I was consulted at 5pm on Friday night on a 74 year old guy who had just arrived in the ICU secondary to "hypotension". Other than some mild dementia and essential hypertension, he was a pretty healthy guy. When I walked in, his wife was sitting at bedside and he was groaning in obvious discomfort. Here's his intial vitals: HR 130, BP 60/40 RR 29. He's on 24mcg of Levophed and the nurse just received an order from the IM primary to start dopamine. Ok then. I'm going to need a few things, I tell the nurse. We'll start with the crash cart. I quickly place a central line and an arterial line and bolus a few liters of saline in over the next 30 minutes. I review the chart. This is his second admission for c difficile colitis within 2 weeks. A rectal tube shows a steady stream of liquid stool into a bag. His abdomen is tense, tender, and quiet. I talk frankly to the wife. Ma'am, your husband is suffering from something called fulminant c difficile colits. It has made him septic and if we don't take him for surgery and remove his entire colon he will almost certainly not survive the night. Even with surgery, his chance of survival is less than 30%. Do everything to save him, she says. With the volume resuscitation ongoing, his BP starts to stabilize. The Levophed is weaned to a more reasonable 8mcg. We go to surgery and I perform a total colectomy, leaving just a short rectal stump, and give him an end ileostomy. I finish at midnight on a friday night. My experience with these cases has taught me that outcomes are about a 50/50 proposition. I've had some live, but none that were as sick as this guy. By POD#1, the levophed is off. The next day he is extubated. His renal function normalizes. Now he's taking clears. I think we're going to make it. But here's the thing that kills me. On POD#1, the primary MD doesn't say anything to me, other than "you know his Phosphorous is 1.2". And then he consults renal (creatinine 2.4 when I first saw him, then down to normal by POD#2), hematology (because platelets are 80), cardiology (occasional PVC's with hypokalemia), and Infectious Disease (infection present). I check my orders from the morning rounds and my KPO4 infusion has been cancelled by the nephrologist. The Lovenox for DVT prophylaxis has been cancelled by the hematologist (r/o HIT?!?). And the cardiologist has changed my fluid orders (worried about possibly accumulating fluid in his legs). Then the nephrologist calls me the next day. Classic phone conversation. "I don't know how to say this without creating an awkward situation", he says to me, "but I think it would be better for the patient if I managed his electrolyte corrections. You ordered 30 mmol of KPO4 and that can sometimes cause vasodilatation. I would also like to manage the TPN." Um, ok, I say. His creatinine is normal now and his urine output is fantastic and I've actually replaced K and PO4 hundreds of times in my life. But that's fine. I don't mind if you perform those duties, I tell him. And then he adds, barely concealing the underlying condescension, "I mean, I couldn't do surgery, but... ha ha ha " just sort of trailing off; the patronizing implication being that, as a surgeon, I shouldn't presume to know what I'm doing in an ICU. Unbelievable. This pateint is going to live. I've busted my ass for him. And now everyone wants to shuffle the surgeon off to the sideline so the "smart" doctors can manage complicated, life threatening emergencies like hypophosphatemia. Just had to rant on that one
But this case reveals an unspoken source of the high cost of medical care in the USA; all the unnecessary consults. The Internist admits a patient from ER with abdominal pain and fever. That means, before the surgeon sees the patient, you're likely to see notes from Infectious Disease and Gastoenterology in the chart. All of them recommending "surgical evaluation " for abscess or hernia or cholecystitis. ID is biggest scam is American medicine. Everyone with a fever or a white count gets ID on board. Here's what they invariably recommend: blood cultures, urine culture, sputum culture, CXR, and maybe a CT. Einsteinian insight they bring to the game. Give me a break. It's a specialty that certainly has a place; HIV, Hepatitis, unusual organisms, non-Western hemispherean illnesses. But now every local hospital has these huge ID groups that are glorified culture-checkers. The biggest census in the hospital belongs to our ID group. I don't get it..... Damn I don't write for a few weeks and I come out all angry and bitter. Hopefully tomorrow I'll blog about the natural beauty of autumn leaves and how I have to rake them for three hours every freaking saturday and stuff them into paper bags, getting little leaf chiggers lodged in my finergtips... well, maybe some other topic.