interesting ethical delima

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opr8n

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so im curious how many of you would respond to the following ethical delima

An intern on the CT service has a very difficult patient she has been rounding on for 10 days since admission. It was a trauma nightmare with mult injuries admitted to the trauma service and in the ICU, vented, unconscious, ect. The pt has a transected aorta, but it is stable (ie held together by adventitia) The CT attending plans to operate in an elective fashion but each time before he plans to go to the OR, the something goes wroung, the pt becomes acidemic b/c of bad vent management, the pt aspirates, the trauma team places a trach without telling the CT team, so the surgery keeps getting delayed
Then one morning the chief trauma resident tells the CT intern to tell her CT attending that if they dost operate on the patient soon they will transfer the patient somewhere where the pt will be operated on . . something the CT attending probably wont want to hear.

What do you do???
Do ytou tell your CT attending?
Do you not?
Interesting delima for an intern :eek::eek:

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I would advise not getting in the middle of that argument. That's an issue that needs to be coordinated on an attending-attending level. At the least, the trauma chief resident might touch base with the CT fellow to see what they can do to coordinate.
 
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I would advise not getting in the middle of that argument. That's an issue that needs to be coordinated on an attending-attending level. At the least, the trauma chief resident might touch base with the CT fellow to see what they can do to coordinate.
no CT fellow or CT senior resident
only CT intern and CT attending
 
no CT fellow or CT senior resident
only CT intern and CT attending

The intern is the most senior resident on the CT service? Did the senior go on vacation or something? Do seniors not rotate through CT at your institution? :confused:

In any case, I think that doliver gave you good advice - just tell the trauma chief to have her attending call the CT attending, and let them work it out.
 
so im curious how many of you would respond to the following ethical delima

An intern on the CT service has a very difficult patient she has been rounding on for 10 days since admission. It was a trauma nightmare with mult injuries admitted to the trauma service and in the ICU, vented, unconscious, ect. The pt has a transected aorta, but it is stable (ie held together by adventitia) The CT attending plans to operate in an elective fashion but each time before he plans to go to the OR, the something goes wroung, the pt becomes acidemic b/c of bad vent management, the pt aspirates, the trauma team places a trach without telling the CT team, so the surgery keeps getting delayed
Then one morning the chief trauma resident tells the CT intern to tell her CT attending that if they dost operate on the patient soon they will transfer the patient somewhere where the pt will be operated on . . something the CT attending probably wont want to hear.

What do you do???
Do ytou tell your CT attending?
Do you not?
Interesting delima for an intern :eek::eek:

There is no "ethical" dilemma here. There are some management issues here that involve some learning points for the intern. First, as the resident on the consulting service of the patient (CT is the consulting service), you need to know the management plan for the patient period. This means that you speak with the attending and get the plan; you speak with the Trauma service and get the plan. If you were on the service that the patient is admitted to, you need to know the management plan and make sure it gets carried out. This is likely why the chief resident made the statement (a bit inappropriate) to the intern.

Second, you, the intern, do not get involved as a "go between" with the admitting service. If, you, the consulting service wants to make recommendations, you are free to do so but the managing team can either abide by those recommendations or ignore them. Since Trauma is the admitting service, they can transfer the patient if that is their desire. You need to know their plans as much as they need to know yours. One thing for certain, once that patient gets operated on by CT surgery, then intern becomes the managing resident.

