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Wednesday, November 26, 2014

Life at Grady: Jackpot

This visit is really just a regular check-up. You know, the annual where you have to get checked out for things like cancer of the cervix and any kind of infection. Usually, I wouldn't have asked anyone to come with me for this. Sure, it's always uncomfortable when the doctor tries to talk to me and realizes that my English isn't so good, but for this, my regular check-up, normally I could survive it.

See, the problem is . . .well. . .that's what makes this hard. I have been having this funny pain. And also just a little bit of discharge and bleeding after Javier and I are together. We've been together for so long that I don't think . . .no. I don't think it's anything like an infection. Like not a bad one. But I need to know why I feel like this.

When I asked my son to join me, he had a fit. A real, true fit. But I needed to be sure that I could explain myself, you know? And sometimes there are people that don't know one single word of Spanish so they go right away and get the interpreter. But then there are a whole bunch of other ones who sort of speak some Spanish but not really enough where I feel like we can understand each other. Then, sometimes, you will hit a jackpot with some Latina who happens to be in medicine that can really, really speak to you.

But that's only when you hit it big.

Javier told our son that he didn't have to go with me. Pulling an 8th grader out of school to go with his mami to the doctor didn't make sense, he said. And our son was just sitting there staring at his sneakers with his hoodie pulled all the way over his head the whole time his papi said that. I tried to make eye contact with him to let him know that this was more but I couldn't get my boy to look in my direction.

I was nervous about explaining to Javier why I wanted someone there to interpret the English words flying at me from the doctor because I didn't want him to think the wrong things. I wanted to yell, “What if I don't hit the jackpot? What if I leave not being able to ask about what I need to ask about?” But, again, it was too much. I would just have to suck it up.

So now I am sitting in this room waiting. Waiting to see the doctor in this open-back gown with my backside out. A metal tray with these things that, I think, are going to be used on my insides, and a little rolling stool right in front of me where, I think, a doctor is going to be scooting all around.

That reminds me. It's also scary when the doctor and the nurse are talking to each other in English about things and I sort of understand every few words but not all of it. This visit is usually the one where somebody else is there in the room. So they start talking to each other and, I guess, it's mostly about what's happening with me. But I don't know if it's bad or just regular, you know?

I hope the doctor and the nurse don't find something in me and then start talking all about it. I'll be grabbing words like “this” and “her” and “vaginal” and that's about it. Which is scary. Yes. That's the word for it. Scary.

I jump a little when someone knocks on the door. A soft knock. Respectful and gentle. It surprises me more that the person waits. Waits for me to say it's okay for them to come in.

“Jes.”

I wipe my hand over my face because my “jes” sounds very much like I'm a non-English speaker. And even when you are a non-English speaker, you try to just stay quiet so people can't hear it, you know? Hear that you live in a place where everyone speaks one language and you—a person who has been here for a long time—do not.

I feel my pulse quickening. My chest is moving up and down, hard. I want to have a voice. I want to be able to say what I need to say but know I probably can't. And I'm scared that something is wrong that won't get checked because I can't explain.

My face is burning up and my eyes feel like they want to cry. Filling up with tears already because I am tired and scared and already giving up on the chance that I'll get to say what I need to say. For me. For my body. Then I feel myself getting mad inside for not knowing more English. But that is just too much to think about so I drag a deep breath of air as the door creeks open.

I see her hand first. Brown skin. She is a black person. Then, I see her face. My eyes sting a little bit more. She does not appear Latina to me. But her eyes are soft and nice. Like she cares. Like maybe she is one of the ones who will call the interpreter. Or at least care.

“Señora. . . .Martinez?” she says.

I nod and smile.

“Hola, Señora Martinez,” she continues with a bright smile. “Me llama Doctora Higgins.” Her accent was easy and her Spanish didn't sound forced. But I've been fooled before by those kinds of greetings. I mouth back “hola” and that's about it. I don't want to get my hopes up. But then, she reached out her hand for mine and shook it. Like I deserved her time and her attention and like she was glad to help me. That's what that handshake said. And it was soft and kind and respectful. Just like that knock on the door.

