On the first day of Grand Rounds, a surgeon gave to me: the tale of a kidney transplant. Dr. Bard-Parker gives details on the origin of organ transplantation.

On the second day of Grand Rounds, a girl shrink gave to me: accountability for performance. Shrinkette chats with Santa about doctors who might have to prove their competence, or face the consequences.

On the third day of Grand Rounds, a student gave to me: an interesting taxi-cab ride. Nick at Blogborygmi describes a harrowing ride through Manhatten, driven by a potentially under-medicated driver.

On the fourth day of Grand Rounds, an RN gave to me: the patience of a thousand saints. Alwin changes his frame of reference – it’s not personal, it’s just bad brain wiring.

On the fifth day of Grand Rounds, a doctor gave to me: a tip that could keep me healthy. Dr. Emer explains why staying active for your whole life can keep your brain fit as a fiddle.

On the sixth day of Grand Rounds, an oncologist gave to me: a facade showing calm concern. Behind Dr. Hildreth’s composed face are the tears of a thousand deaths.

On the seventh day of Grand Rounds, a pundit gave to me: a rain check for the grim reaper’s call. Medpundit has a first-hand anecdote about a terminal patient holding on to life to be present for an important event – and it’s not necessarily for the holidays.

On the eighth day of Grand Rounds, an ER Doc gave to me: ways to be a good consultant. Gruntdoc gives us a fresh view on the age-old Golden Rule.

On the ninth day of Grand Rounds, an intern gave to me: a carry-over ethics consult. The previous intern left Dr. Chaplin quite an ethical mess. What would you do?

On the tenth day of Grand Rounds, a doctor gave to me: a surprise visit from old Saint Nick. A very curious patient stopped by The Examining Room of Dr. Charles.

On the eleventh day of Grand Rounds, a student gave to me: the other side of gastric bypass. Disappearing John is a nursing student who underwent gastric bypass surgery. Read his account of missing the comfort of his old friend, food.

On the twelfth day of Grand Rounds, a boy shrink gave to me: a patient’s right to take medicine. Dr. Baker wonders if patient choice and the patient-physician relationship are being sacrificed as a severe side effect of recent bad publicity over medications.

On the thirteenth day of Grand Rounds, a medic gave to me: a diary of a paramedic. SeaDoc runs through his “run sheet” of a typical day on the job.

On the fourteenth day of Grand Rounds, a head nurse gave to me: a guy with hemicorporectomy. Jo at Head Nurse prepares to take care of a patient that’s one in a million. Maybe a billion.

On the fifteenth day of Grand Rounds, a journalist gave to me: consideration of risk factors. Saint Nate says naproxen is probably not going to be the cause of your stroke, but shows you how to find out what will.

On the sixteenth day of Grand Rounds, Ema gave to me: the correct use of fertility aids. Know the difference between fertility monitors? You do now!

On the seventeenth day of Grand Rounds, an intern gave to me: a poem about Christmas Eve call. A two-part rendition of The Night Before Christmas by Maria.

On the eighteenth day of Grand Rounds, a madman gave to me: a parody about the house staff. Mad House Madman writes a parody every Thursday featuring a selected blog or two.

On the nineteenth day of Grand Rounds, Mike Pechar gave to me: lymphogranuloma vereneum. It fits the song, I swear! Accent on “gran” and “ver.” Try it!

On the twentieth day of Grand Rounds, a radiologist gave to me: a poem from a cent’ry ago. Roentgen rays… naughty??

I hope everyone is enjoying the holidays. Check out Rangel, M.D. next Tuesday for the first Grand Rounds of 2005!.

Do you want to host future Grand Rounds? You know you do. Contact the father of Grand Rounds, Nick, for details on how you, too, can spend a delightful few hours blogging on a Monday night :-)

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Grand Rounds 14 will be hosted here at codeblog next Tuesday! Send your submissions to geena*at*codeblog*dot*com by Monday 9pm (PST). Posting has been light lately because work has been very busy, but I’m looking forward to posting some great stuff on Tuesday!

