Archive for December, 2009

My First Bad Day

Yes, I know, it has been a while since I have written…I fell behind. But in my defence,  there was work drama, emotional drama, the holidays, and being  sick…. Ok, so no real excuse except for I let myself slip. But I have had great ideas for posts, and I have been working on them, just haven’t logged on to post them. SO, here we are. This day that I am about to post happened on November 20th. Thats the bad thing about being a resident. Bad days can last 12 hours, 24 hours, 30 hours or a whole damn weekend. In my case, it was the last two. So, here is the story.

So, there was a seven year old female with Pneumonia who came in with it in her right lower lobe and right middle lobe of her lungs with effusion on 11/10. She has had a pretty complicated course, was in the PICU, and then transferred back to the floor on Thursday 11/19. While in the PICU she was on three antibiotics, one of which was vancomycin. Prior to transfer to the floor, the PICU team decided to stop the vancomycin, and continue on the two antibiotics. Friday, we rounded with Dr. A, the old floor attending, and Dr. B the new floor attending. We presented the patient with the current antibiotic regime and the improving clinical and lab picture. I bring up consulting Dr. C (the infectious disease doctor) for discharge planning ( what abx will she go home on) and what we could do with her antibiotic coverage now. Dr. B did not feel that Dr. C should be consulted because he could not come and see the patient, and evaluate the patient. Dr. B made it very clear that she wanted Vancomycin added back onto the list of antibiotics she was taking. Before I could go into the patient’s room, my senior lets me know that we have two admits, it is after 11:30 and we still had more patient to round on. I write the order to add the Vancomycin back and to get a CBC and CRP at that time. I go in the patient’s room where she is making it clear that Vancomycin is the only antibiotic she wants the patient to be on. She also makes it very clear that she wants the other two stopped. No questions asked. What I should have done at that point was to go back outside at that moment and stop the other two antibiotics. But I didn’t. I instead go and ask Dr. A her opinion because I did feel uncomfortable stopping the meds that had been working for her. She tells me that Dr. B is the attending, and she is making the decisions. She did recommend getting Dr. D’s ( our pediatric pulmonologist) input and perhaps as an ally. I was content with that and was going to write the order to stop the other two antibiotics, but I wanted to try one more time to reason with Dr. B. When they came out of the room I asked if before we stopped the two antibiotics if I could bring in some literature to show why I thought the current regime would continue to work for her. I asked to wait and see what the numbers come back as before changing her current regime. It was clear what my opinion was, she said no, and I accepted my defeat. At this point, My senior tells me we have to hurry and finish rounds because we now have four admits. It is just my one senior, and myself. The other intern was post call and the other had the day off. Dr. B agrees, we should hurry because its almost noon, we have noon lecture, the students have noon lecture. So we hurry finish rounds, after that I go on to do the admits, long story short, the order to stop the other meds doesn’t get written. Latter that evening before I do night rounds, I am going though patients’ labs and general to do lists. I look up this patient’s infection markers. All the numbers are trending downwards, by labs she is continuing to improve. I tell my on call senior this as well, and also tell her that Dr. B wanted me to stop the other two.  We agree to leave them, as she as been getting them all day, she is getting better, we can present the numbers to Dr. B if she still wants to stop the abx, she can in the morning. Again, here I accept fault. When I realized that the order was not written at this point, I should have just gone and done it.

On night rounds, the parents state that they are not happy with the vancomycin. That the are confused as to why everything is changing when they had one plan in which their daughter was improving on. I state that the patient should just be on the vancomycin as was stated to them earlier in the morning, but that I did not write the order in time so she is still getting the two. I did say that with Dr. B’s experience, she feels that vancomycin is the best drug. I then went on to say that she was improving on the regime that she was on right now. I told them the numbers. I did tell them,that  I would let Dr. B know that she ended up getting the three antibiotics instead of the one, and that we would go on from there. They again voiced that they didn’t know why things were changing, if things were getting better, why things were changing. At this point, I said that Dr. B would talk to them about that more in the morning, and that she was improving, and that we would do our best to make sure that she would continue improving. A little later in the night, I get report from the nurse that she was having what seemed like an allergic reaction to Vancomycin called Redman’s syndrome, which is common with Vancomycin.  I gave the order to give the benadryl, which she got, and I received no further complaints.

