One of Dr. Santell's pet peeves was how residents wrote orders for intravenous (IV) fluids. I used to spend an inordinate amount of time trying to figure out how to order fluids on a new admission without doing something stupid--giving dextrose-containing fluids to a poorly controlled diabetic, for example.
I'll admit a lot of this dithering was no more than an attempt to read the old man's mind, because he was always very specific about his fluid orders. For example, he hated it when one of us ordered the default 1/2NS + KCL 20meq at 125cc/hr on a CHF patient receiving Lasix, for example. One of the standard rites of passage at our residency was to have Dr. Santell say to each of us: "You may have heard me say this before, but I don't like giving fluids and Lasix in the same patient." Those of us who'd heard this speech before snorted quietly in the background, but the hapless new intern who was presenting the case turned beet red, although he wasn't really in trouble. You were only in trouble with Santell if you made the same mistake twice.
Once, I admitted an 80-ish woman to Dr. Santell's service with a diagnosis of community-acquired pneumonia. She had a high white count, a history of hypertension, a mild tachypnea in the high-20 range, and a temperature of 101.8. I wrote for antibiotics and the usual tuck-in PRNs but had the nurse's heplock her IV. The next morning, Dr. Santell asked me, rather sternly, "Theresa, why didn't you give her any fluids?"
"Um," I said. "I thought she might go into heart failure, you know?" Tip for interns: never answer a question with another question, it only communicates insecurity.
"Has she ever been in heart failure?" Dr. Santell asked.
"Uh--no, I don't think so."
"Correct. That's because she's never been diagnosed with congestive heart failure," he said. "But you did diagnose her with pneumonia."
"Yup," I said, nodding. Tip for interns: Desperate acknowledgement of having done one thing right will not get you off the hook for doing another thing wrong.
"So here's a woman with lobar pneumonia, she's got a fever and she's tachypneic," continued Dr. Santell. "That's at least two reasons for her to have more insensible water losses than usual, correct?"
"Uhhhhh....."
"So what should you have done?"
"Um--fluid?"
"Exactly." Once an intern's error was publicly demonstrated, Dr. Santell relaxed and moved on to the teaching point. "If you have a patient who clearly has a need for fluid, you give her fluid. Even if she has congestive heart failure, if she comes in looking like this, you have to ask yourself if she needs fluid. Too many residents worry about heart failure when the patient isn't in heart failure when they're admitted. Never let your desire to avoid doing the wrong thing prevent you from doing the right thing. Look at the patient and ask yourself what she needs."
Years later, when I was an attending hospitalist and working hundreds of miles from my residency hospital, I admitted a 36 year-old man with lobar pneumonia, tachypnea in the 30s and a temperature of 103.7. He also had a history of idiopathic cardiomyopathy and was two years out from a heart transplant. I took his history, ordered his usual antirejection meds and antibiotics, and then looked at him again. He looked pinched and miserable. "You know what?" I said. "I'm going to give you some IV fluids. I think you need them, with this fever and pneumonia."
"Oh, thank you!" he said wearily. "I was begging them in the ER to give me fluids, but they didn't want to give me any because of my heart. People are always scared of me because of my heart."
"Yeah, well, you don't scare me," I said jovially. "And I'm giving you some fluid!" I did, and he left the hospital a few days later, feeling well.
I always think about Dr. Santell when I'm on the job. I swear I can hear his voice in my ear, admonishing me to do the right thing.
He sounds like an awesome teacher...
Posted by: dragonfly | November 05, 2008 at 04:31 PM
Every time you tell one of your Dr Santell stories, I wish more and more that I had known him.
Posted by: rlbates | November 05, 2008 at 12:15 PM