Finally, the patient is the top concern and thus, both services need to do what is best for the patient. Keep this in mind as you fulfill your role as consultant or principal managing resident for this patient. What is best for the patient always involves good (and professional) communication between the admitting services and the consultants. As an intern, you can make sure that this happens on your side as much as possible.
 
so im curious how many of you would respond to the following ethical delima

An intern on the CT service has a very difficult patient she has been rounding on for 10 days since admission. It was a trauma nightmare with mult injuries admitted to the trauma service and in the ICU, vented, unconscious, ect. The pt has a transected aorta, but it is stable (ie held together by adventitia) The CT attending plans to operate in an elective fashion but each time before he plans to go to the OR, the something goes wroung, the pt becomes acidemic b/c of bad vent management, the pt aspirates, the trauma team places a trach without telling the CT team, so the surgery keeps getting delayed
Then one morning the chief trauma resident tells the CT intern to tell her CT attending that if they dost operate on the patient soon they will transfer the patient somewhere where the pt will be operated on . . something the CT attending probably wont want to hear.

What do you do???
Do ytou tell your CT attending?
Do you not?
Interesting delima for an intern :eek::eek:

There's a lot to this story that we don't know so it's hard to sound in on this "ethical d-i-l-e-m-m-a." Let me start by stating the assumptions that I made by reading your post.

1. You are marginally involved in this patient's care, and you've simply been "rounding on" the patient for 10 days.

2. You are feeling like your role in the patient's care is elective, yet you criticize the primary team's management, and are upset that they don't run routine surgeries such as a trach by you first.

3. You really don't know your patient very well, which is the main reason you are surprised by all of the routes his care is taking.

Let me follow up these relatively harsh assumptions by saying that most of it is probably not your fault.

1.As someone else mentioned, it's probably not appropriate for a CT service to have only an intern. This means to me that your role in patient care is designed to be limited by the service, and they probably spread you thin between lots of patients, where your main role is to round in the morning.

2. It sounds like communication in your residency is horrible, especially between the two described services.

Regardless, if you are the only resident on service, then it’s YOUR SERVICE, and it’s completely appropriate for the trauma resident to seek you out to discuss patient care, and then for you to relay that to your staff, even if it’s unpleasant.

In any case, I think that doliver gave you good advice - just tell the trauma chief to have her attending call the CT attending, and let them work it out.

That’s called “phoning it in” and is an overall crappy way to act as a resident. You can take a backseat role in your education, and spend five years deferring to your attending every time there is something difficult or unpleasant to do, or you can man up and take care of the problem.

I want to discuss this more with you, but I think it's better if I have my mommy call your mommy.

Trauma needs to man up.

It seems like the trauma team is the only one that is manning up.
 
Then one morning the chief trauma resident tells the CT intern to tell her CT attending that if they dost operate on the patient soon they will transfer the patient somewhere where the pt will be operated on . . something the CT attending probably wont want to hear.

Regardless, if you are the only resident on service, then it's YOUR SERVICE, and it's completely appropriate for the trauma resident to seek you out to discuss patient care, and then for you to relay that to your staff, even if it's unpleasant.

That's called "phoning it in" and is an overall crappy way to act as a resident. You can take a backseat role in your education, and spend five years deferring to your attending every time there is something difficult or unpleasant to do, or you can man up and take care of the problem.

I want to discuss this more with you, but I think it's better if I have my mommy call your mommy.

From the OP, it sounded like trauma is unhappy with the way CT is "handling" the patient's care - i.e. that CT was dragging its feet, and that's why the patient hadn't been taken back to the OR yet.

If you're just relaying messages about treatment plans, then yeah - you SHOULD tell the attending. But getting in the middle of a pissing match between two services? Is that really something that an intern ought to be doing? :confused:

Yeah - the CT attending might want to hear "Trauma isn't happy with us" from someone on his own service (the intern, in this case), but I still think that, mainly, it's an attending-attending conversation.
 
