Tuesday, August 22, 2006

9... Knight C-6 to B-8

The patient had independently gotten up to a chair. The primary doctor had already blown through and the only order they had left was to advance the patient's diet. For the first time in three weeks the patient could take a regular meal.

Not jello. Not broth. Not weak tea made from cardboard shavings and bits of plastic cartons. Real food.

"Anything happen while I was out pestering old sick people?" I asked the patient.

"One of the doctors came in and said he was going to change that," the patient said, nodding towards the intravenous antibiotic bag hanging from the IV pole.

Being somewhat a wordy person, I felt that some sort of explanation was in order. Doctors have little time for these things. It's something that nurses take upon themselves to do, sometimes. A matter of style.

Explaining medication changes to patients is important to me. I feel that if a patient understands why we do things, these things works better. Kind of a logotherapy thing. If the patient has an understanding of how and why we are putting them through things, then the things work better.


The patient's chart indicates that the infectious diseases consulting specialist, Dr. A., changed the antibiotic from IV Zosyn to oral Augmentin. I really like Dr. A. mostly because he usually wears a kufi and though I am not personally of his persuasion I have a few myself that I sometimes wear on special occasions, such as trips to the opera or other special dress-up events.

When I explained this to the patient they said "Oh no, I can't take Augmentin because it makes me sick."

After sending the order to pharmacy, transcribing it, and securing the medication, I halted. Then I put out a page to Dr. A. and waited for his call-back, then explained that Augmentin makes the patient sick, according to them.

"OK, cancel the Augmentin and give Levaquin 500mg p.o. daily and Flagyl 500mg. p.o. three times a day."

"Thanks, Dr. A., " and I dutifully wrote the order in the chart, faxed it to pharmacy, transcribed it onto the medication administration record, and awaited its fulfillment in the computer-controlled medication dispensing machine on our unit.

I stopped by the patient's room to explain that we had changed the medication to different ones.

"Oh no," they said, "I can't take Flagyl, that makes me sick," they said.

So I again put out a page to Dr. A. and when he called back I gave him the patient's concerns, and he ordered to stop the Flagyl.

"What about the Levaquin?" I asked, and he said just to stop it all and return to the IV Zosyn the patient had been on all along.

So I wrote down the phone order in the patient's chart, and faxed this to Pharmacy, and transcribed it back again into the patient's Medicine Administration Record, chuckling as I explained to nurses and staffers around the station that I'd basically just wasted 20 minutes doing nothing but establishing a patient's intolerance towards certain antibiotics.

Right back where we started. No changes, yet several changes. The pharmacists on the other end of the fax machine must've thought I was a fool. Square one, change, square two, change again, square three, another change, square four, put the knight back on B-8. The Breyer variation of the black side of the Ruy Lopez.

So to speak.

I went back to the patient and explained that now we weren't going to really change anything, and forwarned them that they might also have intolerances to other antibiotics as yet untried, to which they nodded possible agreement.

It's a good thing to know.

In the CD changer:

Edward Elgar Symphony #1 in A-flat, Sir Adrian Boult in a live performance at the BBC Proms recorded at the Royal Albert Hall in 1976.

Kiran Ahluwalia, born in India but raised in Toronto, doing Ghazal song-forms.

"Return To Dark Side of the Moon" tribute album. Tommy Shaw, of all people, sings "Money." I almost don't hate him anymore. Frighteningly good. Edgar Winter on sax.

Ruth Laredo playing the complete Scriabin piano sonatas.

The Best of Taj Mahal.

Saving for an I-Pod and pricey headphones.


Marcus said...

Love your blog - gives me some insight as to what life is like in "A big white building with sick people in it - but that's not important right now" (hat tip to Airplane!).

As for the iPod situation, it may help you to save some bucks if you go to the Apple web store and scroll about 2/3 down on the right side. They have a red tag that has 'Save" printed on it there. That link will take you to the refubished items available for sale, and iPods are at the top of the list.

MEC said...

Okay, my first thought was, "Did the doctor think about asking the patient whether they've ever had adverse reactions to any of the medication the doctor was thinking of prescribing? And why not?" Because, y'know, I'm not even a medical professional, but I know that sometimes the reaction is not merely getting sick but going into anaphylactic shock. Shouldn't doctors think about things like that?

shrimplate said...


Docs do their best, and before admission to a hospital bed the ED people will have ascertained medical allergies.

Often a pharmacist will even question an order if the drug is molecularly similar to a prescribed med.

Then they call the nurse who calls the doc to get a different order.

I've had patients claim to be "allergic" to antihistamines, which are used to reverse allergic reactions. It hardly seems like that's a genuine allergy. The patient might not understand the definition of true "allergy" and just mischaracterize it as one, when "intolerance" or "adverse reaction" fits better.

Some people are just plain idiots. I had a diabetic patient recently who insisted they were allergic to water! and would only drink regular sugar-laden soda, which did great things for their high blood-glucose problems.

Anyways, basically it's the nurse at the bedside that spends their hours sorting all these little things out.

Eli Blake said...

You know, I've always lamented the loss of chess as a major focus of social gatherings.

Today, we have a ton of video games that help you hone your reflexes, your thumbs, your trigger fingers and are full of realistic and mostly mindless violence, but the level of strategic thinking is limited in most of them. It's all about reaction time.

Chess honed your mind, and games don't do that much anymore.