“Your level of incompetence is actually quite impressive; it takes real effort to be this wrong all the time.”

Attending Transplant Surgeon, Yale.

Said to me after using the wrong color marker twice for potassium and chloride on the color- coded spread sheet that the interns had to prepare daily for every patient.

  It was finally Friday afternoon, and I had managed to wrap up most of the loose ends on the service.  I was waiting for Kenna to get out of the OR so we could round and get the hell out of the hospital.  I was very optimistic about the possibility of getting home in time to have dinner with my husband.  Unfortunately that optimism was crushed with a single phone call.  A consult from Medicine.  They had called Kenna, who was scrubbed in the OR, so Kenna had the nurse call me to see the patient.  There was nothing worse than the late Friday afternoon consult from Medicine.  This meant they had a patient they had been screwing around with and mismanaging the whole week, and now, because it was almost the weekend, they needed to dump the patient on the Surgery Service. 

     The Interal Medicine service and the Surgery Service have always had a somewhat antagonistic relationship in most hospitals.  Medicine includes all the non-surgical specialties, like Internal Medicine, Neurology, Cardiology, Pulmonary, Hematology and Oncology, and Family Practice.  Surgery, obviously, includes all the surgical specialties like General Surgery, Orthopedics, Urology, or Cardiothoracic Surgery.  These two groups, especially residents of these two groups, are natural enemies.  Each believes the other is incompetent, rude, stupid, and incapable of properly caring for a patient.  This begins in medical school.  As a medical student on the medicine service, you happily join in the ridicule of the surgeons.  Surgeons are viewed as loud, obnoxious types not smart enough to go into an internal medicine specialty, where you have to think and carefully analyze and research and read.   Medicine thinks Surgery is just a bunch of technicians who cut where they are told to cut; cold, uncaring doctors who are not happy unless they get to slice somebody open, incapable of developing healthy doctor/patient relationships.  They think surgeons tend to act without thinking, expect immediate results, and have temper tantrums worthy of any two-year-old if they don’t get what they want instantaneously.  As the student on the internal medicine service, you learn that surgeons are horrible people.

     Then the student rotates onto the surgical service and gets the opposite viewpoint.  Surgery thinks that all Medicine does is think about things and talk about what they should be thinking about, without ever proceeding to take any action that might benefit the patient.  They do work rounds at seven am, the residents and students, where they walk around to each patient’s room to see them and discuss the plan of treatment.  The goal is to decide what they will discuss as a possible plan for the patient when they round with the chief resident.  The plan is to sound smart, well informed, and organized.  Then the chief shows up, and they reround on all the patients.  Then they sit down to discuss a possible plan, such as starting a new cardiac medication, or considering changing someone from IV antibiotics to oral antibiotics.  But no decision is made, because they have to round with the attending.  So in comes the attending, and they all round again as a massive, hallway-blocking group.  But they don’t decide to actually do anything, because they want to discuss it at noon conference.  So at noon conference they decide they better get a specialist, like a cardiologist or an infectious disease doctor, to see the patient.  By that time, it’s time for afternoon pre-rounds.  So they round again, but can’t make a decision to actually do anything, because the attending has gone home already.  Lots of thinking and rounding, no action.  

     In reality, this basic difference in the approach to patient care stems entirely from the disease processes the different services take care of.  Medical illnesses, like diabetes, cardiovascular disease, or neurologic disorders, typically require lots of excruciatingly small steps, like minor changes in the dose of a medicine, over long periods of time.  Little changes in the treatment plan have slow, incremental effects on the disease process.  Surgical diseases, like bowel obstruction, appendicitis, or colon cancer, require quick, dramatic interventions that bring about profound, immediate results, good or bad.  I think different personality types are drawn to one area or the other, and as you progress through your training, these personality traits get exaggerated.  A medical doctor needs to have the patience to tolerate slow progress and extensive, long term commitment to patients with diseases that they may never cure but only alleviate the symptoms.  A surgeon needs to have the self confidence and ability to make quick decisions and perhaps perform drastic interventions in patients’ lives to prevent the disease from killing the patient in the next few days.  Doctors, especially residents, get so wrapped up in and overwhelmed by their patient load that they lose the ability to see that the other approach to caring for patients has value.  Medicine and Surgery continue to have this underlying hostility towards each other.      

