Dr. Mohan, do you have a minute?
MohanYep. Excuse me.
Is there a problem over there?
Mohan
No, her pain is well controlled.
You understand that's my polite way of asking why are you spending so much time with one patient? You're an R3. As an R3, you should be seeing at least two patients an hour.
Mohan
I have two, Joyce and Mr. Wallace, our Good Samaritan.
Who's comatose and stable. You should have four by now.
Mohan
I have the highest patient satisfaction of anyone.
I don't doubt it, but we just had this conversation a couple of hours ago.
Mohan
I know people call me Slow-Mo. You don't have to confirm or deny. It used to hurt my feelings a lot, but I can't help it. I work at the speed I'm comfortable at.
Because you're afraid of making a mistake?
Mohan
I'm always afraid of making a mistake. Aren't you?
Yeah, of course I am. But you know what I mean. You make a mistake once, and somebody dies, and you feel so badly about it, you'll never let it happen again
Mohan
How is that wrong?
Because you waste time and money on unnecessary tests. You keep sick patients waiting too long. You miss out on cases you could be learning from. You shortchange your own education. I'm not saying this to be a hard-ass. I'm saying this because I know you could do this, but you need to do it at a level I also know you're capable of.
Mohan
And what if I'm not?
Then you should look into a specialty that better suits you. Have you thought about psychiatry?
Mohan
I don't want to go into psychiatry. I want to be here.
Being here means no matter how good you are or how hard you try, you're gonna make another mistake, and someone else might even die. That's called being an emergency medicine doctor. And if you can't accept that, then maybe this isn't the place for you.
Mohan
I can accept that.
Mohan
Yes.
OK, good. Go save some lives. Clear some beds while you're at it.
Mohan
Distraction is a terrible strategy. When a patient says, "I'm hurting," we don't respond, "What's your major?"
Oh, I wasn't trying to diminish
Mohan
Additionally, "I" statements work better than "you" statements. "I can see how painful this is" acknowledges the reality of the situation and invites further examination. "You need to move on" has the opposite effect.
Understood, but in my personal experience...
Mohan
Your personal experience isn't germane here. We bring our education to the job, not our baggage.
Mohan
Aren't board rounds at 2:00?
These aren't board rounds. I just want to remind you all of a few things, OK? So we do a great job coming up with the right diagnosis and treatment plan for our patients, but there are still some opportunities for improvement.
First off, always sit down at the bedside of a stable patient. It will make you a better doctor. Second, if there's a discharge to be done, do it before you pick up a new patient. The patients are very aware of the time that they spend with us, so please don't keep them here any longer than they need to be.
They complain about the wait.
I get it, but for the sake of efficiency and running smoothly on our end and opening up beds and opening up rooms, let's discharge before we start with somebody new, OK? Thank you. Lastly, in your medical records, make sure that your decision-making and your notes reflect not just the diagnosis but all the thought that you put into ruling out all the critical illnesses in the differential.
More work? I do enough charting as it is.
The hospital won't admit this, but it's less about charting and more about profit.
OK? Good. That's it. Goodbye. Go.
Mohan
Remember how I said you get good at spotting the fakers?
Mohan
He's exhibiting every sign of opiate withdrawal. Eyes dilated, tearing, skin has piloerection and goosebumps. Hypertension, tachycardia. Agitation, restlessness, perspiration. He's checking every box.
Right, but he said he doesn't take drugs and seldom drinks alcohol, so...
Mohan
That's exactly what he would want you to believe if he was drug-seeking.
Mohan
Thanks. I am.
Mohan
By getting him to admit his opiate usage.
Right. How do we do that?
Mohan
By being smarter than the patient.
Got it. He said he isn't an addict, so why give him an opiate agonist to treat his withdrawal symptoms?
Mohan
Because I don't believe him. And I know this will work. Then once he feels better, we can get him to admit to his addiction and treat him long-term.
How you feeling, Mr. Pugliesi?
IPIvan Pugliesi
Oh, so much better. Thank you. You guys think that I could have a little bit more of that medicine, just for the few days that I'm out here? I just want to be able to walk my daughter down the aisle without shitting myself.
The medication we gave you wasn't morphine. It was something called buprenorphine, or BUPE.
IPIvan Pugliesi
Yeah, no, she said that. I mean, whatever you call it, Doc, it worked great.
It's a medicine specifically targeted to treat opioid withdrawal. That's why it worked.
IPIvan Pugliesi
Wait, I-I don't I don't understand.
All indicators are that you have been using opioids. That would include pain medication like hydrocodone, oxycodone.
IPIvan Pugliesi
I told them I don't do drugs. Wow. You lied to me.
Mohan
I didn't lie. I said I was giving you a morphine-like drug that got rid of your cravings.
IPIvan Pugliesi
Well, you know what? This is bullshit. I mean, you know, I could sue all of you. You hear me? I'm not some junkie on the street. Look, look, I-I got a family. I got a job. I make good money. I, you know, I return my shopping carts. I pay my taxes. That sound like a drug addict to you?
Yes, because anybody can be an addict. You are proof of that. These pills that you were taking, they're not helping you with your pain. They are keeping you stuck in it. A lot of really good people struggle with addiction. It is a brain disease. But social environment and personal choice are also factors.
IPIvan Pugliesi
I don't have a problem.
The good news is that the brain is highly dynamic, as is the environment. But you need to stop now before the damage is irreparable.
IPIvan Pugliesi
No, screw this hospital, okay? And screw you.
Hey. Doctor Mohan -- Doctor Mohan will advise you on our proposed action plan. You can either choose to follow it or not. That is entirely up to you. I wish you luck, Mr. Pugliesi.
Mohan
We're giving you a seven-day supply of a drug called Suboxone. We can set you up with a medic...
IPIvan Pugliesi
Fuck off. I'm not interested.
Mohan
What are you doing?
Giving this guy a chance. He needs a big central line for fast transfusion.
Mohan: You can't do an IJ without an ultrasound, especially on a guy this big.
MDMateo Diaz
You'll kill him if you collapse a lung or hit the carotid.
I'm not doing an IJ. Unhook that blood line. Bring it up here. This is a supraclavicular subclavian. If you have to go in blind, this is the only safe way to access a giant vein. And hold compressions. A centimeter from the lateral head of the sternocleidomastoid, a centimeter off the clavicle, aiming at the contralateral nipple. I'm in. Okay, resume compressions. And squeeze blood.
Mohan
Where'd you learn that?
"EM: RAP" podcast. We'll be ready for a second unit in under a minute. Boom.
The Pitt · 77 quotes