She sat down and looked at me once more with those soft, kind, respectful eyes. Then she started speaking to me.

And then the rest? The rest was like white noise. No. Not white noise, something even better. It was like music. Upbeat, pleasant music. Salsa music. Familiar music. The music in my backyard on Sundays with family. With people laughing and dancing and shaking their hips. The kind that makes you feel warm and good and safe. Yes, that. Safe.

This lady with the brown skin who wasn't Latina and who knocked softly spoke Spanish. Fluent Spanish. But more than that, she was kind. And patient. With me. With my concerns. Like they mattered. Like I mattered. Even though I don't speak English so much.

And she was gentle when she examined me, too. She didn't talk in English codes a lot to another person in front of me, either. But when she had to, she explained and let me in one everything being said.

My eyes filled with tears the moment she stepped out of the room. They ran down my cheeks and landed on that faded blue hospital gown in big splashes. Tears of relief, of joy. Of gratitude. With her and also with the universe for my stroke of luck this day at Grady.

So it turns out that there was an explanation for how I was feeling and Doctora Higgins gave me a medicine for it and scheduled me a follow-up appointment. She also helped me make sense of it, too. I felt so much better knowing, too.

When I left the clinic to get my prescription filled, I bought a lottery ticket. Because once you hit the jackpot once, chances are that, just maybe, it's your lucky day.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

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Wednesday, November 19, 2014

Life at Grady: Eight is Enough

“She isn't happy with our plan,” my resident said. “I know you spoke to her at length already, but she's asking to speak to you again. Actually, she's sort of demanding it.”

I felt my shoulder starting to sag as I stood in the hallway listening to her request. Partly because of the heavy bag I was already carrying in preparation to leave for the morning, but probably more just at the idea of going back into what had already been a pretty energy-sucking encounter to begin with. Instead of speaking, I just let my head fall back as if it could no longer be supported by my neck. Then I winced and squeezed my eyes closed.

My coat was already on. Zipped up to the top with a satchel on my right shoulder, too. My cell phone was in my hand and buzzing in response to the messages I'd shot out in anticipation of heading over to my office. Clinic had been busy that morning and the patients less straightforward than usual. There were a lot of resident clinicians with us that morning, too, so our normally social atmosphere was replaced with hustle bustle, and very little time to even print out a prescription, let alone catch your breath. And Ms. Faison—the last of our patients that session—was probably the most challenging of them all.

You see, Ms. Faison wasn't happy. Not on this day, she wasn't, or even in general. With wretched osteoarthritis in her knees, she really needed not 1 but 2 knee replacements. The problem was, though, that Ms. Faison had smoked for many years and now had developed pretty advanced chronic obstructive pulmonary disease. Putting her under general anesthesia could be life threatening. Further compounding things was her weight. She was more than just a little bit out of range. The 300-plus pounds she bore on those rickety knees would likely not allow for the best outcome if placed upon surgically replaced ones. None of this was good news, which made Ms. Faison even unhappier than her baseline unhappy.

To make matters worse, she was in pain. Pain that wouldn't respond to our medium guns like ibuprofen or naproxen or even those arthritis-fighting salves that we cross our fingers and hope our patients will like. The doctor she had before this resident placed her on a narcotic pain medication which seemed to mostly get the edge off. And that wasn't really that inappropriate given the severity of her join destruction and the unanticipated surgical intervention to improve it.

