Saturday, May 31, 2008

The spiritual purpose of the intern

video: a science teacher demonstrating that potassium in water is dangerous--and to think I prescribe this stuff every day!

Interns working on our floor keep getting pages that go something like this:

"Please address chloride levels on your patients. 43770"

Various interns have done various things in response to these pages, including calling the number which is never answered.

My own response was to think, "What the hell?" The page was like an extreme version of the very common pages we get from nurses: "K is 3.5 on Mr D in 225, do you want to replete" or better yet, "Smith's Mg is 1.8, please put in order to replete". Some time ago some people showed that after heart attacks, people had fewer ventricular arrythmias when their potassium (periodic table of elements label = K) was above 4.0 (but not too high) and magnesium was above 2.0 (but not too high). Now everyone gets electrolyte repletion for K of 4, Mg of 2, even if they came in to the hospital with metastatic cancer in every part of their body except their perfectly working heart. And because a small but active fraction of nurses are more protocol-driven than thoughtful, we sometimes get paged with an urgency that seems to suggest that a K of 3.7--a perfectly normal human potassium level--represents a dire medical problem.

Anyway, looking at my "chloride levels" page, and briefly puzzled that there was yet another electrolyte page but one that didn't make any sense to me, I looked through the chloride levels on my patients. I was figuring I was going to then call a nurse and try to figure out how to explain that I wasn't going to address the chloride levels. (High or low chloride is a symptom of other things, and we don't deal with it as an isolated problem.) Then, I saw that the chloride levels in my patients were all normal. Then I realized that someone was messing with me.

It did not take long to find out that J, a resident, has been delightedly going around the floor sending these pages. "I'm teaching the interns not to be so gullible" he says, earnestly, as if genuinely imparting some kind of teaching point. (At other times, he actually is quite earnest about imparting teaching points.) "If someone believes that you have some kind of teaching point, J" I said, "that's the person who is truly gullible."

The joke page was funny because electrolyte repletion pages are a constant feature of intern life. Perhaps because it represents a simple number which can be addressed with a simple response, and because low potassium and low magnesium are quite common, electrolyte repletion becomes its own justification for nurses and interns alike. So to puzzled medical students, or to attendings who ask why we're ordering electrolytes on stable patients every day, I've taken to explaining the K-of-4-Mg-of-2 obsession by saying, "K of 4, Mg of 2 is the spiritual purpose of the intern. You can't take that away from us."

Someone recently reminded me of my first day as an intern when she described a first-day-of-internship experience identical to mine: writing an order for potassium repletion, and suddenly becoming gripped by fear. During my first K order, I realized that I was writing for potassium, and that high potassium can kill at least as surely as low potassium, so the level of potassium had to be correct. I knew in my brain that this was not a difficult goal to achieve, but in my heart, suddenly the realization struck: "I could kill someone just by putting in an order."

I'm still fearful from time to time, but it's not potassium that scares me.

Video: This demonstration shows very poor safety technique. This common chemistry teacher stunt is elemental potassium reacting with water and forming potassium hydroxide and hydrogen gas; the heat of the reaction then causes the hydrogen gas to catch on fire. You have likely already gathered that we don't prescribe elemental potassium in the hospital; potassium chloride is stable and then the chloride and potassium can each go their separate ways in the body without anything catching fire.

At hospital computers, anonymous toilers Google their inner states allows me to track what recent search terms people have used to find this site. A few people are clearly looking for this site specifically; most stumble on it with Google searches that lead them here--maybe the same way you ended up here.

Here's my favorite Google search phrase that led someone here, from a hospital-based server far far away:

"i'm a medical resident and i feel stupid"

This phrase put into Google's search box led the searcher to this blog. And all I can say is, brother or sister doctor-in-training, I feel you.

Keep searching.

Wednesday, May 14, 2008

Advance by day, maintain by night

If hospitals finally designed truly rational production processes and became 24 hour enterprises, care might work better and be safer--but where would the romance of the night shift be?

I'm quoted today in White Coat Notes, a brief quote in which I say that in the hospital "We maintain by night and advance by day", which might be worth explaining a bit more.

The hospital is a constant production process. But it's in transition: it inherits many of the features of its pre-industrial roots. A truly efficient production process never stops, but the hospital slows down considerably at night. I think there would be a lot to be said for a truly 24-hour hospital. But that would require more health care workers, more money to pay people extra to work overnight, and a completely different way of arranging care.

Hospital care moves in fits and starts. We try to help people with the hospital's resources and then move them out of the hospital before they begin accumulating too many of the hospital's risks, like hospital infections, or unnecessary procedures stemming from results of unnecessary tests.

