Terrified I'll Miss Something...

Cut to the Chase: General Surgery Survival Series — Post 24

An intern called me at two in the morning and apologized before she said anything else.

Probably nothing, sorry to wake you. Her post-op patient's heart rate had been running 110 to 120 for four hours and she couldn't explain it.

He was bleeding.

She had the finding. She'd had it for four hours. What she didn't have was a word for it, and she nearly let that decide whether to pick up the phone.

You'll be told this year that the thing to fear is ignorance. Some presentation nobody taught you, waiting in the dark for your night to be the one it picks.

That isn't what I find.

I've read a lot of bad nights backward. You start at the code and walk it up the chart, hour by hour, reading what was written and when. I have never once found an intern who failed to recognize something rare.

What I find is a chain of small, reasonable explanations. The heart rate is up because he's in pain. The urine is down because she's been NPO since midnight. The pressure is soft because that's where he lives, a phrase used mainly by people hoping not to visit him there.

Every one of them defensible. I'd have nodded at any single one. Stacked in the same patient across six hours, they're a hemorrhage.

Say your explanations out loud in one breath, the tachycardia and the urine and the pressure together. Separately each one sounds fine, which is the whole trouble with them.

You can't read your way out of that. Reading gives you more explanations, and explanations are the mechanism.

You can't feel your way out either. Worry spread evenly across nineteen patients is not vigilance. It is just a bad night, and it leaves you nothing to do at four in the morning.

What you can do is narrow where the fear points.

Nineteen patients can't all go bad tonight in a way that matters. Three of them can, and you can name them before you sit down.

I'm not asking who's sickest. Sickest is a day-team question. I'm asking who has a reason to change in the next six hours.

The fresh post-op, who has a raw surface in him and a clock running on it. The one who already needed something from you tonight, a transfusion, a pressor, a second liter, because a patient who needed something once tends to need it again. And the one the day team got vague about.

That last one is the one people skip. Vagueness at signout means nobody solved it. It has now been handed to the most junior person in the building.

Pick three names before the floor gets busy, and stop at three. A list of nine is the same as no list, and you find that out at four in the morning.

Say the three out loud to someone. The nurse who'll actually be in the room, your co-intern, the senior you're mildly afraid of waking. A list you kept in your head is one you will quietly edit at three.

Now look at what came attached to them. Half the explanations on your list aren't yours. Somebody wrote them at eight this morning and they rode down the chain intact, gathering authority at every handoff.

The tachycardia is pain. The urine output is just his kidneys. The confusion is sundowning.

Most of those are correct. That's the problem. Probably pain is the most dangerous phrase on the ward because it's usually true, and usually true is comfortable enough that you stop looking.

Learn who can't warn you. A patient on metoprolol won't do you the courtesy of 130. The thirty-year-old who lives at 52 is shouting at you at 95, and nobody flags 95, because 95 looks fine.

Learn what your three run at baseline before the night starts. The monitor only knows abnormal, and nobody has ever been paged about a heart rate of 95.

Make the comfortable answer earn its keep. Call it pain and you've made a prediction. Treat it and the rate comes down inside the hour.

Write the hour down. Tell the nurse. In your head a promise like that evaporates in twenty minutes, and at four in the morning your memory is not the colleague you think it is.

A worry with a time on it is something you can act on. Without one you carry it to morning and hand it over heavier than you picked it up.

Go back to the phone call.

What stayed with me wasn't the bleed. It was the apology.

She had four hours of a heart rate that wouldn't settle and no name to put on it, and what almost stopped her was the prospect of being the intern who woke an attending for nothing.

She didn't need the word. She needed the observation and a phone.

"I can't explain this" is a complete sentence. It has gotten more surgeons usefully out of bed than any diagnosis I know of.

One more thing, because nobody says it plainly. The building doesn't depend on you catching everything. Morning labs exist. The nurse is in that room every two hours. Somebody reads your note at six.

None of that lets you coast. It should stop you treating the night as a test you can fail by yourself.

Vigilance is a narrower thing than the word suggests. Not a state you hold until dawn. A few decisions you already made, still running after you stopped feeling alert.

You won't stop being afraid this year, and you shouldn't.

The fear changes its question, and that's the whole difference. Right now it asks what if. What if has no answer, which is why you're still on your feet at two.

Eventually it asks when am I looking again. That one has an answer every time. Give it before you sit down.

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What to Read Next: Post 25, “The ICU Feels Like a Different Planet.” On the floor a patient can drift quietly for hours. Upstairs everything is measured continuously, and the problem stops being what you can't see and becomes how much you're shown.