely ill patient.  I was called to the bedside of an end-stage AIDS patient for severe respiratory distress.  The patient already had dementia, so he couldn't tell us what was wrong, but he was breathing at an extremely fast rate, and only saturating 75% on the monitor.  I increased the oxygen flow rate as high as I could, then told the nurse to keep a strict eye on the monitor while I stepped out to call my senior medical resident about the situation.  When I came back, the monitor was gone and the patient was breathing even worse.  I asked her in a panic about the monitor, and she told me that she had given the nurse's aide permission to take the monitor away and use it to check vitals on the other patients on the floor.  The kicker was that every other patient on this floor was hooked up to a ventilator machine, and therefore did not need an oxygen saturation monitor because the ventilator monitors that for you.  This patient wound up getting intubated because his respiratory failure was so severe.  He died a week later.

Singing the Pager Blues

It breaks my heart to say this, but my pager and I are not doing so well. Perhaps I should modify that - my pager and I are a team, but everyone seems to hate us.

Two nights running, now, I haven't been receiving pages. The first night, it was one of the regular floors that kept paging, and then went to the operator when they couldn't reach me. But the odd thing is, the operator's page went through right away. Near the very end of my shift, I got paged by my senior to ask why I wasn't responding to pages from the ICU. Irritatingly, I was sitting at a computer 15 feet from the ICU, checking labs, and hadn't received the page. Last night, I missed a code, although at least that one had an explanation - the operator (who was new) thought that only the intern covering that patient needed to get paged, when in fact ALL interns have to go to the bedside.

Now, most pages you get in the middle of the night are not emergent. Most often, it's just for something small, like renewal of a medication or an order that wasn't written correctly. Occasionally, there's a problem where you do need to go down and check the patient out in person, like blood pressure issues or chest pain concerns. Naturally, in such a scenario, the nurse wants to reach you. But twice now, instead of trying me via the operator, they went straight to contacting my senior resident, which makes me look like The Lazy Intern Who Ignores Pages and Can't Be Trusted. What kills me is that I really do want to go to all of these pages, because I'm still learning as I go and I certainly don't want to miss something important like a heart attack or stroke.

I don't like to complain about technological pitfalls in hospitals, because the fact remains that only 10% of all hospitals in the United States even have EMR systems, and I picked residencies based in poorer inner-city areas because I wanted the experience. But it seems to me that the whole pager system is shockingly inefficient and cost-ineffective. I once did an ob-gyn rotation at a hospital in New Jersey where, instead of pagers, they had in-house cell-phones. They were pretty big and bulky, more like cordless phones, but they worked great because anyone trying to reach you didn't have to wait for you to call-back. There was no question of receiving a page with a hospital extension that didn't exist (I once got paged to the 5th floor, and we don't have one), or trying to call someone back only to find that they had walked away from the phone. If you were busy and running around the hospital, a person trying to reach you didn't have to wait for you to get to a nursing station with a phone not in use. Also, for anyone in a surgical or ob-gyn residency, if you were scrubbed into a case, the circulating nurse could pick up for you and relay the message right away, or even hold the phone to your ear if necessary. It made getting the work done easier for everyone, nurses and residents alike.

Maddeningly, I have tested and re-tested my pager a million times, and it is working just great. Of course, I could just trade the sucker in for a new one, but then I would lose my Hawaii Five-O theme song ringtone. Fortunately, the important nurses (covering the critically ill patients in the ICU) know that I'm serious about wanting to come and help, and aren't angry at me. Last night, I averted the situation by physically going to each floor and making them page me to prove that it was working, and that I did want to come down for anything important. I also made sure they all had the phone number for the girls' call room phone, just in case something didn't go through. But the nurses on the floor are a little bit less invested in making a real effort all of the time, and the last thing I need is talk spreading all over the hospital that I'm the surgical intern who doesn't give a crap.