As a part of the agreement to put Ms. Faison, or any patient in our care, on long-term narcotic pain medications, the patient and doctor form a very specific contract. Right up front, it's explained that narcotic pain medications have to be taken exactly as prescribed and not mixed with alcohol or other illicit drugs. A discussion about the habit-forming nature of narcotics makes them tricky, so the doctor and the patient must both be super-judicious about how, why, and when they're given. Of course, if the medication causes issues or is in need of a potential dose adjustment, the patient and doctor agree to talk about it and reach an agreement without any unilateral increases from the patient's end. So after all of that discussion, the patient agrees to adhere to taking the medications per instructions, not to mix them with other things, or share them with other people. (Yes, that happens a lot.) The doctor agrees to avail him or herself to the patient should concerns come up. And usually, this—the “pain contract”—goes off without so much as a hitch.

Unless you're in that small percentage like Ms. Faison who gets taken off of narcotic medication due to breaking said contract.

Some folks don't have good intentions from the start with the medications. Their plan all along is either to pop them like candy or sell them for money. The Pollyanna in me refuses to believe that this is anywhere remotely close to most patients' game plans. Regrettably, those folks make it harder for the others. Especially once a provider gets “burnt” by one.

But Ms. Faison wasn't one of those people. She was just in pain. She'd been given a certain number of pills that she started doubling and tripling up on because her knees hurt so bad. She ran out 10 days before she should have and borrowed some other kind of controlled pain medication from a neighbor. And a little bit of cocaine, too.

Now. Before anyone thinks I'm judging her, please know that I wasn't. She was fully honest about all of that—including the cocaine—and said that she just “felt like s***” and was tired of it. We'd already known that she'd been a weekend recreational drug user remotely, but thought this was behind her. When a urine drug screen revealed cocaine metabolites along with detecting some other things that weren't in line with her prescription, that ended her contract. Which meant no more prescriptions for anything stronger than ibuprofen 800 mg.

So she'd still come for her blood pressure pills and diabetes medications as scheduled. But all of that would be suffocated by the circuitous discussion about her disabling knee pain that we wouldn't help her with. On this day, she'd been in the room crying to me, begging for us to check her urine to prove that she wasn't taking any drugs and to please, please reconsider putting her back on narcotics. “It was a mistake,” she pleaded, “and I learned from it. I can't live like this. Help. Please.”

And you know what sucked the most? What sucked the most about it is that I believed her. And I still believe her. Like, I truly don't think Ms. Faison was out fattening her pockets with cash for loose Percocet pills nor do I think her visits were all a part of some diabolic plot to get high. I don't think she'd relapsed into a downward cocaine spiral and I honestly believe that everything she told me about her lapse in judgement was from being delirious with pain.

All of that had happened less than 4 months before. And, frankly, she'd tied our hands. So there was very little we'd be able to do to alleviate this pain that was destroying the quality of her life. And that? That sucked.

So I'd already talked to her about this. Sat there and did my best to be empathic as she wept. Trying my hardest not to feel like crap from knowing that when she left she just might feel so hopeless that she buys a $5 rock on the way home to escape it all. I didn't rush her either. We'd spoken for more than 20 minutes that morning about all of this. So the idea of being asked to go back and talk to her some more? Just as I was preparing to get out of there? Well. Let's just say I wasn't too excited about it.

“Oh, Dr. Manning, I already told Miss Faison you left,” said one of the nurses from down the hall. “Because I thought you had gone already.” That same RN saw me as I slipped into my coat 5 minutes before so I nodded in her direction and then looked back at my resident.

“I don't know what else to say to her,” I said.

“Me either. Maybe it's a gift that Ms. Caldwell thought you were gone. Let's just leave it be.” My resident was obviously frustrated. Before I could respond, she'd already headed back over to the computer bank to finish her charting.

I decided not to overthink it. I knew it was a bit disingenuous but my reluctance to reenter another 20-minute discussion with the same endpoint won over the sword of honesty. I secured my bag on my shoulder, checked my phone once more, and headed out toward the stairwell.

My head was down looking at my text messages as I leaned against the exit door in preparation to go. I was startled when I heard Ms. Faison's voice. “They told me you was gone.”

