Sunday, October 22, 2006

OPP (Other People's Patients)

If you recognized the title of this post as the title of a rather questionable rap song, you are old (just like me). I have mentioned in previous posts that OtherDoc has finally agreed to share weekend call with me. The inordinate luxury of having 2 whole weekends free of the pager is well worth the 2 weekends of double the patient responsibility. I have come to realize, however, that OtherDoc's patient management is a bit different from my own. This leads to occasional patient care dilemmas.

OtherDoc has been practicing for nearly 15 years, and sees probably quadruple the patients that I see, he is board certified, and sticks to the standard of care in most cases. Sometimes, I think, he gets just a little too busy, and can neglect certain duties essential for transfer of care like writing notes in the chart. I come from an era in training where the threat of lawsuits lurk at every turn, and documentation is your very best friend. We were taught that the chart should be able to stand on its own. After being in solo practice for so long, I can see where you could let note writing fall by the wayside, since *you* know what you are going to do/what you have done/what you are concerned about, etc. I, on the other hand, cannot divine the true purpose for hospitalization/plan of care without some documentation. I'm also finding that OtherDoc doesn't get a chance to do a lot of patient education (as evidenced by multiple pages over simple questions this weekend), nor does he share his plan of care with his patients all that often. Such was the case with one of his pregnant patients in the hospital this weekend. As per usual, we did a quick sign out at the office on Friday, where he basically stated the patient was a "chronic hypertensive in for rule out pre-ecclampsia, oh, and her sugars are a little out of whack, too." I left check out with the impression that the patient was to have a 24 hour urine protein, and if her BP was controlled on her new medication regimen, she was to be discharged. Imagine my surprise when I pulled the patient's blood sugars for the last 2 days, 90% of which were over 200 (!) OtherDoc had written for low dose insulin the day prior, but did not tell the patient his reasoning, and therefore she was refusing the meds. I also found, after a little digging, that her 1 hour glucola value (taken last month!) was well over 200 and the baby was macrosomic with polyhydramnios. Woo hoo. Her blood pressure, ironically, was just fine on the meds she was taking.

I sat and had a long talk with the patient, who was (more than a little) in denial about her condition, about uncontrolled blood sugars and the effects on the baby. She still refused insulin, so we compromised and settled on a trial of Glyburide, with the caveat that if Glyburide did not control her glucose, we needed to proceed to insulin. I also had the dietician come in to teach the patient about carb counting and diet control. Her 24 hour urine protein was consistent with mild pre-ecclampsia, but she had not had a baseline 24 hour urine, and I have the feeling that she may have had some proteinuria prior to the pregnancy. In the end, it all got straightened out, but I feel as though I may have taken a different direction than OtherDoc was intending to take. I surely don't mean to question or undermine his management, because there are several correct ways to approach clinical problems. I'm just trying to do the best for the patient under the circumstances. I'm sure, if he desires, he can tweak the adjustments I made when he sees her next. If anything, this weekend has just reinforced how very important it is to document your plan of care, and to share that plan of care with your patients. The good news is that this weekend is nearly over, and I will then have the next two whole weekends off! O frabjous day!


Anonymous said...

Yeah, you know me!

dr. whoo? said...

L&L&LOL! The damn song has been in my head all day now...

Anonymous said...

Are you and OtherDoc in practice together or just covering each other for the elusive weekends off? Either way it would drive me nuts to share care with someone who wasn't writing everything down. I say that with the horrid irony that my charting is starting to look like OtherDoc's because I am solo. I am driving myself nuts trying to figure out what I meant by my own cryptic note taking. Thanks for the kick in the pants ;)

Anonymous said...

