Sunday, August 5, 2012

Cross cover issues

Cross cover is always a sticky situation. You're dealing with patients you don't know and sometimes have to make important decisions about them. I feel like if it's at all possible to defer those decisions to the regular team, that's what should happen. I feel like the only things that should be changed during cross cover are potentially life threatening medications.

Other people feel differently. Here's a snippet from a cross cover I did a while back:

Nurse: "Doctor, Mrs. Chang is getting qAC fingersticks but her daughter doesn't want her to have them. I think she's only getting them because she wasn't eating before but now she is."

Me: "Is she diabetic?"

Nurse: "No."

Me: [checks sign-out sheet from primary team to make sure pt isn't diabetic] "And she's tolerating her diet?"

Nurse: "Yes."

Me: "OK, you can D/C the fingersticks."

Nurse: "Also, Mrs. Chang is written for morphine PRN, but her daughter doesn't want her to have it."

Me: "Uh ok.... well, it's PRN, so what's the problem?"

Nurse: "Can I D/C the morphine?"

Me: "But it's PRN. She doesn't have to take it."

Nurse: "Then I'll D/C it."

Me: [getting paged again] "Fine, whatever."

The next morning, the resident on Mrs. Chang's primary team comes up to me: "Why did you D/C Mrs. Chang's fingersticks? She's diabetic!"

And then he got mad at me for having D/C'd the PRN morphine.

(Here's a tip: If a patient is diabetic and you want them to stay on qAC fingersticks, maybe write that they're diabetic on the signout sheet.)


  1. Replies
    1. Is that really the only abbreviation that's giving you trouble?

      Sorry, that was a very jargony post, in retrospect.

    2. It's because it's not a medical term. "Doctor, Mrs. Chang is getting medical term but her daughter doesn't want her to have them" makes sense, you could say that on ER and people just treat it like phlebotinum. "It's medical term. She doesn't have to take it" works too. But "he got mad at me for having D/Ced the morphine" was like "That's not a medical term, it's just an abbreviation and it's keeping me from understanding the story!"

  2. D/C is discontinue, unless it means discharge or any number of other terms.

    When I come across something I don't understand, I google "medical term XXX" and figure it out.

  3. ha! this rings so true. i'm a senior resident now and every night i work with a new intern on either call or an overnight shift, i explain my philosophy to them at the beginning of the shift: "nurses, patients, and parents [i'm in peds] sometimes think that just because there's a doctor here in the middle of the night, that every single thing that comes to mind is an appropriate thing to call the on-call intern about. it is perfectly okay to say of non-urgent questions 'i'm happy to pass that on to the day team'. i also don't like making any changes overnight unless there is a really good reason."

    some of my favorite (read: least favorite) overnight pages are:

    - 0330: "do you really want that AM CBC/renal/gas/whatever?" our AM labs are drawn at 0400, and generally the other residents don't sign out upcoming AM labs to the on-call person because the whole point of AM labs is that the primary team will follow up on them in the morning. so i don't necessarily know or care what AM labs my cross-cover patients are getting. so my answer is ALWAYS: "is it ordered? then yes."

    - midnight: "so-and-so's aunt wasn't on rounds today but she's here now. she wants the doctor to come and talk to her about the discharge goals/follow-up/MRI results/chemo regimen/whatever. also, is it still the plan for the patient to go home a week from tuesday?"

    as an intern, i always deferred because i didn't know the answer. then, as a senior, my interns would page me and ask me these questions because THEY didn't know the answer. or worse, they would go to the room and fumble through an answer and make things worse, then call me to clean it up. hence the preemptive counseling.

    1. Dealing with family members of a patient who isn't yours is particularly painful. It would always be around 6-7PM that I'd get a call that a patient's family wanted an update. I'd tell the nurse to explain to the family that I knew almost nothing about the patient, so I certainly couldn't tell them anything about prognosis or anything like that. On one hand, I was sympathetic that a lot of family members are unable to visit during the day. On the other hand, what was I supposed to do?

      On one occasion, I said that and the nurse said that the family understood that I didn't know what was going on, but they wanted me to read them the last page from the chart. So I did that. I literally went and, holding the chart, explained the last progress note to them.