     So there I was, Friday afternoon, faced with the consult from Medicine.  The Medical Service had admitted this guy three days ago, with pancreatitis.  Pancreatitis is one of several diagnoses that surgeons hate to see on the medical service.  Treating pancreatitis adequately is another thing on the list of things that surgeons believe no one else can do correctly.  Surgeons learn early in their careers to “respect the pancreas”.   We don’t mess with it in the OR unless we absolutely have to, if we have to touch it, we leave drains forever and don’t let patients eat again for weeks, and we are super aggressive about the treatment of pancreatitis, or inflammation of the pancreas.  The pancreas is hard to get to, doesn’t heal well, and can kill a patient in twenty-four hours if it gets inflamed enough.  The problem is that medical residents never have to take care of bad pancreatitis, because by the time it gets bad, the patient is transferred to the surgical service where they have multiple surgeries, go into respiratory failure, renal failure, liver failure, then die three months later.  Medical residents just don’t respect the pancreas. 

     Anyway, they were letting him eat, despite continued pain.   I was just the intern, but I knew the basic rules for taking care of pancreatitis.  Don’t let them eat.  Eating stimulates the pancreas, and you don’t want to stimulate something that is inflamed and irritated, or it just gets more inflamed and more irritated. 

     He had intravenous fluid running at one hundred cc’s per hour.  Dehydration was really, really bad for pancreatitis.  He needed a lot more IV fluid.  I browsed over the chart, and the residents had noted in the morning progress note that the patient had made twenty cc’s of urine overnight.  A normal adult should make at least two hundred and fifty cc’s of urine in an eight-hour shift.  He was going into renal failure.  This was a very, very bad sign.  They had mentioned something about hydrating him and checking some labs but were waiting to discuss this with their attending.  I checked the nursing note.  Ten cc’s of urine for the day shift, MD notified, and no action taken.

     I took the chart and walked into the patient’s’ room.  He was a little pale, breathing in short rapid breaths.  He looked like shit, ready to keel over right in front of me.  He had a history of drinking too much, and this had caused him to have mild pancreatitis once or twice in the past. 

“Hi, I’m Dr. Sawmiller, from general surgery.  They asked us to come take a look at you.  How are you feeling?  Are you having pain right now?”

     He motioned across his upper abdomen, and said, “My whole upper belly hurts, it has for about four days.”  Between gasps, he briefly told me the story of what had led him into being admitted to the hospital.

“Let’s see if we can get you breathing any better.”   I walked down the hall and found the nurse.

“Can you put some oxygen on him, and run a liter of fluid in wide open?  He’s not looking too good.”

“He’s going to the unit, right?” she replied.

“I’m working on it.”  My night was totally shot.  A transfer to the unit meant dozens of phone calls, pages of notes in the chart, orders, finding the SICU resident, talking to the senior and chief.  This was easily a three-hour project.

     I walked down to the OR and went into the room to tell Kenna I thought the patient needed to go to the ICU.  I told her the details, and I could almost see the steam come out of her ears.  She was infuriated, ready to charge out of the room and disembowel the entire medical team.  She managed to control her anger, I think only because the attending was in the room.

“Find Jessie and get that patient to the unit.  What are those dumb-asses thinking?  Put him on our service before they kill him, I’ll be up as soon as we are done here.”

     She turned to the attending, “Can you believe this?  This is what we have to work with, it’s unacceptable.  That guy is going to die because they cannot get off their asses and do the right thing.  So they consult us, at five o’clock on a Friday.  I am going to talk to …”  she was continuing as I walked out the door.

     I walked back into the patients’ room to tell him we would be moving him to the intensive care unit.  He looked bad, a little scared.

“Am I going to be alright?”  he asked.  Those were the last words he ever spoke, as far as anyone knows, though he didn’t actually die for about two and a half months.

“We’ll get you taken care of,” I tried to reassure him. 

     I paged Jessie, Tad and the medical resident and wrote some orders to check the patient’s arterial blood gas, lytes, and calcium.   Jessie responded and was on her way.  Tad, who was back in the SICU for the month, griped that he was getting another patient.

     My next priority was to find the medical resident and ask them what the hell they were thinking.   Why didn’t they consult us yesterday, before the guy started spiraling the drain?  The guy had at least six Ranson’s criteria, for God’s sake.  Ranson’s criteria are a series of blood work findings predicting who has really bad pancreatitis.  His white blood cell count and blood sugars were high, his liver enzymes were elevated, and his calcium was low.  His hematocrit had fallen over the last twenty-four hours.  Anyone could have predicted this guy would do poorly.  He needed ICU care from day one.  Kenna was going to go completely ballistic.  I almost felt sorry for the medical resident, because she would track him down and make him wish he had never even thought of becoming a doctor.

