I was in charge (again) tonight. The OR called very early in the shift to notify me that they had a patient for us. It happens – sometimes cases go longer than expected, sometimes there are complications… so the patient comes to CCU, usually intubated.

This patient had a huge belly surgery. Usually this means that they have massive fluid shifts. It isn’t at all unusual to pour 5+ liters of fluid into these patients within the first 8 hours. This particular patient arrived at our unit intubated with 2 peripheral (in the arms) IV’s. Usually, if the patient is unstable enough to spend the night in ICU, they come from the OR with an arterial line (aka art line – used to constantly monitor blood pressure and draw labs from) and a central venous line (”CVP” – a line in their neck that facilitates rapid fluid administration and also helps in drawing blood for labwork). Our patient had neither. Since her blood pressure was stable, we figured we wouldn’t press the issue.

We were soon dismayed when our patient’s BP fell to 70. We increased the amount of fluid that we were giving IV and called the surgeon (Who was already on our s*** list for writing out his orders on paper as opposed to typing them into the computer. It takes that much more time to transcribe them and is pointless because he was just being lazy). The patient’s assigned nurse told him that it would be nice if we could have an art line and CVP. The surgeon replied that he wasn’t coming back and that we would have to call anesthesia to come insert the lines.

When we called anesthesia, they informed us that they were about to start another case in the OR and would not be able to leave to come start lines for us. We called the surgeon back; he replied that we were then to call the ICU intensivist to come start lines. We did that; the intensivist told us that this wasn’t his patient and if the surgeon wanted lines in, he’d simply have to come put them in himself. It sounds snotty, but really isn’t… what doctor wants to be at the beck and call of a surgeon who skipped out on his responsibility?

All the while, the patient is very unstable and is by this point requiring the fine services of not one, not two, but three ICU nurses. It seemed as though we were pouring fluid into her to keep her BP up, and it was just as quickly flowing out of the drains she had in her abdomen. (It wasn’t; just seemed like it) Out of the blue, a surgeon and an anesthesiologist walked in and asked if we needed lines. We said we did, and they went to work inserting them. I have no idea why they showed up; as far as we knew, no one was available. I think we just figured that they had some time before the case started. Or maybe Dumbass Surgeon told (begged?) them to go do it.

Unfortunately, inserting lines was not to be an easy task. If they’d done it at the start of her case, it would have been a piece of cake to find veins and arteries to poke. By this point, though, she had a good few liters of fluid under her skin (third-spacing) and it was much more difficult. Apparently they were taking a little too long, because along saunters in the hospital’s medical chief of staff wondering where on earth his anesthesiologist and assistant are. When he finds them diligently working on this woman, he expertly jumps in and has just as much trouble. Not ones to give up easily, they stuck at it until the lines were in. By this time, though, Mr. Chief of Staff was none-to-happy that his case was going to start late and asked who the patient’s surgeon was, and we all happily told him that it was Dr. Dumbass Surgeon.

After things settled down a little, I was telling the nurses on the other side of the unit what had happend. One of them asked if I was going to fill out a QRR (Quality Review Report, aka “writing someone up”). I briefly considered it before realizing that Dr. Dumbass Surgeon single-handedly held up the Chief of Staff’s last case of the day and figured that I wouldn’t need to write a QRR – the matter would probably be taken care of quite quickly without my little piece of paper :-)