The Hospitalist Shift From Hell, and How to Fix It

I came home from my last 12 hour hospitalist shift exhausted.  My eyes were bleary eyed from staring at the EMR , and I was in the state of beatendownness where you have been totally crushed by admissions, cross cover, your coworkers, staff and patients.  Owning a coffee shop was looking better and better, and hey, I love coffee.  However, looking back at the shift from hell is helpful.

Here is a list of what went wrong,and how I will fix it:

1. I didn’t have a check list in front of me.  I was rushed and frazzled, and didn’t go through my usual mental check list.
2. I didn’t take a break.  I should have handed the shock box, I mean pager, to one of my co-workers and walked outside for a moment of peace.
3. I ate too much crap.  Yes, crap. In my frustration I just put my face in to the fridge in the physician lounge and went for it.  Sigh.  I should have brought something from home.
4. I doubted myself.  I spent a lot of time justifying my thinking to myself.  (I had just finished reading How Doctors Think, and was trying to double check my thinking.)  Doubt slowed me down to the point where I began to question everything.  Solution: hmm, brain transplant?
5. I wasn’t wearing my scrubs.  I was trying to look more doctor like, so I had on a nice sweater, pressed pants, and the white coat.  (You men wouldn’t understand…)  Next time, forget fashion, I’m wearing scrubs.
6. I let my colleagues get to me.  We were all crabby from the heavy workload.  Next time I will take a deep breath and remember we are all getting crushed, and put on the lens of perspective.
7. I was quick to anger.  I got mad when a patient didn’t have a call button close to him, and I found it on top of the sharps box.  He had just had a total knee replacement, for pity’s sake!  I asked the nurse if the staff had a check list they followed when they cleaned the room, so this wouldn’t happen.  She indicated that “they’re pretty good at putting the call light where it should go.  I don’t think they need a check list…”  Ha I say!  How many times am I trying to find the blankety-blank call light for the patient?!  Time for another big breath!  (BTW, check out If Disney Ran Your Hospital.  Good ol’  Walt would see it my way!)
8. I was exhausted from the get go.  My own mom was in the hospital recently and I spent a lot of time with her, which was good but tiring.  It was eye opening to be on the other side of the bed.  I tried to do too much, and should have gotten help from friends and family, AND NOT FELT GUILTY FOR ASKING!  (Yes, this is a woman thing,doctor thing,  mother thing, brought up Catholic thing.  I’m working on it.)
9. I wasn’t wearing the no complaining bracelet.  I have a bracelet that I wear to remind me not to complain.  If I do complain, I move it to the other wrist as a reminder to stop carping.  I will wear it today.
10. I worried too much.  I was worried about patients, my daughter, my dog being in a cold dog house, the dinner in the oven that would be waiting for me when I got home at 9:00 p.m.  And yes, I forgot to set the oven.   By focusing on worry, it was harder to place the focus where it belonged: on the patients.  The daughter and dog were fine, my husband turned on the oven, and the patients were okay.  Today I will leave my home worries at the door of the hospital when I go in.  They will be there waiting for me when I walk out late tonight.

By the way, the ED docs I worked with were great!  They knew we were getting crushed, and were kind and gracious in the face of the united hospitalist of grump coalition they faced.  Today will be better, I’m sure!

And lastly, I’m only human.

Disclaimer: I have no association with the authors mentioned above, and recieve no financial gain in mentioning their books.

How Doctors Think Outside of the Medical Box

It was a tough week in Pookieville.  I worked all week at one of my favorite hospitals.  I like working there because the specialists I work with are hypercompetent and always willing to help.  Furthermore, they like to chat. Well, they like to chat about interesting cases.

I was particularly challenged this week because I had to think out of the box.  I will not share the details of the case, as I don’t intend this blog to be about medical cases per se.

When I picked up  my service, I  assumed care of a very complicated patient, with a disease process that was appropriately handled.   Unfortunately, there was an outcome that was unexpected and completely unpredictable .  It was also quite serious.  What I want to share is how hard it was to think out of the box, which was what was required.  Medical statistics and medical science can not predict all outcomes, which is when the “art” of medicine comes in to play.

I walked in to the room to discuss the latest bump in the road, and the various treatment options to remedy the latest bump.  Now, before I went in the room to talk to the patient, I had done my home work.  I had reviewed the latest bump in the road with the surgeons, specialists,  the sub-specialists and several of my co-hospitalists.  There was no clear consensus as to what should be done about this problem, just a general agreement that this problem was indeed, a big problem.  Most of my colleagues were glad they were not me, because it felt as if all options were fraught with danger to the patient.  “Glad I’m not the one that has to write those orders,” was the general feeling.

Great.

I explained to the family what the issues were, and that we were now in rock and hard place territory.  I explained that there were no randomized, double blinded placebo controlled studies for where we were at.  I explained the options, risks, benefits and side effects of each option.  I explained that  I had done my home work.

“Do you just fling sh– at the wall and see what sticks?”  One incredulous family member asked.

It must appear that way, when we can’t quote studies, and cite statistics and supply comfort from numbers.  We must appear like idiots when we have to use our experience, and our colleagues’ experience to make a decision when there is no clear cut decision, and when the road is paved with ill feelings and anger at an outcome only God could have predicted. 

But none the less, a choice on treatment had to be made. 

Here is how I made my decision on how to treat the problem:

1. Identified the problem.
2. Said “@#%*!”
3. Asked everyone involved in the case their opinion, including the PharmD, and the head of the department of medicine.
4. Came up with three options, and picked the one I felt was the safest with the best outcome.
5. Reviewed options with the patient and family.
6. Realized that there may be MORE options, once I talked to the family.  (Interestingly, the family was the most creative in looking at solutions.)
7. Walked out of the room, made more phone calls, and finally came upon the solution that we ended up going with.
8. Called a renowned specialist at the local University and got the specialist’s opinion, who was in concurrence with the ultimate solution I had crafted.
9. Went back in the room (a bit demoralized, as I had said there were no other options, but now had come up with one.)
10. Heard the family’s  intense relief at the more moderate, middle of the road option that we ultimately agreed to implement.
11. Went for it.

So why I am writing about this?  Because it took me TWO hours to do all of this.   It took two hours for me to think and explore every option, and to finally come up with an option that seemed workable, and the least dangerous.  I took the time because I wanted to do what was best.   It was the family that was most able to think outside of the medical box, and who encouraged me to explore further.

Now, was this the right choice?  Only time will tell, and yes, sometimes as physicians we just have to throw sh– against the wall, and then throw some more, and then consult our colleagues, and then think again to find the answer when there is no right answer.

I just hope that in the future, I have enough time to think out side of the medical box.

How do you think out side of the box?