Sunday, August 21, 2011

Why Internists Should Never Be Intensivists.

I had a really interesting phone conversation with one of our internist/intensivists this morning.

My morning on call started out with an abdominal washout from ICU. This unfortunate lady had her anastomosis break down a few days ago.

Much to me surprise unlike most abdominal wash-outs from ICU she arrived extubated and "breathing" O2 through nasal prongs.....with a SaO2 of 81%, She frankly looked like shzt. Rapid sequence induction with ketamine and her sats perked up with the endotracheal tube back where it belonged. The plan had been to try to hook her back up and close everything however even our most cowboy surgeon looked a things and said no way. Anyway 2 hours or so of digging around the abdomen, creating a colostomy and closing the wound ensued. As he got into her abdomen, I noticed I needed 100% O2 and some PEEP to keep her sats up. So my plan was to send her back ICU ventilated. That actually was my plan from the start of the case.

As we were in the home stretch one of the nurses called me over to the phone.

"Why aren't you going to send her back to the ward?" a voice asked.
"Who am I talking to?", I asked.
"Dr. Yankovic (not his real name, but the resemblance is striking)," came the reply.

Dr. Y is our head of critical care, a pulmonologist who was practising ICU when I showed up in town.

"Let me see, " I said, "She came down with a sat of 81%"
"So she needs some oxygen" snapped Yanko.
"She was on oxygen", I said,
"Which you would have known if you actually made rounds before 0900, " I thought. "Further," I said,"the surgeon wasn't able to hook her back up, he is closing the abdomen but it is quite tight, and I don't think she will tolerate early extubation."

"Fine," said Dr. Y, "I guess I will have to finish your job for you" Click.

Now I might expect this from some young whipper-snapper intensivist who hasn't seen a surgical patient since medical school but this is someone older than me who is head of his department. I might even expect something like this if ICU was full and this lady didn't have a bed. More and more ICU has come to expect us to run our recovery room as a step-down where patients can be ventilated for a few hours which usually runs into a few days. One of my colleagues who never complains had a similar conversation with one of Yanko's colleagues, also an internist, which ended with the exclamation, "well, if you can't look after her, I guess we will have to take her!"

ICUs historically were run by anaesthesiologists who understood surgery and actually knew something about medicine. That was until internists realized there was good money to be made in ICU, as opposed to internal medicine. Now a significant number of intensivists have an internal medicine background.

The bottom line Dr. Yankovich: I'm not asking you to finish my job, I'm asking you to do yours and I shouldn't have to ask. And by the way, get a haircut.

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