“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Saturday, September 29, 2007

I hate bullies ....

“When the power of love overcomes the love of power, the world will know peace.”
~Jimi Hendrix

Everyone has a certain perception of themselves. This perception may not be as others see us. Our perception can be clouded by previous experiences, gender deferences, and/or cultural differences. But as we all know, perception is reality.

The perception I have of myself is that I am a relatively level headed guy, very mild tempered, forgiving, hard working, affable, and loyal person. This perception has been verified by what many people have told me about myself (I do understand people do tend to hold back the bad things, not wanting to hurt feelings. Also, one of these people was my mother). One of my major flaws is my inability to forgive and respect someone I consider a "bully". In my value system, other than someone directly disrespecting me or my family, or blatantly lying to me, this is probably high on my list of things that will get my blood boiling. I lose respect for those that pick on the weaker or less powerful (physical, mental, or political) to get their way or things they want.

I understand my role in my group. I am a grunt. I personally have no aspirations of being famous or politically powerful. I do my work to the best of my abilities. I look at try to do what is in the best interest of the patient. All I ask is that all others do the same.

In the academic medical community, there are many bullies. Residents experience this on a daily bases. As a consult service, orthopaedics is not always but often abused. I am going to list a number of stories of blatant abuse by other attending staff towards residents. This is not to say that orthopaedics does not do it's share of consulting/dumping on other services. We are often the butt of jokes about consulting for things that many feel are routine medical issues, diabetes, hypertension, medications (beyond Ancef, Ibuprofen, and Tylenol). These are also stories of things that I have seen or been a part since medical school. These stories are not to pick on any service in particular or to speak of clinical acumen of the particular specialties. They are just stories from the orthopaedic point of view.

Story #1: An attending abusing status for no particular reason.
Ortho: This is Dr. bone
Dr. Iconsultforeverything: Yeah, this is Dr. Iconsultforeverything. I have a girl down here in the ER with an ACL tear. We would like an Orthopaedic consult.
Ortho: Uh, just put it in a knee immobilizer and send it to clinic.
Dr. Iconsultforeverything: We would like a you to come see the patient now.
Ortho: But, there is nothing to do. I am going to put them in a knee immobilized and have them follow up in clinic.
Ortho: Ok ....

(End result is the patient was sent home with a knee immobilizer, crutches, and an appointment for 1 week.)
Story #2: Crying wolf. Calling an emergent consult on something that is not emergent.
Ortho: Hey, this is ortho returning a page.
Dr. Ijustcompletedmyintenship: yeah this is the senior medical resident, Dr. Ijustcompletedmyintenship, and we would like to consult ortho for a possible compartment syndrome.
Ortho: I'll be right there.
(Stryker monitor in hand. Ortho resident runs up to the floor and walks into the Patients room)
Ortho: Hello, I am Dr. Bone, are you Mr. Igetadmittedalot.
(Patient looks up from his full lunch and takes his spoon out of his mouth)
Mr. Igetadmittedalot: Yes, I am Mr. Igetadmittedalot. (He takes another bite of mash potatoes)
Ortho: Does your leg hurt?
Mr. Igetadmittedalot: No.
Ortho: Has it ever hurt?
Mr. Igetadmittedalot: No. But, it is swollen.
Ortho: thank you.
(Resident walks out of the room and finds the senior medical resident)
Ortho: Hey, Dr. Ijustcompletedmyintenship. Why did you think this was compartment syndrome?
Dr. Ijustcompletedmyintenship: Well, his leg was swollen.
Ortho: Was there no other reason for this, like his renal disease, Diabetes, peripheral vascular disease, etc.. Oh, and if you thought it was a surgical emergency, why would you feed him?

