Saturday, June 14, 2014

Dice man

Necessity is the mother of invention.  And boredom is the father.

Having to do solo ward rounds on the weekend is pretty easy.  Most patients don't need radical changes of plan over the weekend, and in any case the services often just aren't there anyway.  So most of the time you can make sure that nothing disastrous has happened and write, "Continue current management" as the plan.  All well and good.

But last year I was having to lead lots of ward rounds with me, the intern, and a med student.  My registrar had been off sick a fair bit and two mornings a week she was in theatre so I was "in charge" those days too. There's only so many days in a row that you can stall and do nothing before even the med student starts to look at you funny and (presumably) wonder if they couldn't do a better job themselves.  (I know this because I was a med student two years ago and frankly, the residents then were two-bit dumbo nothings. Not like now.)

So I needed some means of coming up clinical management plans despite not actually knowing anything.  (Necessity).  And one afternoon I found myself with 10 spare minutes while waiting for a phone call.  (Boredom).  Invention!

Presenting PTR's Patented Platonic Prismatic Planning Pthing:

I took one of the blue rubber cubes that come with ABG syringes.  On each of the six sides I wrote a clinical plan.  When you find yourself needing a quick change of direction in management, simply roll the dice and do as it says.  Here's a quick guide and accompanying commentary:
  1. ICU.  You should call ICU and ask them to review the patient.  All patients benefit from an ICU review.  Even if they are completely clinically stable, ICU loves to be called so they get the chance to review patients before they get really sick.  It gives them something to aim for.
  2. Discharge.  Everyone hates to be in hospital.  Everyone has to go home sooner or later.  We need the bed for the people who will be sick tomorrow.  Are you getting the hint?
  3. Psych.  "You don't have to be crazy to be a patient here, but it helps!"  People who are sick in hospital often feel sad or withdrawn.  It's a reasonable reaction to a significant stressor.  But who is to say where the dividing line is between hidden relief at missing a day of work and crippling depression with suicidal ideation? Who is to say where the line is between an intermittently irreverent blog and complete psychotic breakdown?  A psychiatry registrar would love to get involved.
  4. Nursing home placement.  Everyone hates to be in hospital.  Everyone has to get old sooner or later.  We need the bed for the people who will be sick tomorrow.  Are you getting the hint?
  5. CTPA.  A honking great CT scan of the chest with plenty of radiation and some intravenous contrast to boot.  All to rule out some speculative nonsense diagnosis which was never going to be true anyway.  CTPAs are a great way to buy yourself extra time.  The radiology registrars need the practise, and for added fun you can remove the patient's IV line before the test so the radiologists can keep up their clinical skills by reinserting it themselves.
  6. Palliative care.  Everyone hates to be in hospital. Everyone has to die sooner or later.  We need the bed for the people who will be sick tomorrow.  Are you getting the hint? 
Try it out yourself and let me know how it works out.  I'm thinking of developing a similar one for use in the Emergency Department so I'd love to get your ideas.

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