Tuesday, January 02, 2007

Close enough for government work....

Officially started my stint on "night float" at the county hospital today. I have yet to complete an actual rotation here, but (thankfully in terms of preparing for the experience) I have subbed-in for about a week a couple months back. I have a feel for how things work here at County, although I am not yet adept at getting things to happen.

I'll have plenty of time to learn - this is the first of at least three months I'll be putting in here. This first one is a little different too - "night float" is basically the on-call service from 6pm to 6am. Thankfully I won't have any consulting duties (seeing inpatients from other parts of the hospital that may need surgical intervention of sorts) - it is purely caring for current surgical patients on the floors. And no "rounding," getting vital signs and doing daily notes on the patients. But in trade-off, I'm responsible for several surgical services' patients all at once, not knowing much about their background or current problem other than the two or three lines signed-out to me as I start my shift. And the other trade-off is the derangement to my schedule - I'll have to figure out when to sleep and when to get business done and when to spend quality time with my wife.

Working at County is in itself quite the experience - being government-run and offering care to any that come knocking. It will offer quite a lot of learning, as many patients can be quite ill or quite unique in their presentations. But the inefficiencies and other frustrations will be quite the downside, as I have already experienced in my brief time on a prior rotation. Hopefully I can channel that into working out each day when I get home - killing two birds with one stone and improving my health as a side effect. At worst maybe it will counter-act the rise in blood pressure I can almost already feel...

Hello, Nurse!

(mostly from a prior composition:)

I heard all throughout medical school (from multiple sources) to trust the nurses, utilize their input, keep them part of the team. I never thought I'd have a problem with that. And for the most part, they have been really good to work with. They really HAVE saved my ass - especially on my Cardiac Surgery rotation. As a bleary-eyed intern with no experience, it's nice to have ANYONE experienced who can remind you of what to look for and how to proceed when a patient is starting to look less than stable. There are really some great nurses at Rush University Medical Center.

And then ... there are some that make you cringe. I've been paged in the middle of the night for some of the most ridiculous questions and requests: "can you renew this medication that will expire in the AM?", "Do you know why this patient is a VIP?" I've been called to patients' rooms for "emergencies" like chest pain or shortness of breath - only to find it was a hiccup or mucus plug (ie, cough) or some other extremely transient state that any reasonable 2nd-year medical student would have not been alarmed at. Been called to put in orders on a patient that were already in, but the nurse didn't bother looking for them on the printer. Been informed by nursing that they were blatantly ignoring my order for giving a patient a fluid bolus because they were afraid the patient would become fluid overloaded - despite dropping urine output and raising heart rate (two cardinal signs of hypovolemia).

Needless to say, there is quite a range in the quality of the nurses we end up working with. And unfortunately there is almost no correlation with their personality or friendliness. I've been duped too many times already by confusing good people skills and sociability to quality nursing. And - surprisingly - there's not much of a correlation with how vocally the nurse advocates for the patient and the quality of care. "The squeaky wheel gets the grease," but sometimes pushing for action for patient A is distracting from the care needed for patient B.

I don't mean to rip on nurses - they are a more-than-critical component of patient care. They are actually the ones that perform the majority of day-to-day medical care for the patients, addressing fluid and medication administration, personal hygiene, wound care, monitoring vitals, as well as getting the patients up and about and prepared for procedures and tests. Not to mention addressing the social / spiritual needs of the patient, and advocating for anything left off in routine medical care. On rounds and during the day, I probably spend an average of 10 minutes TOTAL with any given patient - whereas the nurse is dividing his or her time among roughly 2-6 patients over an 8-12 hour shift. It is very fortunate indeed that nurses are available to advocate for the patients that they do get to know better than I. And sometimes there is surely cause for them to question doctors orders, especially given that interns have such limited patient care experience, whereas some nurses have been on the wards for decades.

And when I get to interact with a nurse that is working to collaborate on patient care, in a manner that is constructive and educational for all involved, it's a thing of beauty that I treasure. The system working, efficient, all the cogs in alignment. We're all the better for it, and it benefits the patient to the utmost.