Nothing beats earning nearly a full afternoon off as the result of getting one’s work done quickly and efficiently. I was awakened from a snooze on the couch, however, by my pager…fortunately, nothing to worry about–just a Code Blue. (It surprises me and even bothers me how sometimes I feel relieved when it’s “just” a code, because when I’m not on call, it’s not my responsibility.)
However, the page I received a few minutes later seemed harmless enough: “Please call 6-east.” When I did, the nurse began speaking rapidly, “Doctor, the patient is satting only 85% on oxygen, and the respiratory therapist says the patient sounds wet. I think he needs some Lasix.” (Lasix is a diuretic which we use very commonly to get rid of excess fluid in a patient’s heart or lungs.)
Nothing bugs me like a nurse being pushy with orders. It’s one thing to convey information, and even to make suggestions like the ICU nurses are so good at doing (e.g., “I think the patient might be volume overloaded. Do you think he could benefit from some Lasix?”). The problem is that it’s the doctors job to decide what to do, and it helps to receive the pertinent information without having the relayer of information interpret it for you. If an intern makes the wrong decision because he was influenced by a nurse, it’s still the intern’s fault.
I asked the nurse to request a stat chest x-ray and arterial blood gas. She seemed to think this was reasonable, but then she said, “And then you want Lasix?” “No, just get the tests, and I’ll come assess the patient,” I replied. Within a minute, I was in the car on the way back to the hospital.
Turns out it’s a good thing I wasn’t biased by the nurse’s suggestion. When I viewed the chest x-ray beside the patient’s totally clear admission chest x-ray, there was a roaring pneumonia! The patient was breathing thirty times a minute and was simply not getting enough oxygen, even with his 100% oxygen mask.
After a quick history and exam (after which I viewed the chest x-ray), I told the unit secretary that my patient would be going to the ICU. I sat down to begin writing orders as I paged my attending. Since July, my approach to attendings has changed from, “This is what happened today; what do you want to do?” to “Here’s what’s happening, and this is what I would like to do.” I think attendings like this, and it’s good for me to think through problems myself.
Turns out my attending was totally on board with my plan to transfer the patient to the unit, add a stronger antibiotic, and consult pulmonary in case the patient needed intubated later. It was exciting to make an intra-hospital diagnosis and therapeutic plan virtually all by myself, especially since in-hospital complications can sometimes be more challenging than evaluating someone off the street. And I know I’m still young in my training, and can and will miss important subtleties at time, but I know I’m starting to get a feel for how to be an independent physician.