I remember it clearly, the first time a resident told me something that was completely wrong. It my second day in the hospital as a clerkship student ever, and I had a patient whose chief complaint was abdominal pain, and he was asking for pain medicine.
The resident told me to give him toradol. When I asked whether that was ok, since he was here for abdominal pain, and I thought NSAIDs were contraindicated since we didn't know the cause yet, she said slowly, enunciating each word very slowly and clearly as though was mentally challenged, "Well that only applies to ORAL NSAIDs. Because the pill lands in the stomach and irritates the mucosa that way. It doesn't do that if you give it IV."
Which isn't actually true.
So what did I do? I nodded my head solemnly and said, "Ok, I get it now. Thanks for explaining that to me." I think I did a pretty convincing job since she smiled back and said, "You're welcome."
As for the patient, you're probably wondering whether he was harmed by this. The answer in this case is no. I don't think we actually ever figured out what was wrong with him. Who knows, maybe there really was something else about the case that I didn't understand at that time (and don't remember now) that actually made toradol ok to give under the circumstances. However the resident's explanation of the physiology is still completely wrong.
I just use this story as an example of the fact that I can and do respect the medical hierarchy when I'm in the hospital. I know it's hard to believe given what a whiny loud mouthed pain in the ass I probably sound like on this blog sometimes.
And that is probably to the detriment to patients everywhere. At least sometimes, anyway.
7 Pearls of Wisdom:
I had a high fever at a week postpartum and ended up in the ER. The ER attending told me to take Tylenol, but not NSAIDs, because it would close the ductus arteriosus. I was thinking to myself, "Hopefully, that's already closed!!!" But I didn't correct him because I thought it would be obnoxious.
You probably wouldn't have made it this far if you didn't know how to be strategic with your loudmouthedness. You also probably wouldn't have made it this far without a good measure of independence, intelligence, and nearly obsessive tenacity- the same traits that probably inspire the sass.
I for one am glad you have a balance, but hope you let the rebel out once you're credentialed enough to effect something big. Lord knows we need it.
A lot of people think the same thing about oral NSAIDS vs parenteral. It doesn't matter what field. They don't think about the anti-prostaglandin effects overall, just the local irritant. I've heard some doozies in vet med. Lots of problems in all walks of life could be avoided if people would just think about things, but I digress...
Fizzy -- All I thought here was poor attending. He was probably so proud of himself for remembering that tidbit from med school, even though he was wrong! Haha.
One of my good friends has a chronic GI problem. She's battled the disease since her teens, and watched family members undergo repeated surgeries for adhesions, etc. Anyhow, she can't tolerate NSAIDs because she has been taking corticosteroids for years.
On one occasion, she arrived in the emergency room in too much pain to care what she'd be given, i.e., Tylenol wasn't cutting it. After long experience, she always asks what drugs she's being given, but on this occasion was in too much pain to quiz the nurse about what, exactly, Toradol was. That's how she landed in the ICU with a massive GI bleed. The NSAID could have killed her.
I think that the next time this happens, you should stick to your guns. A person that does not understand something as basic as NSAID pharmacokinetics should not have any patients.... Even nurses should know this. This is why so many people are paying out of pocket for medical advocates.
I'm not actually aware of any literature demonstrating increased risk of adverse events in giving an acute dose of NSAIDs in someone without evidence of a GI bleed. If they are not endorsing pooping or puking blood and have a negative hemooccult, I like Toradol and use it frequently. The attending's rationale was wrong but their practice itself is fine. As happens frequently in clinical medicine, where few us us really hang on to a lot of pathophys.
Post a Comment