Monday, July 6, 2009

Blinded By Arrogance. Is There a Code For That?

Once in a while, I'll read a couple of unrelated blog posts and they create a singular, powerful, visceral reaction...

Nurse K of Crass-Pollination brought to light one of Happy Hospitalist's blog posts relating an interesting experience he had with a "near code" experience. The following is a partial excerpt from his story:
Let me give you a story. I was doing my normal daily rounds on a patient when I walked in and just stopped. I stopped and I listened. I looked for signs of life in my 67 year old man who was admitted with abdominal pain. I stood there. Watching. Calmly observing.

It struck me as odd. For a full thirty seconds I saw my patient breath exactly one time. I turned on the lights and noted a remarkable physical finding (another reason to always turn on the lights). Cyanosis. A physical finding in which the skin turns purple due to an increase in deoxyhemoglobin in the capillaries (I will never forget the cause of cyanosis due to my exposure to one of the greatest pimping attendings of all times).

So I calmly walked out of the room, walked to the nurses station and stated calmly:

"One of my patients is about to code. What would you like me to do?"

This is probably the quickest way to get a nurse to jump out of their chair and come bedside to your assistance. I think in retrospect I lost the golden opportunity of a lifetime to pull the code chord and watch every nurse on that floor flock to my room with me standing there saying

"What would you ladies and gentleman like to do about my dying patient?"

The deluge of comments on both blogs was crazy impressive and made for some really good reading. Nurse K even received this interesting and revealing comment from Happy himself:

Nurse K. The words of distress you express are internally driven. What I wrote was a compliment to the nursing profession.

Your first miscue was to believe that because the drugs where nurse given and not PCA that some how the problem was caused by a nurse. I stated, quite clearly that not every patient responds the same. Contrary to your belief, I think nurses do an excellent job of preventing patients from overdosing and dying in the hospital from narcotics . IV narcotics are used so freely in hospitals these days, it's not a mystery why more patients aren't being knocked every day. It's because of excellent nursing care and evaluations. But excellent nursing care can't prevent every patient from experiencing a side effect. And I made that quite clearly. There is no blame here. It's an acknoledgement that every patient is different and we will never be able to prevent injury in all patients while treating pain in all patients.

This was a compliment to your profession. It's time to accept it as that and move on with your life.

As for your assertion that I should just start bagging, perhaps your experience in an ED clouds your judgement of hospital based protocols. The patient was not coding, nor did I foresee her getting intubated. That would be an astute bedside clinical observation based on my knowledge of the situation.

I did, however, foresee the need to have a team present quickly to assist with her rescusitation. An amazing team of nurses and respiratory therapists that respond to any acute emergency in Happy's hospital

We have excellent protocols in place to make thorough evaluations happen quickly and effortlessly. My asking for assistance from the nurses is an acknowledgement to their abilities to expediate those protocols.

You see, when I ask the nurses what would they like me to do, I was asking for their honest opinion. My first inclination as a bed side physicians after summoning the floor nurses for assistance was to get the patient a quick dose of Narcan and handle it ourselves on the florr. That, I felt would be appropriate.

The nurses suggested I activate the emergency response team due to their excellent evaluation skills.

So I did. I gave Narcan and the ICU team arrived quickly. And that's exactly what I had them do.

The first thing you do when you come upon a patient in arrest or near arrest is call 911. That's what ACLS trains you to do. It is not to start your ABCs. I might suggest you go re review that portion of the protocol

Beings that you proclaim to excel in emergency rescusitation of patients

_(all spelling errors per Dr. Happy)_____

At this point Dr. Happy is so blinded by arrogance that he actually sees nothing askew about calling "911" for a code in an acute care hospital. Okay, so if this isn't having an "arrogance effect" on you, let's try another "code-related" blog topic...

Jay, of Two Women Blogging, wrote an excellent article called Breaking the Code. In this post, Jay discusses a resolution that the AMA considered passing. The wording of this resolution was so shocking to me that I actually thought that this could be a hoax. It wasn't. Here is the resolution in its entirety:

Resolution 710

Introduced by: Michigan Delegation

Subject: Identifying Abusive, Hostile or Non-Compliant Patients

Referred to: Reference Committee G
(J. Leonard Lichtenfeld, MD, Chair)

Whereas, Many patients are becoming more abusive and hostile toward physicians for many
reasons not limited to the economy, increasing co-pays and deductibles, unreasonable
expectations and demands, a lack of instantaneous cure, arrogance and/or the belief that they
“own” their physicians; and

Whereas, There are decreasing numbers of physicians both in primary care and specialties
especially in terms of access; and

Whereas, Increasing noncompliance with treatment can reflect negatively on physicians during
black box audits by insurance companies and oversight governmental agencies; and

Whereas, Abusive, hostile, and noncompliant patients result in increasing office resources
adding to office overhead and added stress on all of the office personnel, which can lead to
potential ill health; and

Whereas, The stress of dealing with ungrateful patients is adding to the stress of physicians
leading to decreased physician satisfaction; and

Whereas, Any complaint to any oversight investigative regulatory body leads to uncompensated
expenditure of time, resources, and monies to defend physicians or the “guilty until proven
innocent” principal; and

Whereas, Physicians need to own the data to simplify patient collection and identification to
defend themselves as well as alert outside investigating agencies to the potential nature of the
patient’s records; therefore be it

RESOLVED: That our American Medical Association ask its CPT Editorial Panel to investigate
for data collection and report back at Annual 2010 meeting: 1) developing a modifier for the
E&M codes to identify non-compliant patients and/or 2) develop an add-on code to E&M codes
to identify non-compliant patients. (Directive to Take Action)

Fiscal Note: Staff cost estimated at less than $500 to implement.

Received: 05/06/09

Ho-lee crap! The good news is that this resolution didn't pass. The bad news is that apparently no one in the Michigan delegation saw anything inappropriate about the wording of this thing. What is wrong with you people? Where did this kind of arrogance get its start? Is there a cure?

I'm no psych nurse, but when arrogance has grown to such a proportion that it distorts reality to this extent, I'd think it would qualify as some kind of personality disorder. Is there some kind of DSM-IV Code for this? If not, I think we need a code.

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insuranceguru said...

Why yes DM, the DSM-IV code for this is 301.81, Narcissitic Personality Disorder. Among other "symptoms" the foremost I see are:
A pervasive pattern of grandiosity.
Has a sense of entitlement.
Requires excessive admiration.
Lacks empathy.
Is interpersonally exploitative.
Shows arrogant, haughty behaviors or attitudes.

These all came verbatim from the DSM-IV additional information included with the DX of Narcissistic Personality Disorder. Unfortunately the treament indcludes things like therapy, social skills training, behavior modification and learning more effective communication skills. Yeah - they'll get right on that.

Buck said...

The Happy Doc's reaction was classic Passive-Aggressive behavior and I would be very concerned should I ever find myself or a loved one in his care. There is one telling statement in his post where he talks about his attending who appears to have used this classic psychological failing disguised as "Socratic Teaching" on him. He sounds like a crass and thorough ass who endangered his patient by deciding her care was secondary to his need to play Mr. Big Shot with the nurses.

Jay said...

Late comment because I'm still catching up on my Google Reader - glad I saved yours to actually read! Thanks for the shout-out. Happy's attitude is one of the reasons I don't read many medical bloggers - arrogant, condescending and patient-bashing (and, in his case, nurse-bashing on top of that). Grr.

dethmama said...

@ Jay... Sorry for my late comment to your late comment. Crazy busy lately... Yeah, I'm unable to read Happy's blog because it pisses me off so much. He definitely caters to a demographic that I'd rather not associate with.