I could feel my face warming up from being caught in what originally wasn't a lie but had become one. “Um, yes. I'm sorry about that. Ms. Caldwell thought I had left already, Ms. Faison.”

“I had asked to talk to you again. They didn't tell you?”

I looked down at my feet and felt my shoulders melting down like ice cream on a hot day. I lifted my eye to hers and spoke. “Let's talk, Ms. Faison. How can I help you?” There. That was all I could do at this point.

“What I'm ‘posed to do, Miss Manning? Just be hurting all the time? Just miserable?” She wasn't mad. No venom shot from her lips and no angry scowl was wrapped around her face either. She wasn't mad. She was sad.

I sighed hard and dropped my bag to the floor. Pressing my lips together, I thought before speaking for a moment. “Ms. Faison? This whole thing is making me feel so sad, too. Because at this very moment, I don't know what to do. I really don't. Like, I think that eventually, some day, we might be able to work out getting you back on something stronger. And last time we injected your knees with steroids but really, you need knee replacements. But right now you can't have that surgery so . . . I just. . . yeah.”

That's when she started crying again. This hopeless cry that broke my heart into a million pieces. I reached out and put my arms around her and hugged her. I didn't know what else to do.

“I wish I didn't have to deal with this,” she sobbed.

“Me, too,” I whispered back. And I just let her cry and rubbed her back and hoped that somehow, some way when all of this was over, that she'd feel cared for enough to keep coming back and to not make any desperate choices.

“What can we do, Miss Manning?”

“I was just thinking. It's been more than a year since we spoke to the orthopedic surgeons and the anesthesia people about you and knee replacements. And actually, I wasn't the one who spoke to them personally. Why don't we try that again and see if there is any chance you can get something done.”

She seemed to like that. I wasn't sure if it would work, but in that moment I did realize that this idea of her never getting surgery was mostly something I'd gleaned from other doctor's notes.

“I know a lady bigger than me that got her hips done. And she used to smoke.”

“I can't promise anything, Ms. Faison. But I agree that maybe there is something that they can do that I'm not aware of. I'll call them myself, okay?”

She nodded while patting her cheeks with the sleeve of her shirt. “Okay.”

“In the meantime, though. . . . we'll have to keep working with the alternating Tylenol and ibuprofen and the knee cream. What do those get your pain down to?” I was referring to the 1 to 10 pain scale that she knew quite well.

“Most days? Like an 8. Sometimes, though, it can get to a 5 or 6.”

I sighed and twisted my mouth. Because I really didn't have anything else I could do at the moment. “Okay.” That's all I could say.

“I guess for now, 8 gon’ have to be enough.” I hated that thought but it was true. But surprisingly she didn't look as sad as she had before. “Miss Manning?”

I raised my eyebrows. “Ma’am?”

“Something about you jest dropping that bag and stopping what you was doing, though? Something about that give me a little hope. And it's funny but it kind of took my mind off this pain.”

My eyes started prickling when she said that. I was still feeling a bit ashamed for trying to scoot out under the radar earlier. But mostly it was because, like her, I felt better after that exchange, too. And a lot more hopeful.

“Oh, Ms. Faison. I so want you to feel better. I do. I hate knowing you're in so much pain. But fight with me, okay? Fight all the stuff that will make it harder for us to take good care of you, okay? I know it's not as simple as me saying it. I know that. But you're strong, Ms. Faison. Stronger than me, that's for sure. Let's fight, okay?”

“Okay. Plus, I been through worse.” And since I've known her for a while now, I knew that this was true. Her life wasn't an easy one and this, comparatively speaking, wasn't the worst thing she'd faced. And you know what else? Now she was smiling. Smiling in my direction in that same back hallway when she said that.

I gave her one more hug and watched her disappear down the hall. Just before I could get out of the clinic, the nurse caught my eye from the other end of the corridor. “Oh no. You still aren't gone?”

“No, ma’am. Ms. Faison caught me so I was speaking to her.”

