Drugs?

A hospital never closes, but it does go down to bare bones staffing at night.  Some smaller private hospitals have few doctors in-house overnight, and some specialties aren't in-house at all.  Large tertiary care centers like the one I work at have virtually every specialty represented overnight.  The hospital is still running with minimal staffing, though, and the rules dictate that only urgent or emergent surgeries should be performed in the middle of the night.  That rule is important since we are a large trauma center and a major trauma case requiring immediate surgical intervention could arrive at any time.

Despite that rule, there are some surgeons who constantly want to operate at night rather than book their cases for the morning (Orthopedics, I'm looking at you).  I was once called by an orthopedic resident who wanted to book a case at 2:00 am.

"Who is the patient and what is the case?" I asked her.

"His name is Mr. Jones and he fell from a ladder.  He broke his right femoral neck."

"What else can you tell me?"

The resident told me what she knew of the patient's medical history (which was not much).  Fairly healthy man, mid-50s, apparently stable, closed fracture.  So far, it didn't sound like a case that needed to be done in the middle of the night.

"Why do you guys want to operate now?"

"We've got a few other cases scheduled for tomorrow so we'd like to get a head start on the day."

Not a great reason to go to the OR in the wee hours, but I asked for the patient's room number and the orthopedic resident gave it to me.  I reviewed the patient's chart and found a few other morsels the orthopedic resident hadn't mentioned, including an EKG that showed tachycardia at a rate of about 140.  Then I went to see the patient.

Mr. Jones was sitting in his bed and looking a bit edgy.  I introduced myself, then looked at the vital sign flowsheet.  The first thing that caught my eye was his blood pressure: 220/120.  It was a surprise he didn't have blood shooting out his ears.

Several things can cause a hypertensive crisis with significant tachycardia, but one of them is more common than the others, especially in a hospital in a big city.

"Mr. Jones, do you use any drugs?  It's important that you're forthcoming with me since that can affect your anesthesia and surgery."

"Sometimes."  He clearly didn't like this line of questioning but seemed resigned to it.

"Did you take anything tonight?"

"Yes."

"What was it?"

He looked around the room and said, "I took a little cocaine.  Smoked it."

I nodded.  It was exactly as I suspected.  "Mr. Jones, we're going to postpone your surgery.  If we proceed while you're still under the effects of cocaine, it could kill you."

The patient didn't have anything else to say so I left and called the orthopedic resident.

"Listen, we're going to cancel the case."

She didn't like hearing that.  "Why?!"

"Well," I said, "your patient is flying high on crack."

Silence.  Then, "Oh.  He is?"

"Yes, he is.  And his blood pressure is through the roof."

"Oh."  This had caught the resident by surprise; apparently her evaluation of the patient hadn't included a glance at his vital signs.  "Well, can't you give him a beta blocker?"

I wanted to bang my head against the wall.   Not only had she just proposed a treatment that would almost certainly kill the patient, but she had shown complete disregard for the professional liability she was asking me and my department to accept.  Tact, I'm afraid, abandoned me.

"Well, in a purely hypothetical sense I suppose I could give him anything I wanted.  But if you're going to have me give him a beta blocker, you really should have him sign a consent form for an autopsy first.  It'll save us having to wake his family this late at night."

The other end of the telephone was silent for a moment.  When the orthopedic resident spoke again, she sounded worried.  "You could give him something else for his blood pressure, though, couldn't you?"

Exasperation joined my anger.  She was still trying to find a way to do the case before morning.  "Look, let me break it down for you.  Your patient is high on crack cocaine.  His blood pressure and heart rate are out of control.  You've got him sitting in an unmonitored bed on the floor.  He is being completely mismanaged right now.  You need to move him to a monitored bed, either in stepdown or the ICU, and get his blood pressure under control.  You should only give him beta blockers if you want him to die.  If you don't know what else to give him, then you should consult Internal Medicine if you haven't already.  And when the drug has run its course, you should call Anesthesia to book your case.  But we are not doing the case tonight."

Sounding a bit rattled, the ortho resident replied, "We've already called our attending and he's on his way in.  You need to call him and tell him you're canceling the case."

I now understood the reason for her nervousness.  Her attending had been woken up in the middle of the night; surely he would be angry about losing sleep just to find that the case was canceled.  The orthopedic resident was trying to save herself the inevitable tongue lashing that would fall to whomever had just wasted the attending's sleep time.  Alas, she would not find salvation from me.

"No, you need to call him and tell him you failed to appropriately evaluate the patient.  This is your problem, not mine."

With that our conversation ended.  The orthopedic resident took my advice, moved the patient to the ICU, and got Internal Medicine involved.  When the orthopedic service called us a day later to book the case, the patient was sober and much more thoroughly evaluated.  He sailed through surgery and out of the hospital without further incident, although he did receive several strenuous admonitions to "just say no."