Working in small emergency departments without any local back up often demands “phoning a friend,” so to speak. I encounter patients who present with findings and disease processes with which I am unfamiliar.
One warm Fall day, I got called in for a kid injured at football practice. Tom was a 16 year old who was hit head on (axially) in a football game. On exam, he had complete numbness and significant weakness in all four extremities.
Strangely, this was only from about 3 inches above the knees and elbows down (not a well recognized anatomic distribution).
Moreover, his CTs were totally normal. I had no surgeons on site, and the MRI is only available 1-2x/week. My next move was in no way obvious.
My questions almost always stem from the vagaries of practicing medicine in the real world and in resource-limited settings. Those limitations often mean the algorithms only get me so far.
On the other hand, I can only imagine how difficult it would be to practice Critical Access Medicine without uptodate and other electronic resources. Thank God for the internet.
So, I phoned a friend.
With Tom, I called the closest Children’s Hospital, I talked to Neurology first who felt he needed an emergent MRI. The neurologist was thorough and business-like. Then, I was routed to the Peds ED Doc, who was similarly helpful and gave me recommendations of immobilization and transfer.
They admitted him to their Neurotrauma ICU, and he made a full recovery without intervention. Diagnosis: Transient quadriplegia, or aka cervical cord neurapraxia. This was a first for me.
This was a neutral phone consult. I get the information I need to help the patient and we expedite his care. Generally, the physician’s at the Children’s Hospital are more civil than most.
In fact, a Peds ED consultant is to date the only accepting physician to tell me I did a good job. The patient was a pediatric DKA. By the time I called, I had fluid resuscitated the patient, the insulin drip was going, and a bag of D10 with 40 mEq of KCL was y-ed in to allow for titration on the 2 hour transfer ride based on POCT glucose testing.
This was the first time since residency a fellow physician had told me I did a good job with the clinical care of a patient. I am not particularly dependent on praise (honestly probably much less so than the average millennial). Nonetheless, it felt damn good.
I was surprised how good I felt being told I had handle a complicated case well. It made me realize how rarely we get positive feedback from our colleagues. And, if I am honest, how rarely we give it.
How much more pleasant would our days be if we battled a dysfunctional and inhumane system with our colleagues rather than in spite or even because of them?
The Normal Experience
Ruminating on my surprise reaction to a little bit of positive feedback, I started to think about my usual experience. After a time, I realized the marker I now use for knowing I did good a job with a transfer is the absence of snark.
If all I get from a hospitalist after I give the report of a patient is a begrudging, “Ok,” I know I have done a good job in setting up a patient for transport.
For instance, John, a 65 year old man with diabetes who had been struggling with recurrent infections of a diabetic wound on an old amputation site came into my emergency department the other day.
Three days prior he stopped his latest round of oral antibiotics. The wound had increased purulent discharge, pain, and surrounding redness. I looked into the putrid hole at the end of his leg, clearly infected.
Moreover, His blood pressures are soft, he was mildly tachycardic and febrile.
“Likely early sepsis,” I thought to myself, a lactate of 2.9 quickly confirms my suspicions. I order a wound culture and blood cultures, fluids, and antibiotics.
After examining the surrounding area, I took a sterile probe and inserted into deep into the wound. It slid past the slimily infected tissue and felt the sure, soft thud of bone at the end of the probe.
“Shit,” I think, “No way infection isn’t in his bone”
“John,” I start, “I think we need to get an X-ray (MRI is of course not available today) to look for infection in the bone.”
The techs wheel him off to X-ray.
Sitting in the reading room, I (the humble ED doc) can clearly see the lytic lesions at the of the bone indicating infection, and the likely need for surgery. My nurse starts the antibiotics and I call a hospitalist at a referral hospital.
I get the hospitalist on the phone. I run through his story ticking off all the important information: Vitals, lactate, white count all point to early sepsis with a clinically infected wound. X-ray showing acute osteomyelitis – he will need a surgeon and long term IV antibiotics.
I detail the care I have already given the patient. I feel he is stable for transfer. Moreover, John and his family requested transfer to the this specific hospital (multiple hospitals are effectively equidistant for transfer).
On the other end, I hear a long pause. Then, the quiet, begrudging, “Ok, we’ll take him.” Those are the last words he speaks to me, switching to addressing the operator to arrange bed placement.
I apparently don’t even merit a good-bye.
The sad thing is, I now interpret this kind of interaction as evidence that I have done a good job. No snarky comments, no prolonged questions and second guessing, no arguments as to why going to some other facility or service would be better.
And I felt good about it. I had won in the battle to deny him any reason to do any of the above.
That is how low my general expectations for civility have sunk when talking to another physician. Moreover, this is a physician with whom I am technically collaborating on the care of shared patient.
Civility is the Grease of Teamwork
Now, the art of the long distance phone consult is a delicate one. I don’t always nail it perfectly. Walking the line of giving someone all the information he/she needs while still making a coherent narrative of why you need his/her help is often difficult.
To boot, my phone call is almost always interrupting some other work the consultant is attempting to accomplish.
Furthermore, as physicians, we all work in high stress environments where it can be difficult to find a moment to focus on the problem at hand. We all have bad days, I get it.
I talk to all sorts of consultants – board certified ED docs in a large trauma center, Peds ED docs, surgeons, OB/GYNs, cardiologists, stroke neurologists, or hospitalists and intensivists for transfers.
I need all kinds of help out here on the High Lonesome.
In particular, hospitalists at large referral centers are slammed with work which is often effectively clerical. I.E., admitting a pre-op hip fracture patient so that Ortho can focus on more important (ahem, profitable) endeavors.
I know civility is rarely at the top of our lists. Nonetheless, I think we as a profession are forgetting or have already forgotten the importance of civility and collegiality.
Afterall, we are all in the game of trying to help sick people, together.
If I am uncivil to a nurse who is caring for a patient of mine, he/she will avoid calling me. If that patient crumps when we could have avoided the situation, I need to take some responsibility for that outcome.
Civility and collegiality are the social tools we have to reframe our interactions from oppositional to collaborative. Without them, our profession splinters and we are all little Lone Rangers fighting our own pitched battles day in and day out.
So, I for one am going to try and put a little more civility back into my interactions. It costs me nothing, and I have found more often than not, it pays dividends over the course of the conversation.
And, most importantly, my patients get better care when their physicians collaborate with, instead of battle against, each other.