I am a big one about complaining about government regulations, partly because if you actually know how to think, you don’t need them, and partly because the stress in following the rules can distract you from the real problem: which in medicine is listening to the story underneath the story that the patient is telling you.

So the teenager with a bladder infection actually needs to start birth control and/or have a pregnancy test, or the grandmother with arthritis is really worried about her drug addicted son who is stealing her pain pills and her social security check.

But there is a  reason we need rules: because often the simple things are overlooked, especially in these days when cost cutting is pushing us to see more and more patients in less time.

So today, while reading an article on Wired about the resurgence of antibiotic resistant bacteria, I remembered the good old days of the 1960’s, when penicillin resistant staph was killing people.

We responded to the problem in a typical fashion: more handwashing, isolation gowns and gloves, and keeping infected patients away from the rest of the hospital. And that helped.

Yet there was a problem: The “isolation ward” was staffed similar to a nursing home, with lost of aides who could do the basic nursing,  supervised by a single nurse. And in those good old days, most of the patients rarely saw their doctor, since they were cared for by residents in training: who alas were often too busy with very sick people to run down and see these patients, most of whom were not very sick.

I was a third year medical student, and in those days, students (and interns) were used as lower level staff, to save money, AKA “Scut work”…We drew blood, delivered specimens to the lab, and picked up lab slips. In the cash strapped county charity hospital, the work included taking the patient to X ray or to the side room to get an EKG.

So when the nurse called up and said Mrs. SoandSo in the isolation ward had a funny heartbeat, I was the lowest of the low and sent to get the EKG and check the patient.

So I trundled around, and found an EKG machine in the closet, one that was rarely used…indeed, after I hooked up the patient, I found the machine would only record two of the twelve leads, and those two looked crazy.

After checking it was hooked up okay, and doing it three times, I decided to recheck with the intern who was supervising me what I should do next.

Now, in those days, there were few women in medicine, but the intern was a woman…and not just a woman, but one of those pre-feminist women woman who hated other women, and made life miserable for myself and the other female student who was working with me.

I showed the intern the partial EKG machine and indeed she bawled me out and told me to find another machine.

This took some time, but I finally borrowed one from another ward, and redid the EK. Alas, again it was a sine wave pattern that I had never seen, being only a third year student whose classwork hadn’t covered reading EKG’s yet.

 

Source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2010/01/ECG_Hyperkaemia_L.jpg

So again, I took the EKG up to show to the intern, tears in my eyes, knowing I would again be bawled out in public for being incompetent.

Luckily, she was talking to the Resident, who grabbed it out of my hand and said “Oh My GOD”.

Her potassium was high: Later we found the lab had measured it as 8 (twice the normal level, and potentially fatal), but overlooked in the lab, since high levels were usually due to a “false positive” lab error if the blood had been improperly drawn (if done incorrectly, the red cells burst, aka “hemolyzed”, and cause a false high level).

So the laboratory didn’t call us with a “headsup”, but the result was put into the “inbox” and delivered at the nurses station promptly at 3 pm, eight hours after the blood was drawn and four hours after the level was known.

In other word, we got the reasult about the time the resident took over and started treating her for diabetic related hyperkalemia.

The good news? With prompt treatment, the patient survived, but when I left, her diabetic foot wound was still smouldering along..

So I often complain about all those regulations we have to follow, but these regulations were put into place to prevent things like this: A lab result that was a dangerous level would now be required by law to be called to the doctor, the first EKG machine, (which was rarely used) would be checked ever month or so by someone that it worked…

And, of course, you don’t get semi trained medical students doing procedures, but trained lower level workers to do things like draw blood and take EKG’s, allowing students more time to care for patients and learn the science and art of medicine.

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Nancy Reyes is a retired physician living in the rural Philippines.

 

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