The five-day-a-week, 10-hours-a-day schedule of much of the healthcare system means that the discharge that could happen on Saturday waits until Monday because there's no skilled nursing facility screener who can come on a weekend to accept the patient. A CT scan that could take place overnight waits until the next day because there are only enough radiology technicians and radiologists to staff emergencies at night.

Meanwhile, there are things we do to advance care at night. For instance, we might start an infusion of medicine overnight. But most of what we do is planned and started in the daytime. We make our plans by day, do most of our testing and procedures and imaging by day, and make most of our clinical assessments by day.

A hospital would be more efficient, and care would happen more quickly and probably yield more clinical benefit if we operated hospitals on a 24 hour schedule. Care would probably be better if it took place at a constant pace rather than a stop-and-start pace.

The argument against the 24 hour hospital is obvious: it's nice that for a while, we can just let our patients sleep. On the other hand, most people don't sleep well in the hospital. If we could get them out 50% faster, they'd get more sleep where they're going than the hospital where they're staying. And at least from the house staff point of view, it's frightening to cover patients on a hospital floor where nurses and other staff don't regularly come in to rooms to take vitals and check on how they're doing.

On the other hand, maybe this is all self-justifying fantasizing from a pre-call intern, the root idea of which is: We're awake. Maybe the rest of the hospital should be too.

Monday, May 5, 2008

old shoes

Late night in the unit. My resident and I are finishing up an admission and hanging out with the night nurses. They're experienced critical care nurses. Somehow we get to dumb ways that interns behave with nurses. These conversations are common and I think it's because they serve a social function: by telling these stories the nurses are saying, "We know you're not that kind of doctor", and also, "You better not even think about becoming that kind of doctor" and also "If you do become that kind of doctor, you better know we're going to laugh about you and tell stories about you behind your back, including to your colleagues." The doctor end of this conversation is, "I really want to be buddies with the nurses" and "I promise I won't become that kind of doctor."

Anyway, the best punchline to one of these stories was from one of their colleagues, who reportedly said to an intern she wasn't happy with:

"Kid, I've got shoes that are older than you."

Sunday, May 4, 2008


[Note: click on the graphs to get a full view including more-or-less readable data labels].

Here's a shout out to the graphic designers at the New York Times, who often produce great pieces of informational design, and who illustrated this op-ed about the black vote and the white vote in the Democratic primary. (I hope one of the data labels is in error: it cites the end of the graph as April 2, when the graph would really only be truly relevant if the end was May 2.) The article and the graphic make an important point: while the media has been fussing about whether Obama can win over white working-class men (many of whom will not vote for Clinton in the general election either), fewer observers of this political spectacle have been paying attention to the black votes that Clinton has been more or less deliberately throwing away and probably permanently losing.

The NYT article and graph are about a very specific question.

Contrast this to the more general and more common political discussion of whether a candidate is viewed favorably or unfavorably overall. Here's my quickly Excel-graphed illustration of Obama's approval ratings from November until now.

This graph uses overall national "approval" polling data from Rasmussen (the raw data are here) to show Barack Obama's approval ratings over time. The graph shows that the primary season has probably not had that much impact on how the overall electorate views Obama: mainly, people's views have on average become more certain (more "very" and less "somewhat"), but have not changed whether they like or dislike Obama.

The biggest shift came in late February where his "favorable" ratings got as high as 56% and his "unfavorable" ratings as low as 42%. In other words, the monumental flux of this campaign has been about 8% of voters who moved the center line between "kinda like" and "kinda don't like" back and forth.

My graph shows the effects of the political circus, the "who's up/who's down" tallies of cable news--and reveals a much more stable and enduring divide among voters, the one that persists election after election and actually does transcend personality. The smaller fluxes in "favorability" of any given candidate may or may not be important overall.

The NYT graph shows something more important: the actual effects of Hillary Clinton's behavior on a specific part of her base, and what could be one effect of her tactics if she were to win the primary. There is a significant inference here--the assumption that favorability ratings drive turnout. Maybe, maybe not. It may be that black voters would dislike her but vote for her anyway, which would probably be a rational choice. And there are a lot of things left unexamined in this graphic: it compares one group's view of one candidate with another group's view of another rather than comparing both groups' views of both candidates, which would likely be a more nuanced and less dramatic picture. Nonetheless, this single comparison and the clear presentation of the difference is much more interesting and reveals more significant shifts than where her favorability/unfavorability ratings have been going overall. (Not much changed.)

Sometimes smaller questions yield bigger answers.