The stupid: It BURNS.

This has been One Of Those Weeks. The level of Stupid has gotten to the point that, if somebody doesn't do something soon, the Stupid will all roll together into one big ball of Damn That Was Dumb and there'll be a cataclysm.

For instance, Doctor Fuquad, you should probably not put a luer-lock access on to an arterial line. (For you non-medical types, an arterial line is just what it sounds like: a big IV-type thing that goes into an artery in your wrist so we can monitor your blood pressure directly during surgery.) For one thing, if you're monitoring pressures with an A-line, the luer-lock access will screw things up and make it look like the patient is running a blood pressure of 264/264. For another, and here is where I start to get all-cappy, YOU ARE NOT SUPPOSED TO PUT ANYTHING INTO AN ARTERIAL LINE EVER EVER EVER AND PUTTING AN ACCESS ON ONE MIGHT CONFUSE PEOPLE.

Let's make it simple, Doc: arterial lines are to be flushed only with pressure bags through pressure lines and are supposed to be directly connected to whatever they're going to. Luer-lock IV accesses are only for intraVENOUS access and are meant to allow you to shoot drugs through them. YOU ARE A MORON.

Gracious. Was that a rant? I think that was a rant.

*ahem*

Okay, boys, second thing: If you've done belly surgery on a patient, and that patient has developed a rigid abdomen and a sharply falling hematocrit about two hours after surgery, please don't keep that patient in the CCU for eight more hours to see if the bleeding will stop on its own.

(Yes, I just said that. And I just put my head in my hands In Remembrance Of Things Stupid.)

Ten hours after surgery, things were going.....badly for that poor bastard. Dr. Fuquad's brother, Dr. Diqhed, looked with some surprise at the lab values that were incompatible with life. A hemoglobin of five-and-a-half and a pH of seven-point-one? (For you non-medical types, these lab values are both fatal and entirely preventable. If you're not STUPID.) Well, then! Let's pour eight fucking units of blood into this guy using pressure bags, and if we don't have enough pressure bags, let's have Jo just stand there and squeeze!

And let's watch the blood we pour into the patient pour straight out into his already board-like belly!

Dr. Diqhed stopped by the unit after his patient's second surgery and expressed surprise at how well the patient looked. I couldn't stop myself--I hate this guy; he's an attending who should be weaving baskets--and said, "Yeah, it's amazing how great people do ONCE YOU STOP THE BLEEDING." (YOU MORON)

Uh, oh. Ranty again. So very sorry.

*koff*

And, finally, Manglement At That Other Hospital? It doesn't matter how sick your immunocompromised patient is with his widely-disseminated herpes simplex: you probably shouldn't put him into a unit meant for people who are seriously immunocompromised. Because if you do, all those poor bastards will be showing up at Sunnydale's CCU, medevaced in with screaming disseminated herpes simplex infections. It really doesn't matter how much negative pressure you have and how much your nurses scrub; that shit will travel.

Herpes encephalitis is bad enough. Herpes encephalitis combined with a cutaneous herpes outbreak bad enough to obscure major anatomical landmarks is worse. Like, if I can't see the person's navel for the blisters, that person is fucking SICK. And, if not for the level of MORON at your fine establishment, this could've been prevented.

*rubs eyes*

Every morning between three-thirty and five I get a little shirty and short-tempered. This week's been worse. I only cry when I'm angry or frustrated, and today I found myself sitting in the locker room on a bench, facing the wall, trying to decide whether breaking my hand by punching that wall was worth it, or whether I should just sacrifice my mascara to the Stupid.

I ended up having some Gatorade and a chicken sandwich and going back to work. Sometimes there isn't enough time to get upset about The Stupid; you just have to try to fix it.

PS: You're a moron.

Part I

Dr X: "Why hasn't the Argle-Bargle T380A test been run on my patient yet?"

Nurse Jo: "Because it's a timed test that has to be done by the lab. It can't be drawn through a central line."

Dr. X: "Why haven't you drawn it yet?"

NJ: "Because...it's...timed. As in, it shouldn't be drawn until a...specific time."

Dr. X, growing upset: "But you could draw it right now! Out of the central line!"

NJ: "No. I can't. It can't be drawn through a central line. The heparin lock we use will screw up the test results, and besides, it's a timed test. It's not due to be drawn until 1630."

Dr. X: (incoherent ranting about incompetence of nursing staff.)

NJ: (finds herself on the opposite end of the hall, unsure of how that bruise got on her forehead. Oh, wait. It was Head-Meet-Wall again.)

Part II

Dr. Y: "Why did you change my patient from calcium gluconate to a calcium citrate and magnesium supplement?"

Nurse Jo: "Because that's our protocol for people who have had gastric bypass surgery."

Dr. Y: "But this patient didn't have a gastric bypass! She had a parathyroidectomy!"

Nurse Jo: "Yes, I know. However, the patient's history shows that she had a bypass six years ago, and her blood calcium levels have been low enough to warrant IV repletion. Therefore, according to protocol, we changed her over to citrate and mag, and her calcium levels have come up."

