The reputation I am getting

My Residency program has a nice setup where you spend most of your time in a level I trauma center with a high acuity of medical patients to get that big-city ER feel, but you also rotate at a smaller affiliated hospital where you get more of the small-town ER feel. This is actually very important in training, since different skill sets are emphasized at each. Anyway, right now, I am rotating at the small-town EC, and am getting a rep for being aggressive in treatment. Aggressive to a fault, I might add. I recently was scolded for treating a patient in diabetic ketoacidosis (DKA) too aggressively. DKA is a dangerous and life-threatening condition which requires fluid/volume resuscitation as the first step in treatment. So, after evaluating this patient (whose blood sugar was in the 900 neighborhood), I went heavy and ordered the patient to get five liters of fluids intravenously, and for the patient to be given ten units of insulin right away. Now, the usual course is to order for a liter or two, and then to re-evaluate the patient, then to order another liter or half liter at a time until their volume is adequately increased. Then, you are supposed to start on the insulin once you get your initial labs back. I had based my decisions based upon how dry the patients appearance was, and the EKG, which showed the peaked t-waves consistent with a high potassium. Well, the attending had great fun at my expense, laughing at my impulse to smash gadflys with sledgehammers, and telling everyone about it. He did, of course, change my orders to the more standard, and safe format. Well, the nurse who was working that patient was ...less than stellar as far as nurses go, and so some things were delayed here and there. The patient went upstairs.

Well, I came back the next day, and while my five liter bolus therapy still got a smile, it wasn't as funny, now. The patient had not done well, and in retrospect, it would appear that being more aggressive might have been appropriate in this case. This is one of the frustrations with medicine. If you were to repeat this scenario twenty times over, and been aggressive with it, in nineteen cases, the patients would have done better, and one of them would have done worse. Still, it is for that one case that we must tread cautiously. "First, do no harm." The attending was right, of course. I was being a little too cowboy in my approach, and eventually, you will get burned if you do that. That said, it certainly is somewhat reassuring that this time, it would have probably benefitted the patient.

Respectfully Submitted,
-doc Russia