Random Reflection on a Sunday: Sick vs. Sick-Sick?

"So I was the one with all the glory,

while you were the one with all the strength. . . . ."

from Bette Midler's "Wind Beneath My Wings"

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When I was an intern doing my very first rotation on the Internal Medicine inpatient wards, I remember hearing my senior resident say to me with her thick Latin accent and a mouthful of bologna sandwich:

"Keem, if you don't learn naathing else this year, you need to learn one thing and one thing only. Seeck versus not-seeck. Period. It doesn't matter how smart you are or how many facts you can regurgitate. It's all crap if you don't know a seeck patient when you see one. Sometimes the smartest thing a doctor can know is when they need to run like-the-hell and get some help."

"But we're in the hospital," I replied, "Isn't everyone technically sick?"

"Oh no! Definitely no. A lot of the patients in the hospital are not seeck at all. I mean they are seeck, yes. But most are not seeck-seeck. So now as-I-think-of-it, Keem," she added with her musical voice, "What you really need to know is seeck versus seeck-seeck." Oh Lord. Seeck-seeck? Nobody told me about that in med school.

"How do you learn it?" I really wanted to know. "I mean, is there something you suggest I read? Like maybe in the Washington Manual?" (In pre-internet-savvy 1996, that was the Internal Medicine intern's bible.)

She threw her head back and laughed. More of a cackle than a laugh. For a few minutes I thought she was mocking me. . . .but then she stopped abruptly. "Read?" She raised one eyebrow. "Oh no, Keem. You don't read naathing to know this. You leesten. You watch."

Okay. I think I was catching on here. This was one of those "Art of Medicine" moments. I was always intrigued with these sorts of teachable moments. "The senior doctors? I should listen to and watch the senior doctors, you're saying?"

"Keem," she spoke carefully with an icy glare (yes, I still remember and am amused by how she pronounced my name),"Keem, you listen to and watch the patient. And then . . .you always, always listen to and watch the nurses. Always, Keem."

Ummm. Okay. I'd heard countless times even before finishing medical school of the importance of remaining in "good graces" with the nurses. Be nice to the nurses, some resident would tell us as students, They can make your life pretty miserable or pretty wonderful. But the advice was always to befriend them, be collegial with them, and depending upon your personality and level on the totem pole, even brown nose them. But listen to and watch them just for the sake of learning how not to be an assassin? This sounded like a new spin.

"I've heard that you should always get in good with the nurses."

"No, Keem. Not that. I'm talking about real patient care. Leesten and watch. The nurses always know who is seeck-seeck first. They always do. Sure, don't piss them off. But leesten. Watch. Especially the really good ones. They always know first."

"Even before the patient they know?"

My resident folded her hands behind her head and rocked on the chair's two hind legs while balancing with her crossed feet on the conference room table. For a split second I feared she'd fall back and need stitches on her head, but she looked so relaxed that I turned my focus back to our conversation. "Even before the patient gives you the clue?" I reemphasized.

She continued her treacherous rocking. "Oh. . . well that depends."

I wasn't sure what she meant. "Depends on what?"

Suddenly, she slammed the chair forward and back down on all four legs. With both hands, she gathered her long, dark hair into a tight chignon and secured it with a pencil sitting on the table. With a knowing smile she said, "It depends on how much experience you have and how much you know. With time you understand more of the subtleties of patients. But long before that and long after you have the nurses--don't forget that." Aaaah. The nurses. Claro que si.

***

Turns out that this sage moment with my resident included some of the best advice I've ever gotten in medicine. . . . .

. . . so today, I'm reflecting on the hospital nurses. . . . . and all of the times they've both figuratively (and literally) thumped me on my head to alert me that a patient was indeed not just sick but sick-sick. I'm reflecting on the one who told me early in the morning before rounds that my patient had refused a lab-draw but not because he was ornery like all the other days he refused but because he was "out-of-sorts". And I'm remembering how "out-of-sorts" ended up being the first sign of septic shock (also known as "seeck-seeck")-- and ended up leading to an early intervention that ultimately saved a man's life.

Now, I'm more experienced. That conversation was over a decade ago, so, yes, I do pick up more on hints from patients that would have previously flown over my intern head. I'll take pause on things like, for example, when this nineteen year old girl with a sickle cell anemia pain crisis in her leg asked me for a bed pan one day. A nineteen year old wants a bed pan? That's weird, I remember thinking. Weird was right. It ended up being severe osteomyelitis (a bone infection) instead. And less than twelve hours after she asked for that bed pan, we confirmed it as such--all because of a simple request that just didn't sound right.

But how does one get there? I'm sure time, experience and a few key physicians help. But, in my experience, Lord knows the nurses played a key role. Like Priscilla, the nurse who used to pound her fist on the wall that stood between my call room and the PICU when someone coded because it was faster than paging me. As tough as she was, I learned quickly that I'd get much further working for her respect than of her fondness. It was with Priscilla that I learned, while chatting with her over tepid coffee as she charted her patients, countless things about really sick (and really not sick) patients that could not be found in books. Like when she taught me that people who say they are really worried about "something being wrong" are often right--even when the tests say otherwise. Or like when she showed me goof-proof ways to start and secure IV lines and when she taught me pearls like drawing blood too close to the IV line can screw up all your lab values or not checking the equipment (like unplugged O2) can make you worry for no reason. Sick versus sick-sick. Experience? Uhh, maybe. Nurses? Sho' nuff.

It's funny. Now that I think about that young woman with sickle cell anemia, I am reminded of what her nurse, Mrs. Nix, said that day after we'd gotten her down to the MRI scanner for her leg imaging:

"Dr. Manning, as soon as I saw that baby, I just knew something wasn't right. Nope. I was thinking during intake, This ain't just a pain crisis. Mmm mmm, no. That baby just wasn't right."

But of course. The nurses always know first. :)

***

"Art of Medicine" Teachable Moment for New Interns and Medical Students:

Sick vs. sick-sick? That's easy. Follow these simple steps:

1. Listen to and watch the patients. (Duh.)

2. Get some experience. (Double duh.)

3. Get enough experience to know well enough to never, ever overlook the warriors on the frontline--the nurses.
(They'll save you and the patients from stepping on a land mine.)

4. The good news is that when you listen to the nurses, they'll generally like you -- no brown-nosing required.

****

With respect, gratitude and admiration for all of my favorite nurses and all they've taught me . . . . .and for being there long before and long after I had a clue. . .
(I started to list your names, but realized it would be too many to list)~

Thanks for being the wind beneath our wings

(and the thumps upon our foreheads.)

Claro que si!


Wisdom from "Mother" Nix -- one of the best nurses I know. . . .