Tuesday, October 2, 2007

Too many Cooks

I was consulted at 5pm on Friday night on a 74 year old guy who had just arrived in the ICU secondary to "hypotension". Other than some mild dementia and essential hypertension, he was a pretty healthy guy. When I walked in, his wife was sitting at bedside and he was groaning in obvious discomfort. Here's his intial vitals: HR 130, BP 60/40 RR 29. He's on 24mcg of Levophed and the nurse just received an order from the IM primary to start dopamine. Ok then. I'm going to need a few things, I tell the nurse. We'll start with the crash cart. I quickly place a central line and an arterial line and bolus a few liters of saline in over the next 30 minutes. I review the chart. This is his second admission for c difficile colitis within 2 weeks. A rectal tube shows a steady stream of liquid stool into a bag. His abdomen is tense, tender, and quiet. I talk frankly to the wife. Ma'am, your husband is suffering from something called fulminant c difficile colits. It has made him septic and if we don't take him for surgery and remove his entire colon he will almost certainly not survive the night. Even with surgery, his chance of survival is less than 30%. Do everything to save him, she says. With the volume resuscitation ongoing, his BP starts to stabilize. The Levophed is weaned to a more reasonable 8mcg. We go to surgery and I perform a total colectomy, leaving just a short rectal stump, and give him an end ileostomy. I finish at midnight on a friday night. My experience with these cases has taught me that outcomes are about a 50/50 proposition. I've had some live, but none that were as sick as this guy. By POD#1, the levophed is off. The next day he is extubated. His renal function normalizes. Now he's taking clears. I think we're going to make it. But here's the thing that kills me. On POD#1, the primary MD doesn't say anything to me, other than "you know his Phosphorous is 1.2". And then he consults renal (creatinine 2.4 when I first saw him, then down to normal by POD#2), hematology (because platelets are 80), cardiology (occasional PVC's with hypokalemia), and Infectious Disease (infection present). I check my orders from the morning rounds and my KPO4 infusion has been cancelled by the nephrologist. The Lovenox for DVT prophylaxis has been cancelled by the hematologist (r/o HIT?!?). And the cardiologist has changed my fluid orders (worried about possibly accumulating fluid in his legs). Then the nephrologist calls me the next day. Classic phone conversation. "I don't know how to say this without creating an awkward situation", he says to me, "but I think it would be better for the patient if I managed his electrolyte corrections. You ordered 30 mmol of KPO4 and that can sometimes cause vasodilatation. I would also like to manage the TPN." Um, ok, I say. His creatinine is normal now and his urine output is fantastic and I've actually replaced K and PO4 hundreds of times in my life. But that's fine. I don't mind if you perform those duties, I tell him. And then he adds, barely concealing the underlying condescension, "I mean, I couldn't do surgery, but... ha ha ha " just sort of trailing off; the patronizing implication being that, as a surgeon, I shouldn't presume to know what I'm doing in an ICU. Unbelievable. This pateint is going to live. I've busted my ass for him. And now everyone wants to shuffle the surgeon off to the sideline so the "smart" doctors can manage complicated, life threatening emergencies like hypophosphatemia. Just had to rant on that one

But this case reveals an unspoken source of the high cost of medical care in the USA; all the unnecessary consults. The Internist admits a patient from ER with abdominal pain and fever. That means, before the surgeon sees the patient, you're likely to see notes from Infectious Disease and Gastoenterology in the chart. All of them recommending "surgical evaluation " for abscess or hernia or cholecystitis. ID is biggest scam is American medicine. Everyone with a fever or a white count gets ID on board. Here's what they invariably recommend: blood cultures, urine culture, sputum culture, CXR, and maybe a CT. Einsteinian insight they bring to the game. Give me a break. It's a specialty that certainly has a place; HIV, Hepatitis, unusual organisms, non-Western hemispherean illnesses. But now every local hospital has these huge ID groups that are glorified culture-checkers. The biggest census in the hospital belongs to our ID group. I don't get it..... Damn I don't write for a few weeks and I come out all angry and bitter. Hopefully tomorrow I'll blog about the natural beauty of autumn leaves and how I have to rake them for three hours every freaking saturday and stuff them into paper bags, getting little leaf chiggers lodged in my finergtips... well, maybe some other topic.


rlbates said...

Great post (you deserve to vent)!

Sid Schwab said...

That's the sort of stuff that drove me absolutely batshit. Starting from the moment you arrived and actually resuscitated the man the way he should have been, you saved his life and the others just jerked themselves off (if that's the correct term. Have to look it up. Believe it is.) When I mentioned the famous line from training that a general surgeon is an internist who can operate, I got some angry comments from a few offended fleas. But it remains true. I did come to find the help of a single intensivist important in some cases. But all those others -- it's beyond annoying. Because of the unnecessary expenses incurred by the patient, it's actually unethical, far as I'm concerned.

Bongi said...

if an internist consults me and i operate, he is welcome to manage icu. however, if i operate and then consult him for whatever, i will not relinquish control. i will respect his advice but i treat my own icu patients. the menagerie you describe is unthinkable to me.

my vote lies with you, buckeye, an internist that can operate.

Bongi said...

by the way, good to see you back.

Anonymous said...

ID plays an important role primarily due to the fact that most internists have little or no clinical experience with a full range of infectious diseases and could mischaratcterize symptoms related to an exotic disease. The main value proposition of a large hospital for the paitent is the availability of interdisciplinary thought around their medical issue facilitated by collaboration between doctors that specialize in several medical disciplines.

Buckeye Surgeon said...

We're not stranded in some African jungle, so "exotic diseases" are not likely to play much of a role in Cleveland Ohio. Furthermore, all it takes is a little effort and motivation and even a dumb general surgeon can check the computer and stay on top of positive cultures and susceptibility data. It's ridiculous that ID has a patient census of over 60 in our hospital. Does every UTI need an ID consult? Every ICU acquired pneumonia? Every cellulitis?

Anonymous said...

Ah, my one Atending would have had a heart attack and probably raised the roof had someone called that many consults in on his patient. Then for the nephrologist to be so friggin' condescending.

I actually never heard the line about a general surgeon being an internist who can operate, but boy is that a true statement. I don't believe that internists get as 'intense' an intensive care rotation as surgeons do.

It is kind of nice being in the "boonies" because there are no cardiologists.


Anonymous said...

Boy am I ever glad you set that person straight about exotic diseases in Ohio. I am in Mich. (not far from Ohio), and have had a high WCC for over 9 years, with no diagnosis. Started at around 12,000 just keeps creeping up around 20,000 now.

Not cancer, not meningitis, not any blood diseases or disorders...Have had bone marrow aspirations and biopsies and every test imaginable and it all comes back fine. But, still there is that high white cell count. I'm also almost certain I have not had a bladder infection for years on end. this talk of exotic diseases was making me nervous.

Every time I have to go to the hospital, for some reason or another, everyone is always in a tail spin over the WCC until I tell them it is just a Leukocytosis of unknown origin. Then they all calm down. Is "Unknown Origin" a diagnosis now days?