Differences In Practice
At any rate, this is a nice town. It has a long history of really rich schmucks building ji-normous mansions for "summer retreats," so everywhere you look, there's some massive relic. The downtown area is nice, though, lots of interesting architecture, wood building dating back to the 1700s. We came in mid-afternoon, so we haven't seen it all, but it's promising.
New Haven is actually a great location to travel to in New England. We have close access to Rhode Island, New York City, Boston, and other areas, and even going up to Maine isn't that far. I hadn't ever imagined that I'd be living somewhere that was only a couple of hours from Newport or NYC. It hasn't really sunk in yet (although it's starting to).
We're both quite happy to be done with the week. For one thing, we finally got paid today, and how great that was. It was pretty awesome to see how well we're getting paid, not to mention the fact that we're not even paying rent or utilities here. Also, it's been a busy week. Jess has been taking care of the sickest kid on the unit, pronounced so by surgeons there, and was even doubled with that patient. She's been pretty worn out by those nights. I'm proud of her.
My last evening, when I wrote the previous entry, went sour about four hours after I'd finished with the entry. I was pretty bored all evening; I even wrote all my notes and had all my charting completely up to date. Good thing, because at four, after being turned, my non-intubated patient suddenly decompensated and quickly went into full-blown pulmonary edema, complete with pink froth and everything. This is where I experienced a sharp departure in the way things are done at the Y and how they were done in the Big D.
First and worst, I had to page the doctor. There are two teams of doctors on the unit, but don't ask me where they are most of the time, sitting in the cafeteria for all I know. So, I paged the doc (an intern--don't get me started on that), and he returned the call quickly enough. I explained that my repeatedly intubated CHF patient had O2 sats in the low 70s and that he should probably come and check it out. Apparently, I wasn't clear enough, or I didn't sound urgent enough. He ambled in fifteen minutes and two pages later, after my patient had gone from comfortable on a simple facemask to barely conscious on 100% O2 through a non-rebreather. Yet he made no decision, instead allowing the resident who actually followed him in to order Lasix, which did nothing. The resident decided then, without further interventions, that intubation was needed.
Granted, intubation was probably inevitable. Still, these doctors should have known that the man's kidneys were useless, and that what had worked for him previously was dobutamine. In hindsight, I wish I'd remembered that I'd discussed his recent dobutamine drip during my report with the day nurse and had brought it up at this point; on the other hand, it's not my job, it the doctor's job to know what has been working medically with patients like this.
At any rate, while nothing else went wrong at this point, it was completely different than what I'd always done up to that point. At the Big D, I'd be busy getting my sedation and code drugs together, as the respiratory therapists and unit doctors prepared to intubate. So, I'm asking the doctors (yes, the idiot intern and his resident friend) what they wanted for intubation, only to get a scornful look. These doctors don't intubate, as it turns out, nor do the RTs. All intubations are done by anesthesia, all of them (maybe not in a code?). So, another five to ten minutes pass, and finally the anesthesia team shows up. Wanting to make myself useful, I positioned myself at the head of the bed with my saline, ready to push drugs. No, not the thing to do, as that only brought me another scornful look.
So, in the end, I just stood aside while it all happened. Even the RT did very little. Granted, it turned out to be a very calm, almost serene intubation, but I always liked the adrenaline rush of a good intubation. The unit team, meanwhile, barely was even aware of the intubation, they sat outside the room on the computer, looking perhaps at CNN, something that was more interesting than patient care. When the paralytic the anesthesiologist used for intubation wore off and the patient's respiratory rate was 45 times a minute, I really had a hard time getting them to write orders for versed and propofol. In fact, I only got a verbal order out of them, and had to get the oncoming day doctors to actually write the order. Needless to say, I wasn't too impressed with this team, as in, what Caribbean island did you get your medical degree? WTH?
Anyhow, I left the room, the charting, everything, a monster mess. I tried to get it all together, but this happened right at a quarter after six, and I couldn't finish everything. I probably didn't make good friends with the oncoming day nurse. All in a day's work, I guess...
Anyhow, it's just nice to have it over, to be in a different place, even different state. Really, the nice thing about traveling is even when you find yourself in a big cluster, it's only a matter of time (thirteen weeks or less) until it's all over and you walk out of the place free and clear. Unless you get fired, then there's even less time.
Not that I want to get fired. No, I hope that doesn't happen.
Until next time, be safe.