She widened her eyes and then looked at her watch. “Oh. . .I'm sorry about that Dr. Manning. It's almost 1:15.”

“That's okay. It was meant to be.”

She chuckled and went back to what she was doing and, finally, I left.

No. I don't have all the answers. I don't. And I'm pretty certain that Ms. Faison is still somewhere wrestling with her pain in her knees that is probably an 8 on a scale of 1 to 10. But this idea of raging against my own impatience, and increasing the dose of empathy as the yet-untapped therapy—this gave me hope. For her and for me.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

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Wednesday, November 12, 2014

Life at Grady: 3 cans a day

“How much do you drink?”

“Not as much as I used to.”

“How much would you say that is now?”

“Two to 3 cans a day. But it used to be 6 or 7.”

“Cans of beer?”

“Yes, ma’am.”

“What kind of beer?”

“Usually Colt 45.”

“Okay. Um. Okay.”

“But no hard liquor.”

“Gotcha. Question: What size cans? Twelves, 16s, 22s or 24s?”

“Twenty-fours is always your best deal.”

“So three 24s?”

“Yeah. That sounds about right.”

“Okay.”

“But it's less than before.”

“That's good that you cut down.”

“Why you still looking at me like that's still too much? I just like beer. That's just me.”

“Mostly I'm just looking at you and thinking, that's all.”

“Thinking ‘bout what?”

“Well. For starters, the fact that you're here. At 8:30 in the morning for a doctor's appointment. Not demanding anything or with any ulterior motive. Just here to see about yourself. So you care. So I guess I'm just wondering if you realize how this could hurt you. The beer, I mean.”

“It ain't as bad as hard liquor. That's what my daddy drank. Hard liquor. Every day ‘til he died.”

“I hear you. But as for it not being as bad, that depends. Beer can be sneaky. You want to talk some about where your drinking falls in terms of your body?”

“I guess. Naw. I mean, yeah. I kinda think I do.”

“Okay. So essentially if you're a guy—I mean, a man—you should limit yourself to no more than 4 drinks in a day or 14 drinks in a week.”

(Interrupts with a laugh) “Ha! See, doc? I drink only 3 per day!”

“Well, not so fast, friend. Ha ha….we base it on a standard drink. So a standard drink for a regular beer is like a 12-ounce Budweiser. But a standard drink of malt liquor like Colt 45 is more like 8 to 9 ounces.”

“Go on.”

“Yeah. So that means you're actually having about 9 drinks each day. And about 63 drinks per week.”

“Real talk? Probably more like 70 something in a week. I drink a bunch more on the weekends. Just being honest.”

“Thanks for that. My point in telling you that is that when you go over those recommended amounts, that's when you start having stuff happen to your body. Like bad stuff that you've probably heard of.”

“Damn. For real?”

“Yeah.”

“Wow.”

“What were you hoping would happen when you came here today? Like. . .do you want to be healthy? I mean, you take your blood pressure pills and you keep these early morning appointments. It seems like you care about your health.”

(Laughing) “I guess I sorta do. Yeah. I do.”

“Okay. Then we'll need to keep talking more about the beer going forward, okay?”

“Okay.”

“Maybe between now and when you come back, you can just spend a little time imagining what your life would be like if you didn't drink beer. Or drink at all.”

“Totally different. A whole ‘nother world, actually.”

“Right. Which would probably be the hardest part, you know?”

“Yeah.”

“But here's what I'll do on my end: I promise to look at you like you can be a person who doesn't wake up in the morning and drink a beer. And like you can be a nondrinker and like you aren't a lost cause.”

“Being honest, doc? I can't even imagine me without a beer in my hand.”

I can.

“You can?”

“Yup.”

“Ain't nobody ever looked at me how you looking at me right now. Like I can win.”

“That's because you can.”

“You think?”

“I think.”

