Wednesday, June 2, 2010
Life at Grady: Sick vs. Sick-Sick
The following post, by Kimberly Manning, FACP, first appeared on the blog Reflections of a Grady Doctor.
When I was an intern doing my very first rotation on the Internal Medicine inpatient wards, I remember hearing my senior resident say to me with her thick Latin accent and a mouthful of bologna sandwich:
"Keem, if you don't learn naathing else this year, you need to learn one thing and one thing only. Seeck versus not-seeck. Period. It doesn't matter how smart you are or how many facts you can regurgitate. It's all crap if you don't know a seeck patient when you see one. Sometimes the smartest thing a doctor can know is when they need to run like-the-hell and get some help."
"But we're in the hospital," I replied, "Isn't everyone technically sick?"
"Oh no! Definitely no. A lot of the patients in the hospital are not seeck at all. I mean they are seeck, yes. But most are not seeck-seeck. So now as-I-think-of-it, Keem," she added with her musical voice, "What you really need to know is seeck versus seeck-seeck." Oh Lord. Seeck-seeck? Nobody told me about that in med school.
(Click "more" button below to continue reading.)
"How do you learn it?" I really wanted to know. "I mean, is there something you suggest I read? Like maybe in the Washington Manual?" (In pre-internet-savvy 1996, that was the Internal Medicine intern's bible.)
She threw her head back and laughed. More of a cackle than a laugh. For a few minutes I thought she was mocking me. . . .but then she stopped abruptly. "Read?" She raised one eyebrow. "Oh no, Keem. You don't read naathing to know this. You leesten. You watch."
Okay. I think I was catching on here. This was one of those "Art of Medicine" moments. I was always intrigued with these sorts of teachable moments. "The senior doctors? I should listen to and watch the senior doctors, you're saying?"
"Keem," she spoke carefully with an icy glare (yes, I still remember and am amused by how she pronounced my name),"Keem, you listen to and watch the patient. And then . . .you always, always listen to and watch the nurses. Always, Keem."
Ummm. Okay. I'd heard countless times even before finishing medical school of the importance of remaining in "good graces" with the nurses. Be nice to the nurses, some resident would tell us as students, They can make your life pretty miserable or pretty wonderful. But the advice was always to befriend them, be collegial with them, and depending upon your personality and level on the totem pole, even brown-nose them. But listen to and watch them just for the sake of learning how not to be an assassin? This sounded like a new spin.
"I've heard that you should always get in good with the nurses."
"No, Keem. Not that. I'm talking about real patient care. Leesten and watch. The nurses always know who is seeck-seeck first. They always do. Sure, don't piss them off. But leesten. Watch. Especially the really good ones. They always know first."
"Even before the patient they know?"
My resident folded her hands behind her head and rocked on the chair's two hind legs while balancing with her crossed feet on the conference room table. For a split second I feared she'd fall back and need stitches on her head, but she looked so relaxed that I turned my focus back to our conversation. "Even before the patient gives you the clue?" I reemphasized.
She continued her treacherous rocking. "Oh. . . well that depends."
I wasn't sure what she meant. "Depends on what?"
Suddenly, she slammed the chair forward and back down on all four legs. With both hands, she gathered her long, dark hair into a tight chignon and secured it with a pencil sitting on the table. With a knowing smile she said, "It depends on how much experience you have and how much you know. With time you understand more of the subtleties of patients. But long before that and long after you have the nurses--don't forget that." Aaaah. The nurses. Claro que si.
***
Turns out that this sage moment with my resident included some of the best advice I've ever gotten in medicine. So today, I'm reflecting on the hospital nurses. . . . . and all of the times they've both figuratively (and literally) thumped me on my head to alert me that a patient was indeed not just sick but sick-sick. I'm reflecting on the one who told me early in the morning before rounds that my patient had refused a lab-draw but not because he was ornery like all the other days he refused but because he was "out-of-sorts". And I'm remembering how "out-of-sorts" ended up being the first sign of septic shock (also known as "seeck-seeck")-- and ended up leading to an early intervention that ultimately saved a man's life.
