Saturday, October 1, 2016


        The modern day medical care is considered comprehensive . The ICU have started collaborative  rounds , which includes physician,nurse, case management, respiratory therapist . pharmacist and some other. The idea behind this concept is that such collaboration will help improve patient care and it will be comprehensive . So now a physician present in ICU 24/7 will help critically ill patent's outcome. This now implemented in ICU across the country. Certainly it will improve some care in some patients and it will also increase the cost of health care as billing will be changed and most likely it will be higher. But what I would have like to think is better care by individual physicians and better communication among patients and doctors and among different physicians. I often see computer generated notes which are neither accurate nor informative and tends to state things that are exaggerated especially the Time spent . If one would add the recorded time in the notes , there would be no time left in a day of 24 hrs. But my question is why do we have such a behaviour and the thought process ? I want to talk about couple of patients in this regards.
     I saw this patient for pneumonia. He was 84 years old and had not smoked for many years . His chest x-ray showed pneumonia and some fluid around the lung . So I did CT scan and it showed fluid . So I drained the fluid and it was positive for lung cancer . I called oncologist and they saw him promptly . But a month went by and no treatment was started as they were trying to decide on which drug regimen protocol to use . Patient got more short of breath , and that was in spite of regularly draining the fluid with a inserted catheter. So he as admitted and it showed a clot in the lung and now more /new fluid on the other lung. So the ER doctor called  at 10 or 11 pm. I started him on intravenous blood thinner . and ordered to check the legs for a clot in the legs. The incident of such clot in patients with cancer is very high and they may need treatment life long or as long as the cancer is there. I also knew that he may need the drainage of the fluid and may need putting a catheter to drain it as needed -just like he had it on other side . The treatment for cancer was not yet started  and that may also need insertion of a port . So essentially he would have needed -potentially 3 different surgical procedures in near future. This meant we will have to hold the blood thinners. Taking this account I had started the blood thinner that could be stopped and the blood thinning would return to normal in less than 6 hrs.
     The next morning I went to See the patient and was surprised to note that the IV blood thinner that I had ordered were discontinued and a pill was ordered. This new pill takes effect immediately and patients can be discharged quickly. But it takes 2 full days to reverse the effect of blood thinning. So while he is on this pill no surgical procedure could be done and will have to be off it for 2 days . I had to change the orders again as we needed to have catheter inserted for fluid and a filter to prevent clot travelling from leg to lungs and get port inserted to give chemotherapy. So why the oncologist give pill?
     The patient got all three procedures done and then about 4-5 days down the road we started the pill and he went home I think the problem is that the thought process that I went through when I started the IV blood thinner was not done by the oncologist , nor was my note seen and it was a knee jerk reaction to start the pill which is correct treatment in most but not in all . 

No comments:

Post a Comment