Dear Medblr, why are our lives like this?
After my last night shift, I got home feeling super exhausted and wondering why. I’ve worked those 24-26-32-???-hour shifts before that didn’t leave me this entirely bereft of the motivation to do anything but faceplant in bed, so what gives?
Then I think back to those shifts.
One patient that I was significantly worried about for the possibility of an intracranial mass required an urgent MRI. Unfortunately, given his history, this MRI has to be under sedation. Double unfortunately, he presented to us on the Friday night of the long weekend, making literally everything way harder.
So... here are the steps for arranging an URGENT sedated MRI in my institution:
As the resident, call your staff and review why you are going to do this sedated MRI on an urgent basis, and what timeline you are looking at
Page anesthesia
Wait for anesthesia to call back
Finally talk to anesthesia to ask them to do an assessment on the kiddo (+/- if they feel it’s necessary) prior to the sedated procedure
OPTIONAL: Anesthesia refuses to talk to you until you’ve gotten the procedure approved by radiology, OR the resident tells you to call the staff who you finally talk to then they tell you to page the resident back and ask them to see the patient
Page radiology
Wait for radiology to call back
Talk to the radiologist on call to get approval for this urgent scan based on the patient assessment (ie/this physician is never going to speak to or lay eyes on your patient so you need to really make them understand why they need this scan)
OPTIONAL: Radiology refuses to approve the scan until anesthesia agrees to do the sedation
OPTIONAL: page anesthesia. wait for anesthesia to call back. Finally talk to anesthesia and say radiology is pending approval on whether anesthesia agrees to do the scan.
OPTIONAL: repeat steps 2-5 and 6-9 until the end of time OR one finally agrees OR your staff ends up needing to step in and call staff anesthesiologists/radiologists directly to tell them exactly what you told them but with the authority of the staff
Call the OR booking desk to put the patient on the “add-on” list, and find out a general estimate of whether your patient will be getting scanned that night or the next day so you can determine NPO status and such
OPTIONAL: the OR booking desk refuses to talk to you because you are not staff
OPTIONAL: call your staff to call OR booking desk to sort that shit out
So... I’ve now queued up ALL THE THINGS from step 1-14 with some back-and-forth on a few things but whatever. (During this whole process, of course, I need to manage 45+ inpatients plus see and review ALL the consults that come in for pediatrics overnight and also try to ensure my junior learners are not dying and apparently somewhere in there I’m supposed to find the time/energy/mental capacity to teach them stuff and also go through a similar process for another patient who needs some other thing done that takes a million and a half years... you get the picture. There are only 3 residents on my team overnight, including me. Also, those inpatients we are responsible for include our hematology-oncology ward which sometimes mostly comprises otherwise ok kiddos here for chemo and sometimes mostly comprises kids who are dying of EVERYTHING and you are just doing your best to keep them comfortable and/or help them make it through the night.) That night also happened to be the night of DKAs--we had 3 kiddos in active DKA meaning labs to check literally every 20 minutes while doing all the other things. I don’t know who put the diabetes in the water but please stop...?
Ah yes, now it is finally morning and I feel a little shell-shocked by how much crap needed to be done all at once, but that’s okay. We did it. We arranged the urgent sedated MRI, among all the other stuff overnight, and all the kiddos did okay! The DKAs are corrected, the heme-onc kids are mostly on ALL the antibiotics (and ALL the pain control), and my junior learners had a chance to eat overnight (I think?).
We finish morning handover, and the poor weekend day team looks like they’ve been hit by a truck. Fortunately, there are approximately 7 of them to take care of all the messes the 3 of us made overnight.
...except then one of the nurses pages us urgently to tell us that my patient’s MRI is NOT happening that day?!?!
So of course this leads to repeating steps 6-8, which turns into this weird discussion about how the radiologist who was on call yesterday approved the scan and INSTRUCTED US TO GET THE KID ON THE OR ADD-ON LIST FOR A SEDATED MRI but no one apparently told the radiologist on call TODAY, and therefore oopsie they’ll do their best to scan the kid today but it MIGHT NOT HAPPEN?!
NO. I made it explicitly clear that this MRI could not wait until tomorrow, it had already waited until today and WHAT PART OF “THIS KID MIGHT HAVE CHRONICALLY INCREASED ICP AND THEREFORE COULD SUDDENLY DECOMPENSATE” DO YOU NOT UNDERSTAND? Perhaps it’s the part where the people managing that decompensation is NOT the people who have the power in arranging these scheduling things?!
So I stayed a few hours after my shift had ended desperately trying to sort this crap out so my colleagues covering the daytime won’t have such a ridiculous issue on their plate. Unfortunately, this does not work. I discuss with the daytime SPR and the staff, who agree that if we can’t do the MRI then they’ll use the sedation slot to just do a sedated CT, which will hopefully mean that if there’s something that needs to be urgently addressed by Neurosurgery, they can either take straight to the OR or neurosurgery can--you guessed it--push for the sedated MRI.
-----
One of my friends asked me, “If you had the opportunity to do what you’re doing all over again, would you do it?” and I told him, “I probably wouldn’t want to do medical school again, having already done it. But pediatrics is what I want, it’s what I think I’m meant to do. The ends here might justify the means to me.”
Then I think about this BS that we put up with in residency and in our system, and I just... things need to change. Bear in mind that this was my take on the situation, and fortunately the kiddo was blessedly stable throughout all of my scrambling and running around and crying on the inside. The bottom line though? He needed a scan and he was being denied this scan because of stupid semantic BS and systems holes and issues that are not his fault. They’re not my fault, either, and I have to keep reminding myself of that when I am then the one that goes to the incredibly anxious and stressed family to tell them, “I’m sorry, but the scan is going to be delayed.”
There is no way that is fair. This family is already fearing the worst--they thought they were getting their kid checked out for a constellation of weird symptoms that other doctors had seen before, but then they got alarmed because the doctor at their endocrinology appointment brought in an opthalmologist to do an urgent fundoscopic assessment for papilledema, and then they were being told that they had to get an MRI ASAP. How could they possibly hear something like that, then be told, “I’m sorry, but the scan is going to be delayed”?
/sleep-deprived over-stressed rant
[Shift 2/7. Wish me luck.]
PS: I’m honestly not trying to crap on any of the specialists we have in the hospital--they’re also not the ones who made up this bonkers system for getting a sedated MRI urgently after-hours/on weekends. They are as much victims of the system as I am. There have been many instances when I wondered why I couldn’t just call one and have one call the other to figure out timing and feasibility of organizing the scan, and instead I acted as the awkward middle person who does not have enough sedation expertise or scan expertise to know the finer points of coordinating those issues...