Dr. Y: "Are you a doctor? I didn't write that order!"

NJ: "It's the standard hospital nutritional protocol for patients who have had bypass surgery. Here it is on the computer (clicks twice)."

Dr. Y: "I didn't write that order! You had no right to change that patient's medication!"

NJ: "Her calcium has been stable at 9.2 for three days, after being between 2 and 3.5 for the proceeding week. Is there a problem?"

Part III

Dr. Z: "Why didn't you replete this patient's magnesium and transfuse blood?"

Nurse Jo, looking worried: "Because I didn't see an order for it."

Dr. Z: "Her hemoglobin is ten! TEN!! Why didn't you transfuse her??"

NJ: "Um... ... ...because her hemoglobin is ten. And has been ten for the last four days. And her magnesium is 2.0 and has been for the last four days."

Dr. Z: "But I always transfuse patients with a hemoglobin less than twelve!"

NJ, taking chart in hand: "See this preprinted sheet? You filled out this preprinted sheet. It says right here that if hemoglobin is less than nine or crit is less than 25, we transfuse. It says we replete magnesium for mag levels of less than 1.7. Her crit and hemoglobin and mag have all been above those levels for four. days."

Dr. Z: "But that's not how I do it!"

NJ: Considers banging head on desk, then decides that the bruise that's already there is enough, and wonders why on EARTH the new docs in rotation aren't briefed on our protocols.

An excellent question

we are not so dissimilar, new nurses and new doctors. so why the disconnect? if we can all acknowledge that we're all here for the same reason - to learn how to do our jobs, and to do as much good as possible, with as little harm - can't we meet in the middle? with the greater good as our goal?

That particular question came from the comments on the post before last, and it's a hell of a poser. Why can't we, in the immortal words of R. King, all just get along?

Ego. Fear. Exhaustion. Territorialness (well, it's a word *now*). Bad examples set by other people. 

I have heard, oh my friends, horror stories from residents and nurses alike about how they're treated by each other. I read once, on another blog, of how an older nurse told the new nurses in her charge to treat residents badly so they'd know their place. I once witnessed an attending telling a resident that nurses tended to get hysterical over nothing. That was the same guy who swept an entire counter full of charts off into the face of a charge nurse, so consider the source--but it goes to show you that there are bad, bad examples on both sides.

There's also the issue of turfing, or of being territorial. We all want what's best for the people in our care, and sometimes we disagree on how to accomplish what's best for those people. If two people have equally compelling arguments on two sides of an issue, and they're both convinced they're right, you tend to get discord. Sometimes it's hard to admit that, even though you have a good plan, somebody else might have a *better* one. We tend to fall a little in love with both our patients and our treatment ideas; getting over that posessiveness can be difficult. So we fight.

And exhaustion. Imagine, if you're a new nurse, doing everything you're doing now, but with increased power and no sleep for the last 48 hours. (Yeah, yeah, I know there are work-week limits now, but they're honored more in the breach.) Imagine that everything that you do will be gone over with a fine-toothed comb by people whose job it is to teach you hard lessons quickly and sharply. Imagine that, if you screw up, it could easily kill somebody--and you feel like there's nobody checking your work.

Contrariwise, residents, imagine being a new nurse: you're dropped onto the floor after a couple of years of school and told--and it's really true--that you are ultimately responsible for every single thing that happens to your patient. Doc writes a bad order? Pharmacy doesn't catch it? Charge nurse and second nurse go ahead and sign it off, and you give that drug or perform that treatment and it hurts that patient? That is, ultimately, the nurse's responsibility. You're also expected to supervise other people, play peacemaker with family members, coordinate getting the person to radiology/ultrasound/CT/whatever, and still find time to make sure they're not lying in their own shit.

Ego and fear go hand in hand. Everybody's afraid of screwing up and looking stupid. Everybody's afraid of losing some perceived power they have in any situation. And that tends to make people jerky at best and assholish at worst. 

The thing is, though, that doctors and nurses have the same feelings and the same reactions to situations. We all get frustrated, we all remind ourselves that you can't medicate crazy, and sometimes we all just need a cup of caffeine and a shower. 

My advice? If you want to work with people who aren't jerks, find a facility that fosters respect among colleagues. If you're unlucky enough to have an attending who shoves charts off of counters and yells at his residents and nurses in common areas, try to be the opposite of that person. Likewise, if you're a new nurse with a preceptor or mentor who views residents and interns with disdain, ask for another preceptor or find another person to hang out with.

Most of all, when you get angry or frustrated, try to remember that the other person is likely just as angry, frustrated, and frightened as you are. If you yell, apologize. If you break down in tears of frustration, that's okay. If you need to, you can take a deep breath, give the issue a rest for two minutes, and return to it in a calmer state of mind.

All of us are in the same boat. Rather than smacking each other with the oars, we ought to dig in and start rowing. Forgiveness, a sense of humor, and keeping hold of your self-respect helps a lot.