Tuesday, February 26, 2008

New Attending, New Plan

So Starting monday we got a new attending surgeon. What are attendings? Attendings are the senior most physicians in charge of you or your loved one's care. They are the - in the words of our eloquent president - 'The Deciders'. All decisions are supposed to be run by them before anything happens, because they are responsible for your care. There are typically residents, fellows, physician assistants, nurse practitioners as part of the team - but all of them are acting on the attendings behalf.

So the center Ananya had a liver transplant at has 4 pediatric transplant surgeons. Each of the four take turns taking care of the patients in the intensive care unit and on the regular floors. Every week a different attending is on 'service' taking primary care of patients.

This rotating model of service is what you find at a lot of hospitals. So If I see Dr. Jones who is part of a 5 physician group - and I happen to get admitted to the hospital for a pneumonia - I may not necessarily see Dr. Jones - I'll see the physician who's turn it is that particular week to see the hospital patients for the group.

A system that makes sense, right? Well a little side effect if you have the misfortune of being in the hospital long enough is that each particular physician may have a different plan for you. So for example, on Sunday Ananya was thought to be in need of more fluid to jumpstart the kidneys. On Monday, the new attending makes a plan to take fluid off to jumpstart the kidneys. I think it can be a little disconcerting for patients and families when plans shift 180 degrees - b/c it suggest uncertainty among the physicians taking care of you, and that someone's wrong. Of course the standard answer I think we as physicians would give if queried about why the plan is so different than our colleagues (we seldom are asked) is to say that the patients clinical status changes on a day to day basis. So Ananya could have had too little fluid on Sunday, and have too much fluid on Monday - so everyone's right. And so everyone's happy that the patients attempt at clearing the mist has been thwarted.

Anyhow, the new transplant surgeon had a bevy of new ideas - Ananya needed lasix to get fluid off, and we should get an x-ray to follow some fluid that was noted in the lungs. I questioned him to make sure I understood why he thought lasix would help - (a diuretic) - b/c if she didn't have enough fluid - a diuretic would make kidney function worse. Ultimately he said the prograf causes the kidney to clamp down, and that little kids, unlike adults just didn't have the capacity to deal with a lot of fluid. So while you or I could pee out 5 extra liters of fluid babies kidneys need a little help. So fine, I accepted. The X-ray was a harder sell There is good data to suggest cumulative radiation dose in kids will result in a higher rate of cancer later on. Now one x-ray is like a drop of water in terms of radiation dose - but I'm thinking of total aggregate dose she may get in the next 5 years - so I absolutely refuse to have her get studies which won't change the teams management. The attending said he just wanted to follow the lung fluid that was noted prior. I didn't need an x-ray to tell me her lungs had less fluid - she had gone from needing 2 liters of oxygen and saturating 93% to being a 100% on no oxygen. In addition her lung exam certainly ruled out a significant effusion. But I was interested to see whether the right upper lobe of her lung that had been collapsed after intubation was now open - so I agreed to the x-ray.

The x-ray result came back first- the lung fields looked great - no fluid...but the right upper lobe was still collapsed. Bummer. So more chest PT, and some breathing treatments to try to break up junk that may still be in there. After ananya got the lasix she peed like she hadn't peed in a while, and it lasted well after the lasix effect should have passed - the labs the next day did show an improved creatinine from .4 down to .3. Yay!

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