Several interesting things occurred that night. Stress on the word night. My fourth patient came in around 2200, so of course it was nearing eleven o’clock when I began writing the admit orders. I got a page for cross-cover. My resident told me to write the orders, and he would check out this patient on the floor. Soon after I joined him. A patient with ascites and intra-abdominal abscesses had fallen on the floor on his way to the bathroom. Subsequent vital signs revealed a dropping blood pressure and fever—worrisome for developing sepsis. The resident had already talked to the primary team’s attending and wanted to write for vancomycin. When I got there and offered to help, I examined the patient, and then offered to page the ID attending. After approval, I wrote my first cross-cover order: “Vancomycin 1 g IV x1, please give over one hour.”
In the meantime, I was paged a nurse who was concerned about my patient with hyponatremia. The day before, some blood was noted in his Foley bag. We figured this demented fellow most likely had tugged on the catheter, leading to hematuria. I discontinued his aspirin and Lovenox to help the blood coagulate at the site of trauma. However, the bleeding continued. We began measuring his hematocrit every six hours. And by this time, the night of Day Two in the hospital, his hematocrit had dropped nearly 10 points. Even the budding anesthesiologist in me felt ready to transfuse. My resident agreed, so I wrote the orders. The nurse, however, realized we didn’t have consent on the chart. I called the patient’s daughter who had medical power of attorney and left a message at her contact number, to no avail. Same with her cell. Called both numbers again with no response. The nurse called the nurse manager, and together they stood firm about not initiating the transfusion without proper consent. Given that the patient was alert and oriented, comfortable, and had stable vital signs, I began to question the need to transfuse at 0200. (It should be noted that my phone message to the patient’s daughter was carefully crafted so as not to worry her.) We’d keep an eye on him, and in the morning transfuse after consent. I ran this plan by my resident, who disagreed. This was a medical emergency: we needed to transfuse, he said. I quickly realized that the nurse and her manager were flat out refusing to transfuse. I felt myself leaning toward their side, so I made the decision to call my own attending. Our conversation went something like this,
“Hi, Dr. ______ , sorry to wake you. I was calling about Mr. _______ , our 73 year old with….” “Just tell me the facts. What is it?”
“His ‘crit is dropping. We need to transfuse, but we don’t have consent and can’t reach his family.”
“Is he stable?”
“Yes, he’s alert, oriented, and his blood pressure and pulse are fine.”
“Then we can’t transfuse without that paper on the chart.” [pause]
I felt a sense of relief. I’d been caught between my resident and the nurses, agreeing with the need to transfuse, but also recognizing the ethical delimma. My attending, brusque as she was, backed me up. And the stat H/H I ordered showed the blood count was stable for the last four hours. Several lessons learned.
- Get consent before it’s needed. (Think ahead!)
- Be aware when you’re in an ethical crisis. If something feels not-quite-right, it probably isn’t.
- Learn to stand up to your superiors. For me, this may have meant reasoning with my resident, and trying to convince him not to transfuse.
- Even in gray areas, do your best to do what is right. There are risks associated with transfusion. One anesthesiologist I know made sure all students were aware of this. In the case of this cheery, demented fellow who was happy to get the transfusion, I knew he really wasn’t able to give informed consent. And I knew it wasn’t a true emergency, given his stable vital signs and mental status.
- And even when nurses seem to get in the way of practicing good medicine, step back and evaluate the situation. They may have a good reason.
I’d crawled into bed and dozed for thirty minutes when I heard two beeps. I fiddled with my cell phone (on which I’d set the alarm), annoyed that it was beeping. Only then I realized that the beeping was my pager. I’d been paged a couple minutes before and slept through it. This time it was a nurse taking care of my elderly woman with the UTI. At the recommendation of my attending, we ordered three sets of cardiac enzymes and serial EKG’s on her to evaluate for MI. The reasoning is that the elderly often don’t complain of chest pain with an MI, and this is a big cause for medical liability. In other words, ordering a few labs can prevent a big lawsuit. This nurse was telling me that the patient was on the floor. (I must have written an order, “Please call M.D. when patient arrives to floor,” or something of the sort. It’s all hazy now.) In any case, this reminded me to check her second set of cardiac enzymes. The first set had shown just a mild elevation of the nonspecific CK enzyme. I napped a few more minutes, and then got up to check the labs. The CK was even higher, and the MB portion (specific for damaged heart muscle) had creeped up into the abnormal range. Great. Do I need to start her on aspirin, a beta-blocker, oxygen, and nitrates? I really wasn’t that worried, and I debated about calling my resident. I called the nurse back and ordered aspirin 325 mg PO, first dose now. Since the troponins (sensitive for heart damage) weren’t elevated, I felt pretty sure she wasn’t having an MI. I crawled back into bed, and thirty minutes later was paged again.
“Mr. W’s sugars have dropped to 135.” It was an ER nurse calling about my severely hyperglycemic patient. We’d wanted him to go to the step-down intensive care unit since patients can develop electrolyte abnormalities with big changes in serum glucose. Unfortunately, neither the ICU nor the step-down unit had beds available, so we left him the ER. The goal was to bring the sugars down slowly with a small but steady insulin drip. In this patient with poorly controlled diabetes, however, his body must have been extremely sensitive to insulin. His sugars plummeted. I asked the nurse to draw a stat electrolyte panel. At this point I called the resident and told him about both situations: The elderly woman’s cardiac enzyme panel, and the dropping sugars. He told me to talk to the attending, ASAP. In sharp contrast to my previous encounter with her, she seemed awake and even chipper. She was down in the ER, and had seen the patient. His stat labs were back, and his electrolytes were fine. She was actually quite happy with his progress. And she agreed with me. The former patient was not having an MI. No need to start additional medications. I thanked her, and crawled back into bed for the third time, with thirty minutes to sleep again. After a quick shower at 5:45—which does amazing things to make a post-call doc feel civilized—it was time to round.