Trusted to take care

A few days ago, I posted here about a recent ICU admission of a patient with pancreatic cancer. Her admitting diagnosis was septic shock, and I'd initially included some detail about septic shock to help illustrate a clinical dilemma in her treatment. Although that portion was ultimately edited out, this is how a snippet of it read:

In septic shock, the blood itself is infected, and byproducts made by the infectious organisms cause the blood vessels to become dilated and leaky. The danger of septic shock is poor perfusion of important organs, like the brain, the heart, the kidneys, and the intestines. Naturally, antibiotics are a mainstay of therapy for septic shock, but intravenous fluids play as critical a role by supporting the blood pressure within the now much larger system of blood vessels.

Fluid support isn't without its own problems, though: Because the blood vessels of the septic patient are both dilated and leaky, a large proportion of the fluid you put into them goes out of them and into tissues elsewhere in the body. Much of the fluid poured into septic patients ends up in their arms and legs, but more often than not, a lot of fluid also ends up in their lungs. For this reason, septic patients sometimes end up intubated and requiring mechanical ventilation. This buys some time for their infection to be treated and for fluid to be drawn out of their tissues and circulation. Depending on their prior state of health, patients with sepsis can recover from all of this with little lasting morbidity. And because it's much harder to recover from a non-existent blood pressure than from pulmonary edema (fluid in the lungs), patients with sepsis always get lots of fluids, period.

I retroactively present you with these paragraphs to show you that I know what septic shock is; that I can identify it fairly well; that I know how to manage it; that I know what some of the challenges to its management are; and that I know how to overcome some of those challenges. I'll add to this that in the past few days, I have been reading quite a bit about septic shock, and can currently quote at least two seminal papers demonstrating the importance of early therapy in treating it.

I tell you this because today, I was peripherally involved with the admission of a man with a story suspicious for septic shock--and because I made some major mistakes in taking care of him despite knowing his illness very well.

He'd come in from home, where he'd had a few days of fever and shortness of breath. He'd coughed up a little blood earlier today, had gone in to his local hospital, and had been intubated for severe shortness of breath. At this point, his blood pressure had plummeted. The staff in the emergency room had started him on intravenous medicines to increase his blood pressure, but had kept him on modest intravenous fluids because of their concern for pulmonary edema.

I had the first look at the patient when he came in, and got a slightly less detailed version of the above story from the EMT's who had transferred him to our hospital. My role in his admission--there was another intern taking charge--was to write his orders.

When I first heard the story, I said, "We should give him a few liters of fluid as quickly as possible." His nurse commented on her fear of flooding his lungs, and I backed down, keeping his fluids at a relatively low rate. Additionally, confused by the many conflicting options on a new sepsis order set, I folded it up and stuck it in the pocket of my white coat to deal with later. Once I'd written the basic admission orders, I went back to the main priority of my evening: checkyboxen.*

About an hour later, I overheard the attending doctor in the patient's room. "This man needs fluids. Bolus two liters of normal saline. Why isn't he getting more fluids?"

I have been asking myself the same thing for the last four hours. Sure, I am ashamed and embarrassed--although I'm not really in this to impress attendings, I definitely didn't impress anyone today. But I'm also scared of myself. It's enough that there's so much I don't know; if there's something I do know and I still don't act on it, how can I possibly be trusted to take care of people?

There are many things I can try to blame for my failure: the absence of senior leadership in the ICU at the time of the admission; inexperienced nursing; my fatigue at fighting with ICU nurses; my fatigue in general; those effing checkyboxen. None of these, however, takes the place of my responsibility for knowing what to do and doing it. And none of it explains how and why all the things I knew didn't come together to move me to action. I don't know how late that will keep me awake.

It's possible that this, too, is part of my training. If I don't make some scary mistakes, maybe I'll stop taking the details seriously--maybe I'll never really stretch myself.

I wish there were a less frightening way to learn.

*Checkyboxen: the small, meaningless tasks that take up most of the time of the average intern. The word originates in the small boxes scrawled next to tasks on an intern's to-do list. Completion of each task is signified by checking its neighboring box. "Hey, medical student! Can you go find this x-ray? I'd do it myself, but I have too many checkyboxen."


More like this


I guess nobody is perfect and isn't it pretty normal to make mistakes and learn by makin 'em?

Still I have more fear of making mistakes than anything else, but I have a whole lotta time to get where you're, being the undergraduate that I am.

I guess coping with that fear is one of those major challenges there are when becoming a physician.

P.S.: Excuse the mistakes - English is not my native language.

You learn by experiences like this. There comes a point when no matter how much you respect your colleagues' experience and knowledge, you know that you should be pursuing a different course of action. It's a nuisance that your attending was not more immediately available to you to consult.

I like that you have evolved checkyboxen but would like to know the differential from administrivia - is it merely the actual presence of the check boxes?

I'd say that this part of the checkyboxen of training, my friend. Of course you know all about the early goal directed therapy, blah, blah mantra - what intern doesn't at this point in the year? More difficult than learning good, home-cooked EBM is the trickier lesson of learning when to fight that fatigue you describe and go out on the limb to voice and apply what you know, "move [you] to action," as you say. This is no easy task; just look at it as one more rung on the ladder of becoming an independent doc (or the senior resident, scary).

If you are going to defer to the ICU nurses on such basic points as whether to use aggressive fluid hydration in suspected sepsis I have to wonder if you are really serving as the role of this patient's doctor.

Listen to the ICU nurses concerns, and then promptly say "FUCK YOU I'M GIVING FLUIDS" in cases such as these. The ICU nurse who told you not to give IVF because of pulmonary edema concerns must be a newbie who has never seen a septic patient in the unit before. Otherwise they would know better.

By Anonymous (not verified) on 20 Jun 2007 #permalink

Speaking of newbies. This blog is all about how I'm learning to be a doctor and DON'T KNOW EVERYTHING. If you can't grasp that--or, at least, can't comment as if you grasped that--keep your condescension to yourself.

Also, I don't say "Fuck you" to nurses. It kind of doesn't make for collegial working conditions.

No wonder you have a large, involved readership.
You express honestly and decently your experiences and trials in trying to accomplishe what we all strive for, (but rarely if ever achieve): perfection.
That in itself is a path to perfection!