Let me start by saying that I OBSERVED this situation and it was kind of distressing to me, which is why i brought it up
There's a lot to this story that we don't know so it's hard to sound in on this "ethical d-i-l-e-m-m-a." .
thanks, i cant spell

Let me start by stating the assumptions that I made by reading your post.
1. You are marginally involved in this patient's care, and you've simply been "rounding on" the patient for 10 days.
2. You are feeling like your role in the patient's care is elective, yet you criticize the primary team's management, and are upset that they don't run routine surgeries such as a trach by you first.
3. You really don't know your patient very well, which is the main reason you are surprised by all of the routes his care is taking.
.
1. true, trauma is the primary team
2. its not criticism, for instance, the patient will need a double lumen tube for single lung ventillation during his operation for his aorta, which is not easy to place when the patient is already trached, it not that easy to switch out in that situation, plus you have created ANOTHER wound
3. not true, especially when it was the intern that discovered many of the problems that lead to the pts first 2 OR dates being cancelled

Regardless, if you are the only resident on service, then it’s YOUR SERVICE, and it’s completely appropriate for the trauma resident to seek you out to discuss patient care, and then for you to relay that to your staff, even if it’s unpleasant.
That’s called “phoning it in” and is an overall crappy way to act as a resident. You can take a backseat role in your education, and spend five years deferring to your attending every time there is something difficult or unpleasant to do, or you can man up and take care of the problem.
.
this is the dilemma
is it appropiate for the chief trauma resident to tell the only resident on the CT service to reley a message to her attending
and if that CT resident does that, and the the CT attending gets pissed, should the CT resident get blammed for starting the problem and bad communication?
 
Yeah - the CT attending might want to hear "Trauma isn't happy with us" from someone on his own service (the intern, in this case), but I still think that, mainly, it's an attending-attending conversation.
so here is the next new wrinkle

lets say the trauma attending dosent share the opinion of the chief trauma resident and dosent know the chief trauma resident said this to the CT intern???

interesting huh?
 
That's a crappy situation. Ultimately, the trauma attending needs to talk to the CT attending. Residents talk to residents. Attendings talk to attendings. That's how it works. The chief resident can talk to the CT attending, but it's inappropriate for them to expect an intern to take an active role in this kind of stuff.
 
That’s called “phoning it in” and is an overall crappy way to act as a resident. You can take a backseat role in your education, and spend five years deferring to your attending every time there is something difficult or unpleasant to do, or you can man up and take care of the problem.

I want to discuss this more with you, but I think it's better if I have my mommy call your mommy.
.

Coming from a PGY-2, I would have thought you'd be a little more savvy about residency hierarchy and politics. It's clear that this CTVS service is an attending driven service rather then a resident or fellow driven one.

Reality being what it is, "manning up" as an largely unsupervised intern is going to get you into situations where you can really get yourself in trouble. I'd be surprised if most interns are fluent enough in thoracic surgery or can can think far enough ahead to really take a leadership role in this patient's care. Your role in this should be a facilitator between the services and try to keep your head down for some of this tension between the 2 services.

It sounds like your trauma chief resident has already badly miscalculated with his care re. this trach issue and what's going to be required for repair of his transection. Remeber this episode as a teachable moment!
 
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there is a fine skill in managing people. i.e. communication of the appropriate information. in the appropriate tone. to the appropriate person.

it sounds as if these rules have been broken here.

i can only speculate what i would do as the junior here:

1. pass it on - "I have a feeling, Dr ____, the the trauma team is a little antsy to get pt ___ to the OR for definitive treatment. Surely, I agree with you that thus far issues X, Y, and Z have impeded that goal. However, I feel quite certain that they are eager to implement said goal in the most timely fashion - regardless of our convenience. And I begin to feel they are willing to go to any lengths to make sure said goal is accomplished"

2. i would then feel (at least marginally, depending upon the response of my attending) that any savy CT attending would realize what issues/tensions were at play and what potential fallout might happen from said tensions (i.e. transfer to another facility, service, attending, etc.)

it is not your job to spell out for them the subtleties of their field and the inherent factions within. however, a little reminder of these tensions might clarify things to the attending.

that said, it is really not your job to take on this role. this is something attendings should take up with attendings. but as we all realize, that is not always the case.

