Busy, Noisy, Smelly
To accomplish this took at least two ER nurses, two surgical residents, an attending trauma surgeon, an anesthesia attending, a nurse anesthetist, two OR nurses, an ER technician, a radiologist, as well as consults from many specialists, depending on their injuries (e.g., orthopedics, head and neck surgery, neurosurgery). The process took hours to get through, often with the SND screaming and puking all over us, all in the middle of a busy, noisy, smelly ER, all of which we ignored and carried on with what we knew was the right thing to do. Yes, they were drunk and annoying, and many of them were repeat customers, but they were also very much at risk for severe injury. Yelling and cursing, for example, might be due to the alcohol, or it might be a sign or severe pain or a head injury. We knew the protocol, and we knew if we followed it we were not going to miss anything.
Now imagine a scenario in which the Trauma Chief’s wife comes in to the trauma bay, with the following results: We can’t cut her clothes off, it might embarrass her, meanwhile missing a major injury. Or: We can’t put this cervical collar on, because it might be uncomfortable, and then it turns out she has a c-spine injury and is paralyzed because of our “niceness”. Or: Don’t put such a big IV into her, it might hurt, meanwhile having no way to resuscitate her when it turns out she has a major bleed. Or: Let’s not get so many CT scans, it’s too scary for her to be in there all alone, meanwhile missing any number of internal injuries. Examples abound, but the bottom line is VIP = substandard care. In the end, the SNDs were getting the best care, which is what the Trauma Chief wanted for everyone, including his wife.
I had many opportunities to witness this phenomenon as a resident. Many patients have the idea that residents are not “real" doctors and therefore provide a lower level of care, and insist that the attending physician is the only one who they will talk to. What these people never realized is that they are hurting their own health. The general practitioner “one doctor for everything” phenomenon works fine when all the GP has to do is prescribe physics and pull teeth, but that concept has no place in modern medicine. Medicine today is a team sport, involving, in a typical hospital stay, 50-100 professionals—attending physicians, consultants, residents, nurses, technicians, physician assistants, pathologists, lab assistants, radiologists and a host of other hospital personnel. It’s expensive but comprehensive. Removing integral parts of that team is like trying to fly an airplane that's missing several of its components, or having a patient tell me to operate blindfold and with one hand tied behind my back. Both can be done, but with similarly disastrous results.
Article comments
1 - Terry
Dr. Tim,
I agree. Some of the worst "victims" of VIP Syndrome are not just the celebrities who have "their people" try to muscle worthless tests and treatments out of us but also patients whose "people" are friends and relatives in the medical field. How often have you had a patient who insists you discuss their case with their best friend from high school (cousin, neighbor, etc) who is a Respiratory Therapist (Lab Tech, EMT,Psych Nurse, etc) before you initiate any care? Most tend to be fairly reasonable but it seems as their level of education and training increases the level of interference rises proportionally. There is nothing worst than talking to a Non-Surgeon physician who lives 2000 miles away and explaining why we don't need another CT scan or MRI to make a diagnosis of acute appendicitis.
2 - Dr. Tim
Terry you must be a doc yourself, or somehow connected to medicine. In my experience, though, their knowledge base is only loosely connected to their Interference Factor, but directly connected to their Ego Factor. Big Easily Bruised Ego = Big Pain In the Butt. My favorite was a dentist who wanted to observe us work on his wife during a trauma code, which was fine, we often let family in, but he kept trying to run the code himsel. I finally had the nurse (now my fiancee) throw him out of the room. But I agree that the further away they are the more they want to run the show, especially with end of life decisions. Worst of all, though, are the parents of small childern, which is why I'm not a pediatric surgeon.
3 - TheNewGuy
Every ER docs has stories like these.
I had one patient with an ongoing anterior-wall MI insist on my discussing her care with her brother-in-law (also an ER doc) before she'd let us treat her. She was threatening to go AMA if we didn't.
Time is muscle, but oh well... if that's it took to get her cared for, I was willing to do it.
The ER doc brother-in-law must not have liked her, because he insisted on playing 20-questions and pimping me on the phone: "what's the EKG show" "are you sure?" "any enzyme elevations?" "what's your training" etc, etc. I finally cut him off, and advised him that what I really needed was for him to talk her out of leaving AMA. He said "Oh..." and we got her to the cath lab.
The kicker? She didn't want to pay her hospital bill, so she threatened to sue me later for delaying her care. No problem lady... think nothing of it... you're welcome.
4 - Dr. Tim
New Guy you cracked me up! Your example is so sad and so true to life. What else can we do except laugh? Speaking of laughing so hard I wanted to cry, there was an article in Sunday's Boston Globe Magazine about Shaken Baby Syndrome, which of course has its doubters. (Is there some special school that these people go to, where they are taught that the Holocaust didn't happen, global warming doesn't exist, and there is no such thing as disease?) One of these clowns is Dr. Leestma, a neuropathologist and hired gun who is frequently retained by the defense in SBS cases to cast doubt on whether the unfortunate baby was actually a victim of child abuse, or if all those broken ribs and retinal hemorrhages just happened by accident. Here's a direct quote: "We tend to be a little sloppy in medicine with diagnosis and treatment, but the law demands a more rigorous approach." The LAW demands a more rigorous approach! I just about fell out of my chair laughing. A rigorous approach! As was seen, for example, in the OJ case, or Jon Benet Ramsey, or any of a thousand jury decisions that find for the plaintiff in medical malpractice cases not because of any wrongdoing but because the jury felt sorry for the plaintiff? My side aches just thinking about it. But it's either laugh it off and get on with saving lives or sit in a corner and cry.
5 - xyz
We also come across a number of VIP syndromes in our healthcare system. What's the best way to deal with them still alludes us.