Pearls for July

As we kick off a new year, I’d like to share some thoughts on our approach to patient care and to each other.

First, let’s not disparage one another. The neurologist says, “can you believe what those idiot neurosurgeons did?” The neurosurgeon says, “can you believe what those idiot neurologists did?” Docs disparage nurses for their lesser facility with pathophysiological mechanisms, or for repeatedly paging about some seeming small issue; nurses disparage docs for their arrogance and lack of practical know-how. University docs say, “I can’t believe that community docs felt the need to transfer this patient.” Community docs say, “Why can’t the university docs just kindly accept my referrals and not give me a hard time?” (As one of my mentors, Dr. Rob Rust, used to say, “the animal is always scarier in the jungle than in the zoo.”) Whether with respect to ethics or clinical competence, there are very few rotten apples out there–just hard working people, often under a lot of stress, trying to do the right thing.

Even better, let’s try to learn people’s names rather than referring to them by their roles, services, or locations. So instead of “OT says bed 4 isn’t yet safe for discharge” how about, “Cheryl [or Cheryl from OT] thinks Mrs. Smith still isn’t able to care for herself on her own”. Instead of “Cardiology want to anticoagulate him” how about, “Dr. Stone [or Dr. Stone, the cardiologist] suggests that we anticoagulate”. When we page a consulting service, let’s not answer the callback with, “Is this ID?” The person we’re paging is not “ID”, he has a name. If you don’t know his name, you might answer, “Is this the ID fellow?” When I refer to another service’s recommendations in my own notes, I usually write something like, “Our rheumatology colleagues suggested . . . ” Yes, it’s a little more verbose, but I think that preserving our humanity is important enough to warrant the small extra effort.

Next, always bear in mind that there’s often more to the story than meets the eye. Here’s a personal example: Years ago, when I was first learning the lay of the land around here, I transferred a patient in from a rural community. The patient wasn’t that sick and despite ground transport being medically appropriate, the referring ED doc sent him by air. I found this to be very annoying–a waste of money and an unnecessary risk for our pilots. But I later learned something important: Some rural communities only have one ambulance rig. If that rig is hauling a patient 100 miles to Madison, then that community is left without ambulance service. If someone goes on to have an MI and calls 911, there may not be anyone to respond. Flying the patient allows the local EMS to return to home base, ready to respond to the next emergency. So, what seemed to me, in my ignorance, to be a stupid decision by the ED doc was actually the appropriate decision for that community. (Dare I say it? We need to consider that there are unknown unknowns).

With that in mind, go see the patient! Yes, some consults seem silly on their face. “Gee, this man was drunk, fell down on his elbow, and now has numbness in his hand. Do I really need to go do a full consult to tell the ED that he has a traumatic ulnar neuropathy? Shouldn’t I just tell them to call ortho?” Yes you do, and no you shouldn’t. Maybe the story is different: Maybe he has numbness not just in his hand, but in his face as well. Oh, and he’s in afib. So what really happened is that he got drunk, flipped into afib and had a small stroke. Or maybe he’s got a Horner sign, so what really happened is that he got drunk, fell down, dissected his carotid, and had a stroke. The point is that you can’t really know the story until you go get the story yourself and you certainly can’t know the exam until you go do the exam yourself.

See you soon; I’m on service as of tomorrow night . . .

About Justin A. Sattin

I'm a vascular neurologist and residency program director. I created this blog in order to share some thoughts with my resident and other colleagues, and to foster my own learning as well.
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