so i usually try to gently make the pending issues clear without involving MYSELF in those issues. harder in reality than fantasy. and not easy with everyone. either that, or keep your head down and your mouth shut. my two best tactics - employed depending upon the situation.
 
im curious if winged scaplua wanted to comment on this situation
i almost see you as the mother of the surgical forum
 
is it appropiate for the chief trauma resident to tell the only resident on the CT service to reley a message to her attending

I guess they could just tell the CT resident and let the CT resident do what she wants with that information. Most residents would relay the message to their attending, so the trauma chief may have just been providing a sign post for the intern, telling her what she should do with his treatment plan.

and if that CT resident does that, and the the CT attending gets pissed, should the CT resident get blammed for starting the problem and bad communication?
What would make you think the CT attending would get pissed at the CT resident? Maybe at the trauma resident, but the CT resident was just relaying a message. Sure, I've seen people take it after delivering messages, but that has nothing to do with your presented "ethical dilemma" (read: your case isn't specific to that kind of problem).
 
What would make you think the CT attending would get pissed at the CT resident? Maybe at the trauma resident, but the CT resident was just relaying a message. Sure, I've seen people take it after delivering messages, but that has nothing to do with your presented "ethical dilemma" (read: your case isn't specific to that kind of problem).
ok, let me be more specific, here is how it played out . .
cheif trauma resident told CT intern to tell CT attending
CT intern told CT attending
CT attending got pissed
CT attending went to Trauma attending
Trauma attending didnt know what chief trauma resident had said and didnt agree that was how the staff felt
Trauma attending went to Chief trauma resident for explanation
Chief Trauma resident got a talkn too
Chief Trauma resident didnt like it and thus made life hell for the CT intern
Thus the CT intern got caught in the middle of a very sticky pickle
 
cheif trauma resident told CT intern to tell CT attending
CT intern told CT attending
CT attending got pissed
CT attending went to Trauma attending
Trauma attending didnt know what chief trauma resident had said and didnt agree that was how the staff felt
Trauma attending went to Chief trauma resident for explanation
Chief Trauma resident got a talkn too
Chief Trauma resident didnt like it and thus made life hell for the CT intern
Thus the CT intern got caught in the middle of a very sticky pickle

That's just the trauma chief resident being s****y. Chances are, that individual is like that in most situations, not just this instance. Again, I don't think it has anything to do with an "ethical dilemma" as much as it does poor interpersonal skills on the part of the trauma chief resident.
 
And based on this story, this is one intern who needs to pick it up a little, since clearly he/she pays zero attention to what is happening with his own patients.
why do you say that?
 
So what would you suggest? Tell the Trauma Chief you refuse to pass on the message? Nod, then hide this information from your attending?

The correct thing to do is pass on the information you are given. This is done on a chain-of-command basis. You pass the information you receive to the next level in the hierarchy. In this case, the attending is the next level, so you pass on the information to him. That's not "getting in the middle of an argument", that's being a good intern by conveying all relevant information to your seniors.

Wait a minute.

Tired - I'm well aware that you're an intern, and that I am not. But based on what's been said in this thread, what good would it be to pass on the trauma chief's message to the CT attending? Particularly since, in this case, the trauma chief's comment is not even a reflection of what the trauma ATTENDING wants!

I can't imagine that that would be a fun conversation:

CT intern: So Trauma is angry that we're taking so long about getting this guy to the OR. They've said that they will transport him to another facility if we don't do something ASAP.
CT Attending: Oh, is that so?!? Is that what that trauma attending said to you?
CT intern: Well, no...that's what the trauma chief said. I...uh...I don't actually know what the trauma attending wants.
CT Attending: This didn't come from the trauma attending? You don't know what he thinks?

That just seems to be asking for a lot of trouble to be brought down on the head of that poor CT intern.

