That Occasional Unexpected Road Flair

Taking care of patients is never a dull day.  The days are always filled with variations and permutations of common themes.

I have previously stated that a great deal of what I do in the hospital is evaluation and management of the same diseases.

Over

and 

Over

and 

Over again.

Lets face it.  There are common conditions that present themselves day in and day out in the hospital setting.

This is the bread and butter of hospitalist medicine.

Managing these conditions constitutes a large majority of my time and energy in the hospital.

These conditions include

Pneumonia

COPD

Stroke

Heart Failure, CAD, Afib

Diabetes and their complications

Cellulitis

Colitis

Infections of all kinds

surgical co-consultation and anticoagulation management

These are just a few of the many common conditions that I care for on a daily basis.

When I admit a patient or come on to service to take care of a patient,  in my mind,  I have a general sense of how long the patient will be in the hospital.  I can tell, based on the presenting complaints, their age, their confounding mental illness,  their reserve capacity, their functional capacity, and their families expectations, managed or unmanaged.

I can tell based on my over all experience how long their hospital stay is going to go.  

This is expecting the expected.

For a middle aged schizophrenic with COPD that smokes 4 packs of cigarettes a day on 8 liters of oxygen, complaining of being short of breath and needing a cigarette at the same time.

I expect them to need a week in the hospital.

I expect they will need a nicotine patch.

I expect they will have mental issues in the hospital.

I expect they will need mood stabilizing drugs.

I expect they will not like some of my therapies and treatments.

For the 90 year old little ol' lady with dementia from the nursing home who falls and breaks her hip.

I expect delirium and agitation

I expect a high risk of pulmonary complications.

I expect a high chance of mortality within the next year.

I expect difficulties with anticoagulation.

For the young patient with traumatic cellulitis

I expect a quick recovery

I expect just a few days in the hospital

I expect no long lasting problems and no hospital complications.

A lot of what I expect is based on my experience with other patients just like the one sitting in front of me.  My expectation is based on my experience.

When I have to tell the 10th family of the week that grannie's confusion is the expectation, not the exception.  That we do everything we can to try and minimize delirium but that it is a common side effect of the triad:  old, sick and hospitalized.

Not a day goes by where I don't have a patient with delirium.

A lot of my day is built around managing the expected.  

The  expected good things (improvement)

The expected bad things (complications)

Complications, as most families either don't know, or don't want to know,  are a normal part of being sick. 

Every human body carries without it's own genes, reserve, and "fighting power".  The starting point of fighting the battle of illness, is in most part, determined on the protoplasm of the individual.  

And in my experience, the two factors that categorically give good protoplasm and fighting power for a hospitalized patient are

1)  Never smoked

2)  Remains physically active.

Good genes certainly help as well.

Hospital protocols and "patient safety initiatives" are instituted to try and minimize complications, when possible,  but the human body is not programmed in your IT department.

You cannot simply create a binary code to do away with every possible patient complication.

There is a lot of protocol driven medicine.

But safety protocols won't cure complications when many complications are the result of poor protoplasm,  not poor medicine.

A lot of what I do in the hospital is trying to help the body heal itself.  When you destroy your temple,  my therapies don't work nearly as well.  

And no protocol in the world will prevent complications in poor protoplasm.

For example,  Mr Ritter recently died at the hands of high cholesterol and excess weight and poor follow through on his own care.  He did not die at the hands of poor medicine.    There isn't a protocol in the world that would have saved him in that ER that day.  

I expect complications from poor protoplasm.  I expect delirium.  I expect pneumonia.  I expect erratic anticoagulation.  I expect erratic blood sugars.  I try my best to prepare families and minimize the side effects of these expected complications.   

I expect the course of hospitalization to play out my expected way for so many of my patients.  

BUT.

I also know that at any given time in the hospital,  the unexpected can occur.  

Anytime.  Anyplace.  Any floor.  Any reason.

The unexpected can range from code blue, to increased oxygen needs, fast heart rate, to stroke like symptoms,  to uncontrolled hiccups,  to an angry patient out of control, to leaving AMA, to massive GI bleeding, to hypotension,  to rapid respiratory failure, to an abnormal lab value, to an irate family with a lack of understanding, to sudden death.

There are lots of things that happen unexpectedly in the hospital.  

I expect the unexpected, only in so much that I know anything is possible.

I can't prepare for them.

I can't warn the family about them.

I can't minimize their chances.

They are by nature,  unexpected.

Many complications are expected.  Many complications are not.

And many times,  completely unexplainable.

They are the result of randomness in our universe.  

Sometimes, the opposite occurs.  

A patient sure to die,  makes a remarkable recovery.  Completely unexplainable.  

Septic shock.  Pneumonia.  End stage renal disease on dialysis.  Severe hypotension on 4 pressors.

My experience says no way will this protoplasm survive, despite all massive supportive therapy. 

Unexpectedly,  in 48 hours,  normalized blood pressure off all pressors.

Some things you just can't explain.

They are the unexplained.

The unexpected.

Drama TV is great about beaming  out to the world the unexpected.  It makes for great TV.  But is also skews  an entire nation of TV watchers into believing that what they see on TV is reality.

It is not reality TV.  

It has turned the  unexpected into the expected.  

I deal with expected's all day long.  Every day.

I can tell you.  My reality is not TV material.

It is just good boring expected medicine, with an occasional unexpected road flare to mix things up.  

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