i heart doctors

Yesterday the medical staff changed the flow of O2. This was not the plan. This started a flurry of parent-doctor struggles.

As of last Wednesday changing his O2 was not the plan. That plan, as documented in my hand-built chart, and ratified by the then pulmonary attending, showed we were to start decreasing Julian's diuretics first. The important parts of the plan are that it maps out a course of changes to Julian's diuretics, O2 support and feeding in a way that makes one change at a time and tries to change the most important things first. It's simply the old scientific method. When we make a change we want to understand what's impact was.

Probably the most challenging part of partnering with the medical staff is to get a plan that reaches out over more than one attending shift. Our attending changes every week, but Julian only changes ever other week or so. The tendency to move quickly, to change multiple things simultaneously, or generally to change the order of things breaks this experiment and leads us to make potentially incorrect conclusion. For example if we changed his diuretics and his O2 support at the same time and then he started working harder to breath we would wonder - was it the O2 or the diuretics. And be back at square one.

Joy insisted that the old flow be restored in the early afternoon. And Joy and I switched places at the hospital at around 4:30pm. I waited until 7:30 for the attending to show -- instead one of the residents showed up. She started (nicely) with the standard back-to-basics explanation of Julian's state. After about 5 minutes I asked her to grab the chart behind her which explained our plan. She said she didn't know there was a plan.

So we're back on the plan. Hopefully securing agreement to it (or modifying it as appropriate) from this attending. And hopefully sticking to it. This attending doesn't take the time it takes to build consensus or a plan. He also doesn't articulate one when he is barking at us.

Scott

P.S. This is snarky so I'm leaving till the end. And yes, I know all about projection...:-) We continue to debate with the medical staff about the frequency of CBGs (blood gas tests). They would really like to do them every other day. We ask why, they say he doesn't need it. We like having the data, and it allows us to see trends over the last 2 days (usually the decision making unit) at any time. This was very helpful two weeks ago. The doctors argue that having the CBGs may make them (or us?) react to one bad number. I mean seriously if you know your algorithm for taking action might include over reaction would you a) monitor less or b) change your algorithm to delay your reaction (hysteresis). Holy crap! Or here's another one. Let's agree to disagree. Let's do the blood test every day and I'll just tell you the number every other day.