From this post, I received a lot of comments about the pain scale that we use in healthcare. In the last couple of years, JCAHO (our accreditation bureaucracy for health care) has mandated that we must ask if our patients are having pain at least every 2 hours. Of course, for this to be of any use at all, we must first ask the patient what a tolerable level of pain would be; a level of pain that would require no intervention from us in terms of getting pain medication. For most people, that number is 4. Don’t ask me why; that’s just what most people say.

Most of the commenters said that the pain scale was stupid: “I also hate that pain scale. JCAHCO imposed it on us. If someone walks into my office there is no way that I am going to believe that their pain is a 10.” And: “I was always told that 1 is barely any pain at all, and 10 is the worst pain that YOU have ever felt in your life. That means that everyone has experienced one or more 10′s in his life, doesn’t it? I mean, my 10 might be a new mother’s 3, but like, how am I gonna know that?”

I believe the second commenter got it right. The pain scale is supposed to rate YOUR level of pain in regards to your tolerance of it. When I had a kidney stone, I walked into the ER and confidently rated that pain a 10. It was the worst pain I had ever felt in my life. Of course, this process breaks down if the worst pain someone’s ever had in their life is, like, a splinter.

“I think the pain scale is pretty much useless.. I had cancer in 95 went through 3 surgeries and the recovery from one of them was the worst pain I could ever have imagined. so, now when someone asks me what my pain is I can’t imagine it ever being a 10, so of course that is what I compare my pain to, and even though it may be very bad pain I will say something like a 3-4.” But you CAN imagine it being a 10! You lived through the worst pain you could have imagined. Regardless, it all depends on your tolerance. If you said that you could tolerate a 5 or 6, then I doubt the nurse would give you pain meds for a 3 or 4.

“I totally understand the frustration with the pain scale and not wanting to be poked. I had my gallbladder out last March and would get extremely frustrated during my trips to the ER. Luckily I had a friend there to point out that I am extremely stoic so I was probably in more pain than I would admit. I think I was poked by 3-4 nurses and doctors one day and was ready to say yes, I hurt because you’ve been poking me all day.” This comment just made me roll my eyes. As if I don’t have enough to do, now I need to learn how to read your mind? Listen, do yourself a favor: screw being stoic. If we ask you if you’re having pain, and you say no because you’re being macho, what do you expect us to do? Furthermore, I’m sorry that you had to be poked so much, but until we invent and regularly start using medical instruments from Star Trek, there isn’t much else we can do. We don’t really relish causing pain.

One more thing about pain… Pain medications aren’t really intended to completely take away pain. Sometimes they do, but mostly they just dull the pain to a tolerable level. If you feel like the pain scale is stupid and that you simply cannot come up with a number that reflects your pain level, just ask for some pain medicine if you need it. Maybe that’s what we should be asking instead, anyway.

Katy, RN, writes:

I am a two year RN who works in OB, though I only do post-partum and well-baby care, not Labor & Delivery. Tonight I baby-received at my first C-section where we had to transfer the baby to our level 2 nursery (we call it Special Care Nursery). The young mom had all ready lost a 23 weeker and this baby was 36.6 wks. This is the point of pregnancy where being off on your dates by two weeks can make a big difference and that may have been part of this baby’s problem, though he didn’t really look premature. She had to have a repeat C-section due to having a classical incision the first time and had gone into labor, which is why we sectioned her when we did.

It took a long time to get through all the scar tissue so we were waiting around forever. Once the baby was born they put it in my charge nurse’s arms and she ran with it to the table. He was blue, floppy and making no respiratory effort. I was rubbing his back and face and body as hard as I could and begging him in my mind to breathe while trying to appear calm so the dad wouldn’t freak. The other nurse asked the dad his name, and we called him by it while we told him to cry for us. We were about to ambu bag him (same concept as mouth to mouth, but with straight oxygen and more sanitary) when he started weakly crying. We kept rubbing and suctioning him and giving him blowby O2, and he was very slowly pinking up centrally, but his tone remained completely floppy. He was also flaring his nostrils and retracting with each breath.