(End result, the medical team receives an impromptu lecture on compartment syndrome)
Story #3: Attending trying to get resident into trouble.
Ortho Attending: (ring ring, answering phone) Hello.
Dr. Iconsultforeverything: This is Dr. Iconsultforeverything. I called your resident about a patient with back pain. The radiology report shows a possible coccyx lesion.
Ortho Attending: Well, get a CT scan.
Dr. Iconsultforeverything: Well, he has back pain after being hit in the back with a chair. The radiologist read a possible fracture or lesion in the coccyx. (Then going around in circles about something, ortho attending tunes him out for a bit)
Ortho Attending: What do you want us to do?
Dr. Iconsultforeverything: I just think someone from orthopaedics should see him.
Ortho Attending: Why? What are you concerned about?
Dr. Iconsultforeverything: Well there is a possible lesion or fracture of the coccyx and the patient has back pain.
Ortho Attending: Well what does the exam show?
Dr. Iconsultforeverything: He has back pain.
Ortho Attending: But, does he have @$$hole pain. What does the rectal show?
Dr. Iconsultforeverything: (silence) ... Well, I just think someone should see him.
Ortho Attending: Ok, Dr. Iconsultforeverything, I will send my resident down to do your examination.

(End result, patient was actually examined. He had back pain. Neuro exam negative including negative rectal exam)
Story #4 (Break in Chain of Command)
I really don't have a story I can share. I believe in a chain of command. This probably has to do with my military background. I have been involved with many situations where the chain has been broken. It causes problems that are not needed and situations that are blown out of proportion. It is usually done by people that think they are "above" the chain, or forcing their perceived power.
These are some basic stories that are not to say how good orthopaedics is or how much I am above other services. They are just stories. In residency and in practice, we all have them. I would like to open the comment box for more stories. Orthopaedic patient bashing stories welcome.

“Justice and power must be brought together, so that whatever is just may be powerful, and whatever is powerful may be just.”
~Blaise Pascal


Chrysalis said...

This may seem like a stupid question. So, forgive me if you're all going to roll your eyes, but how do you determine or gauge the amount of pressure in a compartment syndrome? Do they all become surgical cases?

Someonect said...

Chrysalis Angel: (rolling my eyes and getting in my professor voice) obviously we use a pressure monitor. (coughing because of the stress from sounding so pretentious).

(back to normal voice) this is actually a good question. we monitor compartment syndrome usually with something called a stryker monitor, which is a pressure gauge. it comes with a needle and a syringe that attaches to it. you can use a art line pressure monitor. these are the most come ways.

not all are emergent. but acute compartment syndrome (that occurring over several hours) is.

the key to diagnosing compartment syndrome is the clinical exam (in an awake sensate patient). we all remember the % "P's" -- Pallor, paresthesias, pressure, paralysis, and pain on passive extension of the compartment. the most consistent thing in the diagnosis is pain. with a mechanism (i.e. fracture, crush injuries, etc.) and clinical exam of increasing pain, pain with passive stretch, and tense compartments, some feel that this is enough for the diagnosis. if the exam is questionable, checking all of the compartments is indicated. a difference in pressure (diastolic - compartment) of 30 or less, or symptoms with a pressure >30, would be considered compartment syndrome. in a sensate awake patient, the most common symptom is pain.

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Chrysalis said...

Well, I'm glad your tone changed - otherwise I would have slunk away and learned nothing... Thank you for explaining. Those not in the field still have inquiring minds you know?

I doubt if that patient was sitting their comfortably enjoying his food, he would have fallen into the emergent category for this syndrome - thus Dr. Ortho was needlessly contacted. tsk, tsk

Someonect said...


thanks for inquiring :) you are always welcome.

Midwife with a Knife said...

It seems that hospital systems, particularly academic ones, tend to encourage this sort of consult bullying. And it really sort of builds on itself, because people who get bullied as residents (or even as attendings) have a tendancy to bully others. It sort of starts to look like normal, acceptable behavior.

It's not entirely clear how to stop the cycle, but certain things like teaching residents how/why/when to call a consult may help, I think.

Someonect said...

MWWAK: i agree. the system feeds itself. it is hard not to get caught up in fights between services. of course, i have never been at fault (sarcastic grin). in my practice, we get a lot of attempts at bulling by pediatricians by either telling us how to treat a particular disease or threatening to stop referring patients if we don't see the emergent in toeing. all i say is, just be nice. i can get a totally ridiculous consult, but if the person is reasonable and nice, it is no big deal. ya know.

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