Yay. Love this place.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

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Wednesday, November 5, 2014

Learning medicine and some principles for teaching

This New York Times article stimulated thoughts about teaching internal medicine: Better Ways to Learn. It reads: In the new book, “How We Learn: The Surprising Truth About When, Where, and Why It Happens” (Random House), Benedict Carey, a science reporter for The New York Times, challenges the notion that a high test score equals true learning. He argues that although a good grade may be achieved in the short term by cramming for an exam, chances are that most of the information will be quickly lost. Indeed, he argues, most students probably don’t need to study more—just smarter.

For most students, first 2 years of medical school are a survival hurdle of cramming, with a mad dash to pass step 1. Many third year students transform from memorization to learning. The principles of learning concepts in various ways come more naturally during the clinical years.

We must not conflate learning medicine with memorization. While we sometimes have to memorize some facts, most excellent physicians succeed through careful thought processes and understanding of physiology, anatomy, pharmacology, etc.

We who teach medicine have a responsibility to help our learners through a careful explication of our thought processes. Sometimes we should make our thought processes explicit; sometimes we should help the learners “discover” the thought process through Socratic questioning.

We must not assume that when we give a wonderful summary of a topic, that the learners have absorbed that topic fully. Again, the article states: Understanding how the brain processes, stores and retrieves information can also improve your study habits. For some people, cramming for a test can work in the short term, but by studying only once in a concentrated fashion, the learner has not signaled to the brain that the information is important. So while the initial study session of French vocabulary words starts the process of learning, it’s the next review session a few days later that forces the brain to retrieve the information—essentially flagging it as important and something to be remembered.

“When you are cramming for a test, you are holding that information in your head for a limited amount of time,” Mr. Carey says. “But you haven’t signaled to the brain in a strong way that it’s really valuable.”

If we want to help our learners, we must remember that they do need repetition. We have several ways to help them. One is a trick that Dr. Kelley Skeff taught me almost 25 years ago. At the end of a learning session (rounds, morning report, etc.) ask all the learners to write down their 2 most important points. The act of writing it down on a piece of paper enhances retention.

Perhaps more important, and difficult for many educators, we must willingly repeat our teachings. Our repetition may seem boring, but it is not to most learners. As an example, I regularly give several chalk talks during morning report. Having had some learners as third year students, fourth year acting interns, interns and residents, they tell me that each time I present the material they learn something new. They do not find the repetition boring, so neither do I. The purpose of teaching is all about the learners. We must do whatever helps them learn, and repetition works.

Finally, we should recommend that our learners read some each day. I tell students to write down a couple of things they heard or observed during rounds, and read about those topics. When the topic has relevance to patient care, the importance becomes obvious. And we do tend to remember things that we regard as important.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

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Life at Grady: Critical Caring

The patient was sick. The kind of sick that isn't straightforward or classic for the textbooks, either. He had the kind of labs that make your head hurt from thinking; numbers that forced you to sit down at a desk with a pencil and paper to figure out calculations before writing orders. To make matters worse, he wasn't very old, either. And, generally speaking, when people aren't up in age and they're very, very sick, there is usually some unifying diagnosis to explain it all. Here's the problem, though: We couldn't figure out what it was.

I mean, it certainly wasn't from a lack of trying. We did our due diligence by combing the literature for case reports and consulting with experts. Despite all of these efforts, he continued to slide in the wrong direction. His vital signs teetered on that very fine tight rope between “intensive care unit team level of sick” and “step down with the regular ward service level of sick.” On a couple of those days, I had my resident and interns call over to the critical care/ICU team to come and assess the patient for their team. Each time, they would look at everything and agree that it was perplexing. That said, with all of the very clearly ICU-level patients they already had, they kindly declined. And mostly, that was fine.