     The senior medicine resident finally called back.  I told him the patient was going to the unit, and we would take him on our service.  He instantly got defensive and said he would decide if the patient needed to go to the ICU.  No one had asked us to take the patient, they just wanted us as consultants, he explained.  As an intern, I really hadn’t developed that power to intimidate the senior medical residents yet.  I could easily intimidate the medical interns, even though I was always pretty calm and soft spoken, but the senior medical residents were not so easily rattled.  They still thought of me as an intern, so because of that whole hierarchy thing, he was pretty confident about telling me that I wasn’t going to do anything with his patient.

“Well,” I said, “I suggest you get up here then, because I’m writing the orders now.”

     So Medicine thought we were “stealing” the patient.  This was another very strange interaction between Medicine and Surgery, the transfer of patients from one service to the other.  A patient transfer was usually either a dump or a steal.  Dumping patients onto the other service was much more common, because this kept your own service down to a manageable size.  For surgery, the ideal patient to dump on Medicine as soon as possible was the very elderly patient with a list of twenty-two medical problems who had undergone surgery.  They may recover from the gallbladder surgery or the colon resection, but they linger with problems like labile hypertension, cardiac arrythmias, poorly controlled diabetes, or renal failure.  They never get well enough to go home, but the surgical problem that brought them into the hospital has resolved.  They end up waiting for nursing home beds to open up, hanging around on the service indefinitely.  Dumping them on the medical service gets rid of the problem and makes one less person to round on, one less note to write.           

     Medicine loves to dump patients with abdominal pain of unknown origin on surgery.  These patients are hard to deal with because we often find no reason for the pain, and they become very frustrated.  As the patient gets more dissatisfied, the medical team caring for them runs out of tests to order, but the patient keeps demanding that something be done.  CT scans and ultrasounds and lab work and colonoscopies and upper endoscopies and small bowel x-rays are all normal, but the patient has constant pain.  So Medicine calls up surgery and says the patient has an “acute abdomen”.  To a surgeon, the term “acute abdomen” implies a tense, rigid, tender abdomen that will likely require prompt surgery to correct some major catastrophe.  Medicine knows that using the phrase “acute abdomen” will get our attention and then they can dump the patient on our service. 

     Stealing a patient involves getting the patient onto your service despite the medical team, meaning the residents, wanting to keep them.  This is much rarer, because the goal of most residents is to get rid of patients.  A patient sometimes had to be stolen for their own well-being, but the primary team doesn’t want to give them up because of pride.  The other service is insulting their medical capabilities, pretty much saying they are to incompetent to care for that patient.  Surgery frequently had to steal pancreatitis patients, bowel obstruction patients, and patients being treated for cellulitis when they actually had huge abscesses that needed draining.  Medicine occasionally stole a patient from the surgery service who turned out to have too many heart or lung problems to safely undergo anesthesia and surgery, but the surgeon was planning to operate anyway.  Or the surgery service was just ignoring something like a blood sugar level ten times higher than normal, or chest pain, or funny heart rhythms on the telemetry monitor.  Again, the patient has to be stolen for their own good.

     Jessie showed up on the floor, and we walked into the room just as the blood work results came back.  He had very low levels of oxygen in his blood, and was building up high amounts of acid, a sign of shock.  He had become quite lethargic, not responding to our questions.  Jessie was working on getting him intubated when the medical resident showed up, looking really irritated.  He was a third year resident, so he thought he knew quite a bit.  Most medicine residencies are three years, so at this level, they are as cocky and confident as they get.  Before he could say anything, I handed him the blood work results.

“Oh, shit.  He needs to be tubed,” came the weak reply. 

     Jessie glanced up and gave him a look as if she was thinking “No kidding, genius.”  But Jessie was very gentle, rarely ever got mad at anyone.  Kenna, however, was heading down the hall towards us.  I could hear her ranting about the “idiotic medical team”, and something about “not knowing their asses from a hole in the ground.”  She was on the warpath. 

     Kenna walked in, chart in hand, not acknowledging the medical resident at all.  Jessie filled her in on the patient’s deteriorating course, then headed to the unit to find Tad and start their ICU rounds. 

 “Are you the medical resident for this patient?” Kenna snarled.