The next morning during rounds, we start with my patients since I am post call. Things are going well till we get to this particular patient. I tell Dr. B that I didn’t get a chance to stop the other two antibiotics, she cuts me off, tells me she is not happy, takes the chart, writes the order to stop those two antibiotics and then goes into the patients room. Myself, my two other fellow interns, my senior and two medical students quietly follow her into the room, and well, the real drama begins.

Dr. B tells the family that she wants the patient to only be on one medicine, the Vanc, and that didn’t happen, but she made sure it would happen now. The patient’s mom tell Dr. B, that she is actually happy that the other two medications were still running, because she feels that her daughter is getting better, and that the other medicine ( the vanc) was making her get red and itch. Dr. B says that we can fix that, but that with her 15 years experience, she feels that vanc is the best medication for her daughter. The parents tell her, well, no offence, but they don’t really know Dr. B, and that she is coming in, and changing the plan, when the plan is working for her  daughter, and she would like to know what the rest of the team thinks. At this point the rest of the team…myself included, just kind of look at the floor, and avoid eye contact. Dr. B says, well, that though we are great doctors, but we are still learning, and she has more experience than we do, and that she is the one who ultimately makes the decisions.

They two of them go back and forth, and it grows VERY uncomfortable in the room, the mom keeps building the team and myself up while we, and especially me continue to sweat and shrink under her comments. Finally it comes to a head and the mom says I want to know what they think (she points at the residents at this time), they have been with her from the start, they know her, I know they care about her. Man, it was awful. No one says anything. Dr. B looks at me, and says “answer her!” So, I do, and I say what I feel. I say I think we should keep it all on board and consult an ID doctor to find out what the best medication is. My two fellow interns back me up, the students are shitting their pants. The mom looks at my senior and says, you too, what do you think. He says there is no right or wrong way, that there are many different approaches that can bet taken. (Wish I had thought about that!) Anyways, it was awful. Dr. B backs down and says fine we will do it  your way and storms out of the room.

Outside of the room, she looks at me, says she is not happy, that infact, she is pissed, and will be back in half an hour. I try calling her, to try and explain. But she would have none of it. She tells me that she will talk about it on Monday with the Residency Program Director, the Chair of the Peds department, and the Pediatric inpatient floor director. I was pretty sure I was going to get kicked out of the program, and I went home that Saturday depressed. What’s more, I kept getting pages and phone calls regarding the patient’s mom, who wants to talk to me, because she doesn’t like Dr. B, and thinks she is crazy. The patient’ s family ends up transferring to another hospital.

Well, luckily this story has a happy ending, as I still have a job. The meeting that was supposed to happen, never happens because my program director sides with me and realizes that I didn’t do anything wrong and that had evidence based medicine been used, none of this would have happened. However, I should still apologize to Dr. B for my professional well being. The patient when she was transferred to the other hospital was placed on the two medications that we originally had her on, that team consulted a Pediatric Infectious disease specialist, she recommends an entirely different medication and she gets well enough to be discharged the next day. That family finds me, and I am now the pediatrician for that patient and her two other sisters, and I have seen her in my clinic twice since the incident, and will see her again in January. Dr. B and I are cool. We worked together last month while I was in urgent care. We are professional and cordial to each other, and even smile. Heck, we are still facebook buddies. But things have changed. I used to really like and respect her, and that is all gone now. I no longer respect her, and I am sure she feels the same about me.

The thing is, Dr. B has had this reputation for being well…crazy, and sometimes making poor clinical calls. I used to stand up for her, now I am just quiet. It sucks. I was placed in a horrible position, and for better or worse, I stood up for my patient, and I learned A LOT from this experience. I really don’t want to be in this position again. The truth is, I probably will be in a situation like this again, but I will know how to handle it differently now. Hopefully better.

I never, NEVER EVER want to hurt a patient. I never EVER want to let my ignorance, ego, whatever get in the way of doing right by my patient..but what if I don’t know what that is? I mean, Lord knows, I will always ask for help, but, what if I think I am doing right by my patient, but I am not. Then what? What happens if you not only don’t know what the right answer is, but you don’t know how to find the right answer?

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