Ancillary services

[Mumpu]

So, perhaps I'm naive or old-skool (I'll confess to the latter) but I don't understand the importance people place on the ancillary services. In my experience, doing the ECG or a blood draw yourself is usually the fastest way to get it done (ECGs are hard to do now though... the techs hog the carts). I always do my own urine dipsticks and microscopy (if the lab lets me, seems to vary hospital by hospital) because I can have the diagnosis in 5 minutes instead of 3 hours. I also review (but admittedly not make) blood smears from my patients.

I don't buy the "busy busy intern" argument (from personal observations and otherwise). With night float in most places cross-cover is becoming less of a horrid beast and most of these ancillary things take only a few minutes. Btw, the props you get from a patient when you leave with their urine and come back in 15 min with a diagnosis feel gooood.

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[cd95]

So, perhaps I'm naive or old-skool (I'll confess to the latter) but I don't understand the importance people place on the ancillary services. In my experience, doing the ECG or a blood draw yourself is usually the fastest way to get it done (ECGs are hard to do now though... the techs hog the carts). I always do my own urine dipsticks and microscopy (if the lab lets me, seems to vary hospital by hospital) because I can have the diagnosis in 5 minutes instead of 3 hours. I also review (but admittedly not make) blood smears from my patients.

I don't buy the "busy busy intern" argument (from personal observations and otherwise). With night float in most places cross-cover is becoming less of a horrid beast and most of these ancillary things take only a few minutes. Btw, the props you get from a patient when you leave with their urine and come back in 15 min with a diagnosis feel gooood.

Hey, I share your view that an intern should be comfortable doing that sort of stuff if necessary (i even like doing my own peripheral smears ), but if you're carrying ten patients it can become very burdensome. But speaking of old school, nurses used to get up if a physician wanted a chair. I'm not asking for that, but I think that at some programs the ancillary staff acts like you're asking for their first-born child if you request an EKG. When I'm not busy, I don't mind doing a blood draw or an IV to get it done fast, but it gets tiresome when you do it all the time and when the ancillary staff is hanging out playing solitaire while there are no computers for you to check labs. Part of it is regional, and related to labor shortages, but I think that to a certain extent it also displays the measure of support a program puts behind the housestaff. I know where you're coming from, and I know what you mean, but I also subscribe to the "old school" view that if people are paid to do a job, they should do it, and not get indignant about it. I've just encountered way too much ancillary staff that does not do the job that they are being well-compensated for.

 

[Mumpu]

True. Therein lies my argument that if you want something done pronto (stat, if you must), you almost always have to do it yourself. Easier for me than to fight the Sysiphean battle against the ancillary staff.

I guess my point was that having to do ECG/blood/UA/etc is considered to be scutwork by people and I fail to see why. I can just see some graduate from a county hospital-based residency doing EJ draws on their clinic patients because their nurse is on sick leave and EJ is the only peripheral vein they know how to hit.

 

[Bobblehead]

Several things to consider would be patient comfort (fewer sticks from an experienced phlebotomist vs. potentially more sticks from a new crop of interns every year), decreased false positive rate on blood cultures (experienced phlebotomist trained in proper sterile technique vs. intern who got 15 minutes on the topic crammed into intern orientation), and standardization (scheduled blood draws vs. intern who arrives 2 hours early to draw bloods on every patient).

You are no longer able to do your own point of care testing without adequate daily QC due to JCAHO regulations including urine dips, urine micro, fecal occult blood testing, etc. Most hospitals only do fingerstick blood sugars and you'll note each machine comes with QC supplies in the box. Of course you can always go to the lab to look at the results yourself but that's a different story.

I think any hospital that continues to solely rely on "free" labor from housestaff to perform routine testing (i.e. scheduled blood draws, EKGs, etc.) is doing a disservice to their patients. That's not to say if the situation calls for it you shouldn't try to help/intervene by pushing things along yourself but I see no rational argument for having to do everything on your own. That argument can easily be extended to the person registering the person (doctors should learn about insurance and you want the family information), the X-ray tech (after all you can get the CXR faster this way), transport (you can get your patient to the room faster), etc.

Again, this is for routine services. When the situation calls for you can and should always take the initiative and act in any of those capacities. But having the expectation is a different story.

 

[BStein76]

I don't buy the "busy busy intern" argument (from personal observations and otherwise). With night float in most places cross-cover is becoming less of a horrid beast and most of these ancillary things take only a few minutes. Btw, the props you get from a patient when you leave with their urine and come back in 15 min with a diagnosis feel gooood.

I think ancillary services also refers to social work (discharge planning for shelters, bus tokens, setting up social services) as well as patient transportation, and translators. Individually doing a little here and there isn't bad as a student, but it can build up as an intern with more patients/less time.

 

[tachycore]

I've had enough run-ins with the VA nurses for some of the patients I've taken care of. Giving metformin AFTER finding a blood glucose of 40? Seen a nurse do that. And she reported the blood glucose only because of the call house staff order. Have the course of an empyema set back because the nurse didn't turn off the tube feeds? That's happened, too, with the chest tube's vacuum trap overflowing with the junk. This was after the nurse decided to page cross-cover, for an O2 sat in the low 80's!

If you have a shortage of nurses, your more experienced ones will also be overworked (extending the burdened intern argument). Also, the ones you retain may have diminished quality. Many nurses and good ones that can catch things can make or break you as an intern, if my experience as a sub-I's any indication.

Plus, cross-covering can some times be insane in terms of busy-ness. Mumpu, have you cross-covered or done night float? It can be nerve-wracking while you're trying to wrap up your own patients, when you suddenly get paged about Mr. X going septic or Mrs. Y passing BRBPR. Or worse, you only know the little that the team signed out when the page comes. That's when you hope you have good ancillary staff to keep tabs on everyone else while you're taking care of these little emergencies.

For me, it's ultimately about making sure the patients get the best care possible, making sure they're covered at all time. That's where ancillary staff count. It's irresponsible of me to think I am an island unto myself in that regard.

 

[inositide]

ancillary services are very important for an intern and resident.

Do you want to spend all of your time doing blood draws and ekgs on your patients or actually doing some learning? As a student it might sound cool at first, but think about carrying your whatever number of patients as an intern and every morning losing an hour of sleep because you have to budget time to do your own blood draws or collect urine or whatever else you may need.

Imagine having to start peripheral IVs on all of your patients. See how much time is wasted? You could be sleeping, reading, thinking, learning, etc etc.

Do not underestimate the value of ancillary services.

 

[sienna]

I would agree with the above posters. I would encourage you as an intern to draw blood and start IV's occasionally so you don't lose those skills (the nurses will be more than happy to let you have a turn), but if you have several patients who are "crumping" it is invaluable to have good support staff who will do EKG's, transport patients, and do stat blood draws. That way you can spend time actually thinking about a differential for your patient.