“Well, yes, we took him over after the night float admitted him.  I’m gonna have to check with my attending about transferring him, we didn’t plan on…”

“You didn’t plan on what?  Having the patient survive?” she cut him off.  “This guy should have been in the unit two days ago.  Look at his admit numbers – he’s got five Ranson’s criteria listed in the history.  Someone took the time to write them down, then completely failed to recognize what that means – it’s all right there.  Any first-year medical student could tell you he’s going to crump.  You guys have no idea what to do with pancreatitis, but you still think you can admit it to your service and then call us when you’ve nearly killed the patient.”

“I didn’t admit the patient, the night float did, so,“ he started to say. 

     Big mistake, I thought to myself.  This poor guy is going to hang himself.  Mentioning the night float would only enrage Kenna more.  The night float resident worked only the twelve hour night shift and was a creation of the medical service to alleviate the stress of long working hours for their medical residents.  They had a cap on the number of admissions they were allowed to do per night, usually six, so they wouldn’t get overworked.

“So what if you didn’t admit him, that’s totally irrelevant.  Just because the night float is incompetent doesn’t mean you have to follow his lead.   Haven’t you been seeing him for the last three days?  Have you rounded on him?  Are you capable of assessing a patient and having an independent thought?  He’s been sitting here for three days going down the toilet and you haven’t done one damn thing!”  Her face was beginning to flush.  Her eyes were narrowed to a slant, her lips pressed tightly together, a ball of fury about to explode. 

“We have been taking care of him, we were going to get him started on imipenem … “

Oh, why was he mentioning antibiotics?  I thought.  This guy doesn’t need antibiotics. 

Kenna interrupted, starting to get a little louder. 

“You are a moron.  You still have no understanding of what you have done to this patient, do you?  You don’t treat pancreatitis with antibiotics, it doesn’t start out as an infection.  Now that you have ignored him and let it get bad enough that his whole pancreas is going to die and rot, he will probably end up with infected necrotizing pancreatitis, but he doesn’t need antibiotics now.”

The resident had beads of sweat on his forehead and was looking very pale.  “I am trying to tell you…”  That’s all he got out.

“You don’t need to be telling me anything.”  Kenna shoved the nursing notes under his nose, hovering about six inches from his face.  “Look at this!  His oxygen sat has dropped steadily, he has slowly gotten more and more tachycardic, and he hasn’t peed for twenty-four hours!  Does he need to clinically die for someone on your team to realize he is sicker than shit?”

The resident babbled something very quietly.

“Look at the vitals.  He needs fluid.  Even the nurses tried to tell you he needed fluid.  Look at this – someone even wrote about his low urine output in this morning’s note, eight hours ago.  What the hell have you been doing?  Why haven’t you been hydrating him?  If you let these patients go into renal failure, you will kill them.  He is going to go into renal failure because you screwed up.  Pancreatitis patients need fluid.  It’s so simple, yet so far out of your grasp.”

“Well, um, uh, he was drinking…”  the resident offered.

“HE HAS PANCREATITIS!  You don’t feed them, he needs IV fluid.  My God, am I talking to an actual MD?  Did you actually make it through some medical school somewhere?” she roared.

     He had given up any attempts at explaining anything and just wanted out of the room.  “I need to talk to my attending about transferring…”

“Yes, that’s the first decent idea you’ve come up with.  In fact, who is your attending?  I am talking to them myself.  This entire conversation is just wasting my time.  This same patient could come in next week and you’ll do the same thing.” She grabbed the chart back from him and looked.

“Dr. Robbins.  Great, the blind leading the blind,” she growled.

     The medical resident had managed to back out of the room, and from a distance murmured a little more confidently that he would be discussing this with his program director in the morning.

“Fantastic, I’ll probably be discussing this patient with the coroner in the morning because you are an incompetent idiot,” was her reply.

     Now it was time for the venting.  Kenna turned to me.

“Do you believe that guy?  He’s nearly let this patient die on his service, but he is going to go complain about me, the big, bad, mean surgery resident who hurt his little feelings.  And he still doesn’t have the faintest idea of how wrong he is.  And he’s the senior resident.”  She was still pretty outraged, and this discussion about the various incompetencies of the medical residents continued for about thirty minutes, while we organized people and equipment, then rolled him over to the unit.  I sat in the nurses’ station in the unit, finished writing the transfer orders, and started on my note, as Tad and Kenna got the patient all tucked in.  About two hours had gone by, and we still needed to go up and do rounds.  We only had twelve patients to round on, but my chances of getting out of the hospital at a decent hour were long gone.