We then tried to get an O2 saturation level on him but couldn’t find the sensors in this particularly infrequently used OR, then when I ran and
got one from another OR had a horrible time getting it to pick up. This whole time we are giving him oxygen and stimulating him (we were by then scratching his feet and being quite rough to get him to cry more). I had to check his heart rate and listen to lungs several times and once got my stethoscope all tangled up in my OR hat and it felt like HOURS till I could get it untangled and out so I could listen. After 10 min of this we called Special Care Nursery down to evaluate him. By then our O2 sensor was working and he was satting anywhere between low 70s without oxygen to almost mid 90s when I would cup my hand over his face with the oxygen tube in it to increase the concentration of oxygen he was getting.

We put him in the transporter and the level 2 nursery nurse pushed while I kept my hand inside it with the tubing in his little face. After I passed along what information I had, I returned to the nursery. At that point I started shaking and was near tears for a couple minutes while I relayed the story to the nurse who’d been watching the nursery for me. Even though I’d been gone for about an hour, she still told me to go sit down and take a break.

Shaking and still near tears I called my mom. I was just going into how scared and dumb I felt when I looked up at the greaseboard in our break room. We often leave general messages to the staff there and someone had written:
“Kudos to whoever had the great idea for putting a cut-down hat under the bili goggles.” And someone else had written in my name above it. It was an idea I came up with several weeks ago out of frustration with the little goggles our babies under bililites wear to protect their eyes. The dumb things never stay in place and we are constantly adjusting them. Now, I don’t actually think it is that big a deal if the things are slightly off for short periods of time, but it REALLY bothers the parents of these babies. One night I got the idea to chop off the top of a hat (since overheating is a concern with these kids) and put the soft band of it over there eyes and the goggles over that. It keeps the goggles in place a lot better. It has met with a really positive response from the other nurses and the parents, as well.

So, just when I was feeling really low and crappy and scared I got a major pick-me-up. A night nurse mentioned to me the other night that I had written her a little note wishing her a good night a few months ago as she was starting what promised to be a rotten shift. She told me that it had meant so much to her that night and that she had taken it home and put it on her bulletin board.
I guess what has struck me tonight is how you never know when something that seems small to you can mean so much to someone else. I hardly even remember writing that note, but it really touched that nurse and helped her through her night. It probably took the nurse who wrote the message on the greaseboard less than a minute to write it, but it made the difference between feeling really rotten and feeling okay to me. It’s like that book, “The Five People You Meet in Heaven” which is excellent, by the way.

I don’t know how the baby did.

At our hospital, we have Wow! cards. These are cards kept around the unit for us to use – we usually write one out and give it to a coworker who has done especially nice or helpful things for us. I’ve written them to nurses who have started IV’s for me on my patient when I was unable to. I’ve received them for being able to get especially difficult ABG’s on another nurse’s patient. (For some reason, I’m great at hitting the artery, but I suck at threading veins.) There are a zillion more reasons to give and receive these cards, but it’s always really nice to come to work and see a Wow! card in my mailbox from someone who has appreciated me. :-)

First of all, let me direct your attention to some newly added blogs to the right. I made some new buttons. The medblog list gets longer all the time! If you don’t like your button, feel free to design your own and send it to me. It needs to be a .jpg 90pixels x 25pixels.

Nextly, Enoch has posted a link to Family Medicine Notes’ very first medblogger Podcast. After some academic stuff at first, Jacob outlines the trials and tribulations of a day in the life of Family Medical Practice. I think it would be challenging to talk for 13 minutes without some major “uh” and “uhm’s” thrown in there, but Dr. Rieder does a stellar job.

Lastly, Echo Journal has proposed a 2004 Medical Blogger Award. Details are here. I think this is a great idea, but as I commented on their site, I think there needs to be a few categories. Maybe if they ask nicely, someone can design some buttons for the winners to put on their blogs? Hmm… there’s an idea. :-)

Dear Doctors,

How about we strike a deal here? You decide on what treatments to give a patient, and I’ll (usually) gladly administer them – as long as you tell the patient what you’re ordering.

This sounds very obvious, I know, but several doctors that I work with do not prepare their patients for the treatments that are forthcoming. Case in point: I recently admitted a man with a low hematocrit (blood count). It was determined that he was GI bleeding, and in addition to a few units of blood, also needed a dose of anti-ulcer medication.