Now, I'm more experienced. That conversation was over a decade ago, so, yes, I do pick up more on hints from patients that would have previously flown over my intern head. I'll take pause on things like, for example, when this nineteen-year-old girl with a sickle cell anemia pain crisis in her leg asked me for a bed pan one day. A nineteen-year-old wants a bed pan? That's weird, I remember thinking. Weird was right. It ended up being severe osteomyelitis (a bone infection) instead. And less than twelve hours after she asked for that bed pan, we confirmed it as such--all because of a simple request that just didn't sound right.
But how does one get there? I'm sure time, experience and a few key physicians help. But, in my experience, Lord knows the nurses played a key role. Like Priscilla, the nurse who used to pound her fist on the wall that stood between my call room and the PICU when someone coded because it was faster than paging me. As tough as she was, I learned quickly that I'd get much further working for her respect than of her fondness. It was with Priscilla that I learned, while chatting with her over tepid coffee as she charted her patients, countless things about really sick (and really not sick) patients that could not be found in books. Like when she taught me that people who say they are really worried about "something being wrong" are often right--even when the tests say otherwise. Or like when she showed me goof-proof ways to start and secure IV lines and when she taught me pearls like drawing blood too close to the IV line can screw up all your lab values or not checking the equipment (like unplugged oxygen) can make you worry for no reason. Sick versus sick-sick. Experience? Uhh, maybe. Nurses? Sho' nuff.
It's funny. Now that I think about that young woman with sickle cell anemia, I am reminded of what her nurse, Mrs. Nix, said that day after we'd gotten her down to the MRI scanner for her leg imaging:
"Dr. Manning, as soon as I saw that baby, I just knew something wasn't right. Nope. I was thinking during intake, This ain't just a pain crisis. Mmm mmm, no. That baby just wasn't right."
But of course. The nurses always know first. :)
posted by Jessica Berthold at
9:00 AM
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Previous Posts
- Breaking news: there are hospitalists!
- Debunking five myths of the hospitalist-haters
- AHRQ: 1/4 of all hospital patients are readmitted
- Life at Grady: Patients are People
- Handoffs as a priority, not an afterthought
- Introducing: Life at Grady
- VAP in a snap
- The Grandma protocols
- Bad news about quality
- Weird image of the day
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Members of the American College of Physicians contribute posts from their own sites to ACP Internist and 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.
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.
CasesBlog
Ves
Dimov, MD, ACP Member, is an allergist/immunologist and Assistant
Professor of Medicine and Pediatrics at the University of Chicago,
where he evaluates and treats both pediatric and adult patients.
David
Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally
renowned authority on nutrition, weight management, and the
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db's
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Robert M. Centor, MD, FACP,
contributes short essays contemplating medicine and the health care
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DrDialogue
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K. Mavromatis, MD, FACP, provides a conversation about health topics
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Dr.
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Matthew Mintz, MD, FACP, has practiced internal
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patients.
Everything
Health
Toni Brayer, MD, FACP, blogs about the rapid
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FutureDocs
Vineet
Arora, MD, FACP, is Associate Program Director for the Internal
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education and research focus is on resident duty hours, patient
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Glass
Hospital
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Gut
Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist
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I'm
dok
ACP Member Mike Aref, MD, PhD, ACP Member, is an academic
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Just
Oncology
Richard Just, MD, ACP Member, has 36 years in
clinical practice of hematology and medical oncology. His blog is a
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MD
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Elaine Schattner, MD, ACP Member, shares
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Justin Penn, MD, ACP Associate Member,
attended medical school at the University of Washington School of
Medicine and trained in internal medicine at the University of
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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.
Technology
in (Medical) Education
Neil Mehta, MBBS, MS, FACP,
is interested in use of technology in education, social media and
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White
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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.
Other blogs of note:
American
Journal of Medicine
Also known as the Green
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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
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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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