Crying wolf or making sure you need someone before paging them stat overhead.
I was on call Tuesday night and it was one of those calls that made me question the intelligence of my colleagues. There is a resident in the department of medicine who came very close to getting a loud earful from me on the inappropriateness of their behavior. The reason they didn't is because the incident in question happened around 8pm, not 2 or 3 am.
In anesthesia you don't really get many pages. Usually they're from the OR telling you the room is ready or the coordinator telling you what your next assignment is. If you're on call, you will get paged by the ICUs or floors for an elective intubation on your personal pager. But you almost never hear an overhead page unless its a code or something similarly urgent. So when I hear the "Anesthesia STAT MICU B pod" page go off overhead, I was on the elevator with the code box in hand before my pager even went off. Because an overhead page indicates that they want you there so fast you don't have the time to actually return the page - you are needed NOW. So I go charging into the room, put the code box down in the nearest flat surface and start getting my stuff ready for an intubation. As I'm doing these (getting my tube out, the CO2 tester, syringes, gloves on, taking a quick history to know what drugs to use) I'm told (not by the resident who had me paged but by another one in the room) to "hold my horses." See, even though I was paged overhead, they weren't actually sure if they needed to intubate this patient. The oxygen saturation monitor wasn't really reading well, they hadn't sent off a blood gas yet, and the pt was lethargic but responding to things. In addition to me running over, respiratory therapy heard the overhead page and also came running, figuring that they needed to get a ventilator set up ASAP. After hanging around for about 10 minutes, while I tried to get someone to tell my if they definitively wanted me to intubate the patient or not, I was finally told, "I guess we'll just page you after we get the blood gas back if we need you." It turns out, I wasn't needed at that point or anytime during the night for this patient. In fact, their blood gas showed no need for intubation.
So why does this bother me so much? First off, I was called to what I felt was going to be an emergency situation only to be essentially told I was not needed. Second, at the time, I was preparing for an emergency surgery and the arrival of that patient. The only anesthesia personnel in house were myself and my attending. This means that there could have been a delay in the start of the surgical case. Third, I am responsible for all intubations needed in the entire hospital outside of the ER. If, God forbid, there was a code elsewhere in the building, my arrival could have been delayed because I couldn't get an answer out of this team as to whether I was needed or not. And if it had been 2 or 3 am and they woke me up only for me to got there and find out they didn't actually need me, believe me they would have heard about it. When I went back to the ICU to check on the patient after my case got out, the nurse who had the patient apologized to me for the fact I was called before.
Here's the deal, I don't mind running up to the ICU or a floor for that matter if I'm actually needed, no matter what time of day it is. But let me tell you, incidents like this one and others like it, make me very frustrated. I can't begin to count the time I've been called to intubate someone who is a DNR/DNI, a patient who is struggling to breathe but is telling the team he/she does not want to be intubated as I'm walking into the room, or just showing up and being told that they've changed their minds and they don't need me. Sometimes I (and some of my fellow anesthesia residents) have been called by the ICU team to assess if we think someone needs to be intubated. Unfortunately, that's not what we're supposed to be doing. We really can't come in and eyeball someone and tell you yes or no, we are not their primary physician, you are. Use some clinical judgement and actually assess the patient. Please make sure you need us before you call.
In anesthesia you don't really get many pages. Usually they're from the OR telling you the room is ready or the coordinator telling you what your next assignment is. If you're on call, you will get paged by the ICUs or floors for an elective intubation on your personal pager. But you almost never hear an overhead page unless its a code or something similarly urgent. So when I hear the "Anesthesia STAT MICU B pod" page go off overhead, I was on the elevator with the code box in hand before my pager even went off. Because an overhead page indicates that they want you there so fast you don't have the time to actually return the page - you are needed NOW. So I go charging into the room, put the code box down in the nearest flat surface and start getting my stuff ready for an intubation. As I'm doing these (getting my tube out, the CO2 tester, syringes, gloves on, taking a quick history to know what drugs to use) I'm told (not by the resident who had me paged but by another one in the room) to "hold my horses." See, even though I was paged overhead, they weren't actually sure if they needed to intubate this patient. The oxygen saturation monitor wasn't really reading well, they hadn't sent off a blood gas yet, and the pt was lethargic but responding to things. In addition to me running over, respiratory therapy heard the overhead page and also came running, figuring that they needed to get a ventilator set up ASAP. After hanging around for about 10 minutes, while I tried to get someone to tell my if they definitively wanted me to intubate the patient or not, I was finally told, "I guess we'll just page you after we get the blood gas back if we need you." It turns out, I wasn't needed at that point or anytime during the night for this patient. In fact, their blood gas showed no need for intubation.
So why does this bother me so much? First off, I was called to what I felt was going to be an emergency situation only to be essentially told I was not needed. Second, at the time, I was preparing for an emergency surgery and the arrival of that patient. The only anesthesia personnel in house were myself and my attending. This means that there could have been a delay in the start of the surgical case. Third, I am responsible for all intubations needed in the entire hospital outside of the ER. If, God forbid, there was a code elsewhere in the building, my arrival could have been delayed because I couldn't get an answer out of this team as to whether I was needed or not. And if it had been 2 or 3 am and they woke me up only for me to got there and find out they didn't actually need me, believe me they would have heard about it. When I went back to the ICU to check on the patient after my case got out, the nurse who had the patient apologized to me for the fact I was called before.
Here's the deal, I don't mind running up to the ICU or a floor for that matter if I'm actually needed, no matter what time of day it is. But let me tell you, incidents like this one and others like it, make me very frustrated. I can't begin to count the time I've been called to intubate someone who is a DNR/DNI, a patient who is struggling to breathe but is telling the team he/she does not want to be intubated as I'm walking into the room, or just showing up and being told that they've changed their minds and they don't need me. Sometimes I (and some of my fellow anesthesia residents) have been called by the ICU team to assess if we think someone needs to be intubated. Unfortunately, that's not what we're supposed to be doing. We really can't come in and eyeball someone and tell you yes or no, we are not their primary physician, you are. Use some clinical judgement and actually assess the patient. Please make sure you need us before you call.
posted by dr. nic | 10:38 AM
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