First off, the doctor did not tell the patient that he was being admitted to Critical Care. This concerned the patient when he found out (“Just how sick am I? How serious is this?”). Secondly, he did not tell the patient that he was to receive multiple units of blood and FFP (Fresh Frozen Plasma – contains some nice clotting factors). (“Just how many units of that am I getting?”)

I don’t mind explaining treatments to patients; in fact, I enjoy that part of the job immensely. However, I do not relish the look of … weirdness that comes on my patient’s face when he finds out that I’m about to administer treatments that he isn’t expecting and hasn’t been prepared for. I can’t quite describe this look – it isn’t distrust per se; I guess I would describe it as slight bewilderment. As if they’re thinking to themselves, “Now why didn’t the doctor mention that I’d be receiving 8 units of blood products??” I thought I would have to start another IV, but rigged his current one IV to allow me to infuse several blood products at once. He was pretty happy that I wouldn’t have to start another IV.

Then another doc comes in and talks with the patient for awhile. This doc states that he wanted to do a procedure the next day and explained that pretty throroughly and obtained informed consent from the patient. Then the doc proceeds to walk out to the desk and enter an order for a continuous infusion of the anti-ulcer medication, definitely necessitating another IV to be started. This just after I’d informed the patient that I wouldn’t have to start another IV. I was pretty annoyed because I knew that the doctor did not mention to the patient that he’d be getting this continuous infusion.

Anticipating that look of bewilderment again, I asked the doctor if he could please go back in and tell the patient that I’d need to start another IV, what medication I’d be infusing, and the reason for it. This time when I went in with my IV supplies, the patient completely expected it and was much more open to the idea.

I believe that it’s up to the physicians to outline the treatment plan. The nurses can explain the finer points of said treatment plan, but shouldn’t have to be the ones to introduce it unless it’s an emergency or the middle of the night. I think this applies most to patients that have just been admitted to the hospital – they’re already shaken up about having to be admitted into this unfamiliar place. After they’ve been there for a day or two, they’re much more receptive to the nurse introducing new treatments.

So please, I beg of you – letting the patient know that they’ll be NPO (nothing by mouth) and the reason for it, what medications they can expect to receive, what treatments that will be ordered – all of that will foster trust in the patient and everyone benefits. Just a brief explanation (no jargon!) should do the trick – and we’ll gladly take it from there.

Medpundit is hosting an excellent Election Day Grand Rounds. Go vote, then check it out!

You know that ad that says, “Friends don’t let friends drive drunk?” There should be one for doctors: “Friends don’t let physicians treat friends.” Well, that didn’t really make sense, but you get the idea.

Quite awhile ago, we had this patient. One of his several doctors was a personal friend of the family. The patient eventually died, but not after having every single treatment in the book thrown at him. I truly believe that because the doctor was a close friend, he completely lost all objectivity, and was unable to see the situation as the rest of us saw it: hopeless.

He even, at one point, asked if I thought that the patient (who was trached) could just live like Christopher Reeve. On a vent. In a wheelchair. He asked me this about a man who was 50lbs. up on his weight from swelling; his lungs, kidneys, and liver had failed. He was comatose. Hell, he was a living corpse. Because the doctor refused to accept this, he kept trying herbs and natural remedies… giving the family false hope. After all, this was a man they trusted. If he said that the patient could get better, of course they’d want to latch onto that.

I finally convinced him that no, the patient could not live like Mr. Reeve, because of obvious reasons (Mr. Reeve was not in multi-system organ failure at that time, for one). I even went so far as to ask him to make the patient a no code… I didn’t even bring up withdrawing treatment at that point. I think he finally saw my point and did just that. The patient ended up dying on a ventilator and on continuous dialysis. (No code does not mean no treatment – and the family refused to withdraw.)

A few weeks ago, a 90+ year old man came into the unit with a gastrointestinal bleed. This diagnosis can go several different ways, but it usually buys you a few units of blood, some nice anti-ulcer medications, and an endoscopy. When the GI doc went to talk to the patient about the endoscopy to get informed consent, the patient refused.

Huh. Imagine that. A completely competant man who has decided that this is it. It took some doing for the man to convince his family that this was the right decision, but he managed to do just that. Since we weren’t going to be doing any intense treatments for this man, a transfer order to the medical floor was written.

