Why I Love My Job: Reason #35

I called my first code today since I've been in Madison. When I worked in the NICU codes were a monthly event. But here, I've been relatively unscathed by the heart-thumping "oh crap this kid's going to die unless I do something" scenario. Until this morning. My patient is 2 months old and I have spent the last week stretching the limits of my brain trying to figure out what is wrong with her. Her parents, young and oh-so-trusting, have put their faith in me day after day. And day after day I go into that room and explain that we don't know what is wrong and that the tests we ran did not help explain what is happening with her. This morning I was at her crib listening to the resident explain to the parents yet again the plan for the day, the plan to continue our testing and investigation. Then, she decided to quit breathing and turn blue in a matter of seconds. And in a matter of seconds I was back in the NICU, calmly asking for the bag and mask, asking the nurse to please call a code, asking the resident to listen for a heartbeat, all the while reassuring the parents that we had this all under control. And they looked at me with complete trust. She recovered and I transferred her to the ICU. I went to check on her this afternoon and to see how those parents were holding up. And you know what? Despite being hooked up to a ventilator and under the care of excellent critical care physicians and nurses, those parents wanted to know what I thought was going on and what I thought should be done. They told me all the things the ICU doctors had suggested and they wanted to know my opinion. In spite of everything that had happened, they still thought of me as their doctor and they still trusted me. Even though I had spent the day doubting myself and my abilities, they never stopped. I can't express in words how much that meant to me. For some, a day like today might make them question their choice of medicine or pediatrics as a career. For me, I question how I ever thought I could do anything else.

A Gentle, Hairy, Non-English-speaking Co-pilot

Have I ever told you about our dog Swayze? Well, she's crazy. She's part Boxer and part Lab and part Wookiee and super excitable, especially around other dogs. And squirrels. And fast moving children. When we lived in Chicago, our back deck was surrounded by a high fence and whenever she would hear people or dogs she would go crazy whining and clawing at the fence to get out. So, when we moved to Madison we bought a house with a big yard and no fence. Solved that problem didn't it?

Under the influence of our realtors and the fact that we could not imagine the ridiculousness of putting Swayze on a leash to walk her in our front yard, we had an invisible fence installed. The way this works is that she wears a special collar when she goes outside that delivers 'an uncomfortable sensation' when she gets too close to the perimeter of our yard. The discomfort level is really variable dog to dog and since our dog has bloodied her own paws while playing we honestly had pretty low expectations that this would work for Swayze.

It took a couple of weeks for her to 'get it' and make a definite association between straying to the edge of the yard and getting 'shocked' but alas....it happened. Now when children ride by on their bikes and couples walk their dogs by our yard and a squirrel darts across the road, sometimes all at the same time, Swayze automatically sits and wags her tail and stares. Sometimes she trembles with the effort, but she makes herself stay far from the edge of the yard. She knows that the 'uncomfortable sensation' is a powerful motivator for avoiding that situation.

A coworker was in an unfortunate situation last week where she felt she had not managed a patient in a manner in which she felt proud. The patient was ultimately transferred to the ICU and there were rumblings about her 'sitting on the patient' for too long. She was in my office beating herself up about this and she asked me "How do I get over this? How do I move on?" And I responded that the only way I have gotten over this same awful feeling is to remember it and the situation that gave birth to it. Not trusting your gut and deferring to someone else just because they have a few years on you = this same awful feeling. So, next time I encounter that situation, I remember and I make a different choice. A choice that will hopefully allow me to avoid the 'uncomfortable sensation' of feeling like I failed a patient.

Learn from your mistakes and move on. Take comfort in that. If Swayze can do it, so can you. Trust me on this one.

The Voices in Your Head

I had this attending my intern year who would always send us in to see a patient and then ask, when we came out of the room, "sick or not sick?". I spent my 3 years of residency honing that skill, that gut feeling supported by experience and clinical knowledge, which allows me to assess a patient within minutes (sometimes seconds) as perhaps someone who needs more critical care than I can provide. To this day, I ask myself "sick or not sick" anytime I see a patient on the floor.

I had the opportunity to listen to this voice last week. Another physician from a hospital a couple hours away transferred a patient to me billed as more puzzling than anything. They had run multiple tests and thought they had a diagnosis and were ready to discharge her when her symptoms returned and gave them pause. I accepted the transfer and proceeded to wait for her arrival to the floor. However, there was something nagging at me. Something about the story was troubling me but I tried to reassure myself. After all, she had already been in the care of another physician who I'm sure has more experience than me. Surely they would have noticed and ruled out the very things that were scrabbling around my brain and causing me to have my 'nervous stomach'. Right??

As tends to happen on a Friday afternoon when the residents are all at lecture and I am finishing my first week on service...I walk into the room as soon as she arrives and my 'gut voice' is screaming "sick! sick! everything you thought was going on IS going on!". My gut voice doesn't have much tact, but she is phenomenally insightful. I'm learning that I should really listen to her more often. Thankfully, I had the support of the critical care team and specialists right away and she was taken to the critical care unit, where she remains today. Looking back, I should have been more focused and skeptical in my questioning of this other physician. I should have trusted my instincts and told the ICU about the patient and my suspicions before she ever arrived. As a young and fairly green hospitalist, I am quick to defer to others' judgment. This experience taught me that I can and should rely on my clinical assessment. I may not always make the right diagnosis right off the bat, but I can tell sick from not sick and that is the first step. Now I'm the attending who sends my interns into a room and asks "sick or not sick?".

The Virtue of Regimentation

The other night at work, a very astute nurse came to me with what appeared to be a medication error. The dosing seemed strange so the resident and I sought to find the reason for the anomalous dosing. Here's what we found: When the patient was initially admitted to the general peds floor for respiratory distress, the dose of this home medication was ordered as 3mg. Now, looking through the patient's discharge summary from his previous stay in the NICU, it appears that he was sent home on 0.3mg which was the recommended dose for his weight. For reasons completely unrelated to this medication, this patient's condition worsened so that he was transferred back to the NICU (he is a former premie, hence his previous stay with us) after 3 days and when this medication mishap was discovered, had been in our unit for another 3 days. In other words, he had been given this 10 fold dose of medication for a week while in the hospital.


It is tempting to look at the original admission order writer and place blame there. But, that is an oversimplification of the checks and balances that are supposed to be in place in hospitals to prevent medical errors. The collective "we" failed this patient on many levels. This dose got by the doctors, the nurses, the pharmacists, the computer ordering system on a daily basis. For a week. Why did this particular nurse decide to check the dose before giving the medication that night? Was she just being diligent? Was she following a protocol that says that nurses need to review medication doses periodically? I have no idea. But I do know this. Mistakes happen, we are human after all. Therein lies our responsibility as the deliverers of healthcare to police ourselves. Yes, its nice to expound on the 'art of medicine' and to delegate our brains as the keeper of all minutiae pertinent to our respective fields and maybe even deem ourselves a bit above 'following the protocol'. But is that best for our patients?


Atul Gawande, a physician writer and a man I credit for opening my mind to so many things in medicine, wrote a fascinating article about the value of checklists in the ICU and the resistance to implementing such a simple change. Checklists, he postulates, are a way to assist memory recall for mundane matters that are easily overlooked in patients undergoing more drastic events. In our patient, his home medication had nothing to do with his breathing issues and his subsequent transfer to the ICU. But, it was an error nonetheless. There are multiple checkpoints in place to catch these errors before they ever reach our patients. But, checkpoints and checklists are only as good as those enforcing them. Kudos to the nurse who that night, considered diligence a worthy endeavor.