The C-Word

Collaborative.

It's one of those magic buzzwords that we in health care like to liberally sprinkle around in our conversations when we're feeling particularly self-righteous and saintly.

Please don't mistake my flippant comment as total disregard for the concept. I do, in fact, believe it is absolutely the best possible framework for patient care. I just wish people used it for more than a feel-good talking point.

I think nursing as a whole accomplishes collaborative care the most consistently, at least at my hospital. We actually coordinate much of the inter-disciplinary care; we often facilitate the communications between disciplines. We're like home base--everyone checks in with us. The way we choose to phrase patient condition or answer questions can significantly alter the course of patient care.

It's a power not all nurses realize we wield. Maybe it's most seen in the ICU setting where patient condition can drastically change by the time a doc walks from one end of the unit to the other. They truly depend on our eyes and ears. Still, even we nurses don't always play nice either. How many times have you heard nurses complain when case management steals the chart? Or grumble when X-ray shows up just as we got the patient settled (regardless of the fact that we called them)?

The docs though, they can be real stinkers. (Not all docs, but enough to stereotype.) I often wonder if they think we don't have ears, or that we only hang out at the patient bedside when they're there. Do they not realize that we get the whole picture? From shift beginning to end, we entertain every discipline, and that we actually see what really takes place regarding the things they complain about?

I've heard several docs make snide remarks when pharmacy leaves notes to them in the chart. Often it's regarding vancomycin dosing, or GI prophylaxis--not entirely unimportant issues. In fact, I had a doc tell me to tell the pharmacy to "shove it up their ass" when they had me contact him about ordering Bactrim and Zinacef on a patient with documented sulfa and penicillin allergies. I hadn't caught it yet, but I hadn't given a dose of either yet. The patient did however receive doses of each in the OR--I guess that's what that red truncal rash was, aye doc? Funny how it disappeared after a dose of Benadryl.

Or how about the docs that brush aside the palliative care team? Or disparage the lab for taking so long with their stat super-specific free level neutrogenic assay panel level?

But docs aren't just hard on other disciplines, they have it out for each other too. For example, take the double lung transplant we had last week. The surgeon, Dr. Particular, put the patient on an epi drip to keep cardiac output up, and blood shunted centrally. Not a lot of epi, 0.03 mcg/kg/min, but it was enough to keep the patient in sinus tach and SBP in the 150s. The pulmonologist, Dr. Low-Key, came in and and D/C'd the epi because he didn't like the pressures that high on the new anastamosis and the lung capillary beds.

Having worked with the Dr. Particular before, I was pretty certain he wasn't going to take someone monkeying around with his drips too well. So I discontinued the epi while Dr. Low-Key was there, and as soon as he left, I paged Dr. Particular.

"What!?! That is MY drip. All the vasoactive meds are MY meds! Why would Dr. Low-Key D/C drips that are mine! We don't just D/C drips like that!" Etc, etc, ad nauseum.

So the epi went back on (actually, as far as Dr. Particular knows it was never turned off). And when Dr. Low-Key came back through for afternoon rounds, I had to play the other side of the fence. "You know how Dr. Particular is, he likes his drips." And we had a round of teasing and snide remarks at the expense of Dr. Particular. In the end, Dr. Low-Key left placated. But the drip was still running.

When Dr. Particular came through to write his progress notes, I was able to bring up Dr. Low-Key's concerns carefully disguised as nursing recommendations, and got the epi weaned to 0.015 mcg/kg/min, which kept her CO/CI at 4.8/2.7, but allowed her pressures to settle into the 130s. All the while bantering about Dr. Low-Key's "slip-shod practices", just turning off a drip without weaning, and generally talking up the other side of the fence again. Gleefully, Dr. Particular left vindicated.

And the patient maintained perfusion, with tolerable systolic blood pressures.

Yeesh, I think foreign relations in the Middle East aren't this complicated.

But that's collaborative care.

The C-word.