Before the patient left, however, another doctor came to see him. This doctor had been treating this patient for decades and was a personal friend. The patient started vomiting large amounts of old blood, and the doctor asked me how many units we planned on transfusing. I replied that the patient refused to have transfusions. The doc’s jaw dropped and he actually said, “He’ll consent to the blood after I’ve talked to him.”

Now it was my jaw’s turn to drop. I stood transfixed as the doctor explained that bleeding to death was a horrible way to die, and surely the patient wouldn’t want to die of heart failure, unable to breathe? The patient looked a bit stricken, but then asked if it would be painful. To which the doctor replied that of course it would be painful! “Now if we could just get a few units of blood into you, you’ll be feeling so much better.”

Uhhhh… okay. I stopped the doctor outside the room and asked him what a few units of blood was going to accomplish… the patient refused an endoscope, so we wouldn’t be finding the source of the ulcer to cauterize it. He’s refusing anti-ulcer medications, so there wouldn’t even be an environment for the source of bleeding to heal. The doctor said that if it were an ulcer, of course there was a chance it would heal… and “Oh, by the way Mr. Patient… it wouldn’t be so bad to just take some medications to help the source of bleeding, right? Oh, and while we’re at it, why don’t we just stick an NG tube in so that you won’t have to throw that blood up and possibly get it into your lungs.. it’s a terrible thing to choke on that sort of thing, now isn’t it?”

To say I was appalled would be an understatement. Here was a man who had adamantly refused all forms of treatment, saying that his time had come, and he wished to join his wife in heaven. Then this doctor comes along and completely disregards this man’s wishes. I never heard the patient agree to any of these treatments. When the doctor wasn’t getting an enthusiastic response, he told the patient that his daughter really wanted him to have these treatments, as it “would make him more comfortable.” The patient stated that he no longer wished to be a burden on his family and was ready to go. At which point I thought Uh oh… now we’re going to establish depression and an inability for the patient to make decisions in his own best interest.

I reminded the doctor that the patient did not wish for any of these treatments, and the doctor again told me that bleeding to death was “a horrible, just a terrible way to die, you know?”

So I then asked him point-blank, “Then just how will you let this patient die?”

The doc didn’t have much to say to that. At this point I felt that the charge nurse needed to be brought in, so I updated her on the situation and she pulled the doctor aside to speak with him. She told him that the nurses felt uncomfortable going against the patient’s wishes, and that the patient himself told her that he was sad that a grown man was not allowed to decide such things for himself. The doctor said that he was a friend of the patient and just new that these invasive treatments were what the patient needed. The charge nurse then told him that the very fact that he was a friend made treating the patient unethical.

Surprisingly enough, the doctor agreed with her. He eventually told her that they could disregard any or all of those orders that he gave. Unfortunately, the patient’s nurse had already put the NG down, with the patient’s daughter holding his hands down while he struggled with it.

I know that excessive bleeding can cause heart failure which leads to heart attack. This is painful. Fortunately, there are many pain medications that are available to deal with this. I think we could have reasonably assured that this patient would have died peacefully and pain-free. Now that the doctor had the family all in a tizzy about these treatments (they wanted them; after all, their doctor friend said that these things would make him comfortable!), the patient most likely died with a tube in his nose, medications going through his veins, and blood products that could have gone to someone who really wanted them.

Welcome to Grand Rounds Five! We have some fascinating stories and news commentary this week.

Come back for more next week! Here’s the upcoming schedule:

November 2: Election Day Grand Rounds hosted by Medpundit
November 9: Grunt Doc
November 16: DB’s Med Rants
November 23: Shrinkette
November 30: Doctor Mental
December 7: The Examining Room of Dr. Charles

Previous Grand Rounds are archived at an Undisclosed Location.

And lastly, Nick at Blogborygmi is our fearless leader. E-mail him if you’re interested in hosting future Grand Rounds.

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Wow! I’m already getting submissions for next week’s Grand Rounds! Don’t forget to check out THIS week’s at Echo Journal.

To submit an entry for Grand Rounds on October 26th here on codeblog, email me at geena -at- codeblog dot com. Please put “grand rounds” in the subject line!

Just in case you were wondering: submission guidelines.