Dr. Whoo? Just found your blog. Very interesting. It is sad so many women choose elective c-sections and inductions and miss the experience of a natural delivery. I am 55 and had my first baby at 29 with an "emergency" c-section" due to mild pre-eclampsia, (bp 140/90 which came down immediately upon admission to hospital) after a failed induction with pitocin. Twenty four hours in pain with contractions camelbacking with horrible back pain but the nurse told me they weren't bad per the monitor. I didn't take any medication but was scared to death by the 16 year old in the next room screaming for hours. Finally they medicated her. It was torture to listen to her. The baby's head never really engaged in the pelvis and I never really dilated. The c-section was done with general anethesia, my husband wasn't there and my baby was very sleepy for days. I was breast feeding and did not take any pain medication after the second day because I was sure the baby wouldn't ever wake up. I had planned a natural delivery without medication, my husband present and was devastated at what happened. The doctor told me the induction failed because my 8lb. 4 oz. baby was too big for my pelvis. When I went for my 6 week checkup, I made the mistake of asking the doctor, not my doctor but the doctor in the group practice who delivered me, some questions about what had happened. I was really depressed and grieving the loss of the experience that I had hoped for. He became angry and two days later I received a letter telling me to find a new doctor.
When I became pregnant again 3 years later, I was determined not to repeat the same experience. I got information about VBAC, joined a support group in the area (founded as the Cesarean Prevention Movement), found a new doctor who supported VBACs, hired a labor coach who was actually a lay midwife who did home deliveries for the local Mennonite women (didn't tell the dr. that!). My plan was to stay home until just before delivery because I knew going to the hospital started the time clock running to deliver in a set number of hours or be sectioned. I had to deliver in a special room (OR?)with an IV in place not a birthing room so they could do an immediate section if anything went wrong. Two weeks after my due date (thank you Dr. W. for letting me go so long, most would have just scheduled a repeat section), the Dr. said if I hadn't delivered by July 5, he would do a section. My coach/midwife reassured me that I was going to be OK and would go into labor, the baby had dropped down. July 3rd. labor started, I labored at home, walking as much as I could. Twenty four hours later, she said I was in transition and it was time to go to the hospital. When I arrived, the Dr. covering for my Dr. checked me and said I wasn't dilated much and it would take 7 or 8 hours before the baby would come. Get comfortable, he said. I looked at my "coach" who had come to the hospital with my husband and me in dismay. She just smiled a little and shook her head no just slightly so only really I saw her. My contractions were strong but never as bad a the pitocin induced pain and the pain was tolerable. A nurse put in the IV with a heparin lock BADLY, all the time making it very clear that these VBACs were such a waste of her time and clearly annoyed that I wasn't being a good little patient by just scheduling a repeat section. I still remember her name, Bridgette, and what she looked like, 22 years later. Despite the Dr's. pronouncement, I was in transition and threw up. Soon I was surrounded by medical students or residents who had come to see the "VBAC". I tried to focus on my labor and use the Bradley method which teaches you to accept the pain and move into it not away. About an hour after admission, I told the dr. and his nurse-midwife (She was so nice to me, I also still remember her name and what she looks like)that I felt like pushing, a new experience to me and truly a primal urge not to be ignored. He said "no, that couldn't be possible but let me check you" (still surrounded by at least 10 hospital people but I didn't care anymore). Sure enough, fully dilated with the head crowning. I started pushing because I didn't feel like I could stop it and it felt right.Women need to listen to their bodies! They couldn't get me into the other room fast enough. I was supposed to be on the table with my feet in stirrups but the baby wouldn't wait. I was still in the bed but they are saying don't push which I tried to do, then push as hard as you can because of meconium in the fluid. The head popped out with about 2 pushes, then instructions to not push while they suctioned her. Then push again as hard as you can to get the body out as soon as possible. Two pushs then the body slid out. I had a big tear because the delivery was so fast in concern for the baby's condition. But I didn't care, I just felt bad for the CNMW who had to sew me up still lying in the bed. It took forever and she was hunched over trying to see what she was doing. Her back must have hurt terribly when she was done. I kept offering to get on the table so she could sit down and be more comfortable but she wouldn't let me move. Maybe she was afraid of nurse Bridgette getting mad about messing up another area because she had many comments about the mess in the bed. I was so happy-I had delivered naturally a 9 pound 6 oz, healthy baby girl without any pain medication, with minimal intervention, awake and aware. The doctor asked me after the delivery it it was really "worth" it to have a VBAC. My response was an unqualified YES! There was far more pain with the C-section and induction and I was in pain for 2 weeks. The labor pain was never intolerable. While the tear hurt for a while, it no where came close to the section. For women to choose a repeat section or schedule a primary section for convenience is inconcievable to me.

Sorry about this very long post. I guess I just needed to let people know my experience. Get it off my chest. Thanks for listening.

medstudentitis said...

O is for Other P is for People scratchin' temple
The last P...well...that's not that simple

Enjoy your weekends off!

dr. whoo? said...

frectis~ Are you and OtherDoc in practice together or just covering each other for the elusive weekends off?

Well, it's kinda complicated. We are both employed by the hospital, and we share an office and office staff. We aren't really partners in a practice, per se, and we tend to only see our own patients unless we are covering for one another. So we are kind of solo with call coverage, I guess? Personally, I'm hoping that the hospital hires a third doc soon, I'd love to have someone with whom to operate and share more of a partnership!

hi beth! Thanks for sharing your birth story. I think it is great that you had a successful VBAC. I try to advocate for women attempting VBAC, but it isn't for everyone. I do wish that women had more faith in their body's ability to handle birth. Thanks for reading!

medstudentitis~ Hee! and you aren't even that old! I am so looking forward to these next two weekends! :)

apgaRN said...

Hey Dr. Whoo,

Just came across your blog... speaking from a nurse perspective, it can be very frustrating to field the questions and frustrations of patients who can't figure out why every doc they ask gives them a different answer. As you say, "there are several correct ways to approach clinical problems." But sometimes patients just don't GET IT. We have a perinatology practice at my hospital with four docs, each of whom have very different management techniques. I felt bad for a friend of mine who was hospitalized with preterm labor and high blood pressure... depending on who was on call that day, the plan changed. She never knew what to expect!

Hope to visit your blog again!