I think a lot about triage decisions when I am working on the hospital service. Like, who should be admitted in the first place versus who should be on the medical floor versus who should be in a stepdown unit versus who should go to the intensive care unit. I speak to my teams ad nauseum about this, drilling it into their brains that, really, triage has a great deal to do with nursing needs. If there is something going on with you that will be difficult or dangerous to manage at home and having nursing support nearby will improve it, that's generally the first decision point. Especially if it is the kind of problem that could cause you to take a turn for the worse.

Then, once we give the green light for you to stay, it comes down to how much attention might you need from your nurse. If you need a lot of attention—say because you have in lines or are intubated—you need a nurse that doesn't have much else to be focused on other than you. That generally happens in the intensive care units. The nurses there have one to two patients and can devote all of their energy on the shift to them. Contrast that with the regular medical floor where the RN may have as many as 6 or 7 patients.

So what happens when a patient is waxing and waning in between? I'll tell you what happens. A collection of people deliver bursts of critical care (i.e. ICU level) while it gets figured out. Sometimes it is the nurse. Sometimes it is the physicians on the team. Sometimes it is even a family member standing vigil at the bedside. And mostly, it's okay as along as it lasts for very short periods of time until some clear answer is reached. But when it is prolonged, it robs other patients of time and energy that they deserve.

Here is the other thing that I never used to think about but now I do. ICU admission is about more than just nurse-to-patient ratios. It is about EXPERTISE.

When it comes to the sickest of the sick, nobody manages them better than doctors and nurses who work regularly in the intensive care units of hospitals. Additionally, ICU nurses and even clerks are a special breed. They handle critically ill and seriously sick-sick patients all day every day. That crashing patient that freaks me and my team out is no different than a barking dog on a mailman's route to them. Not only do they not freak out—they thrive in it.

My colleagues who work in the ICU at Grady are pros at all of this. And, generally speaking, the sickest of our patients generally have several different organ systems going awry at once. And those critical care folks? Those intensivists? Their mental muscle is trained for all of this. They are thinking fast and working on all cylinders. Which is good when the issues are life or death. That's what this was becoming with my patient. I didn't know what else to do.

So here's what I finally did. With my intern, I physically walked over to the ICU to speak directly to one of my intensive care colleagues. When I got there and found G., he was as gracious and patient as always. I let him know that not only was I concerned that this patient needed a higher level of nursing attention, but my patient needed an intensivist's brain working to get him better. As a matter of fact, I think I may have even said, “This is more about me needing your expertise and experience to save his life than one-to-one nursing. I need your brain and your help.” And G. offered collegial suggestions and engaged me in a true medicine-nerd dialogue about what could unify all of what was happening with my young patient. He did all of that, yes. But then, without any pushback, he accepted my patient to his service.

My intern saw the whole exchange as did the residents in the ICU. I realized what an important role-modeling moment that was, watching 2 faculty members work through what was wrong and finding what was best for the patient. An attending admitting out loud that “I don't know what to do and I need your help” and the other saying “right now, I don't know either but I will help.” I also had this ah-hah moment that, many times, the discussion has to take place at this level—the senior physician to senior physician level—for things to move forward. I am glad my intern asked me to come with her to the ICU that day. It turned out to be pivotal.

So what happened? Well. Let's just say it was good that the patient was transferred to the ICU. Things got much, much worse before they got better. But when they did go south, you'd better believe those ICU nurses were all over it, working in concert as only they can, and those critical care guys put their ICU brains in turbo gear. They sure did. They ran codes on my patient, found answers, and fought to do the thing that they do better than anyone else in any hospital setting—save my patient's life. They sure did.

Here's the thing: In medicine, there is a lot of pride involved. We beat our chests and tell stories of how we intubated someone with one hand while placing a line with the other hand and doing chest compressions with a foot, like some kind of one-man show. But all of that is really ridiculous, isn't it? I mean, we are taking care of human beings. But the other thing is that WE are human beings. Human beings fall short and they don't know everything.

My lesson for my intern that day: “Advocating for your patient sometimes starts with admitting that you need help. And that you don't know what to do.” Yep.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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