I mean, I agree - it WOULD seem prudent, as the CT intern, to tell your attending "Well, trauma may be changing their plans in regards to the management of Mr. Jones. The trauma attending will be in touch shortly to discuss it further." But that's different from saying, "The trauma chief says that they'll transfer the patient out to another facility because we haven't taken him to the OR yet....I haven't talked to the trauma attending, though."
 
CT intern: So Trauma is angry that we're taking so long about getting this guy to the OR. They've said that they will transport him to another facility if we don't do something ASAP.
CT Attending: Oh, is that so?!? Is that what that trauma attending said to you?
CT intern: Well, no...that's what the trauma chief said. I...uh...I don't actually know what the trauma attending wants.
CT Attending: This didn't come from the trauma attending? You don't know what he thinks?

Typically, the chief of a service will not be so bold/stupid as to tell other services their "plans" before s/he has run them by the attending, particularly when those plans involve telling another service what to do/major change in management. Trauma tends to be more of a resident-run service than other surgical services, so a lot of time other services don't actually talk with the trauma attendings and are safe in taking the chief's word. I honestly can't think of the last time one of my surgical attendings asked, "Really, is that what their attending says?" when a message was conveyed about the other service's plans, as (1) no resident will make a move like this without running it by their attending and (2) most attendings know this, recognize the heirarchy and figure the word of the chief represents the word of the attending. Basically, the trauma chief broke a cardinal rule of surgical training heirarchy. Just know that, when you are a surgical resident, you should be able to trust the word of a chief resident as that of his/her attending when dealing with other surgical services. Medicine residents, however, are a completely different story, particularly early in the year with the interns...:rolleyes:
 
Particularly since, in this case, the trauma chief's comment is not even a reflection of what the trauma ATTENDING wants!
the CT intern does not know this, see next post
 
Trauma tends to be more of a resident-run service than other surgical services, so a lot of time other services don't actually talk with the trauma attendings and are safe in taking the chief's word. (1) no resident will make a move like this without running it by their attending and (2) most attendings know this, recognize the heirarchy and figure the word of the chief represents the word of the attending. Basically, the trauma chief broke a cardinal rule of surgical training heirarchy. Just know that, when you are a surgical resident, you should be able to trust the word of a chief resident as that of his/her attending when dealing with other surgical services.
and i think this is the point of the whole argument
i agree
 
and i think this is the point of the whole argument
i agree

Right, but to be even remotely close to (what I would consider) an ethical dilemma, the intern would need to know, upfront, that the feelings of the chief resident did not reflect those of the attending. If she didn't know that, then there is no ethical dilemma. If she did know that, she could have engineered an attending tete-a-tete to figure out what the plan really was.

This all assumes you aren't saying the ethical dilemma was the chief making decision plans on his own without attending involvement. If so, you didn't do a very good job of framing that in your initial post.
 
(1) The intern is unaware when the primary team is planning to do procedures on the patient (trach)
.
lets be honest, trachs on the trauama service are not exactly planned procedures, they are commonly done either at the bedside or during traumas blocked OR time, which dosent have to post their cases evena day in advance
and if the decision is made more than a day in advance it should be noted in the pts daily progress note
like"we plan to trach tommorow"
which did not happen in this case

(2) The intern does not double-check the primary team's management of the patient (vent settings)

Just because you're the intern on the consultant team doesn't mean that you get to ignore the primary team's basic surgical management of the patient. As the OP makes clear, failure to know these basic facts about your patient can torpedo your own team's plans.

this is another thing, the intern on the CT service can have up to 20-30 pt ADMITTED to their service, with 10 or more consults, for the intern to take care of ALONE. Second, most consultants lay their plan down in their daily note and dont reround on the patient untill the next day. It is the PRIMARY teams job to properly manage the patient and optimize their care, not the consultant, especially when the pt is in the ICU and not admitted to the consultants service. Thats unreasonable to expct the intern to manage the vent when they are not on the primary team, that is certainly stepping over boundries. Its not about ignoring the other teams managemnet its just about not being there. The CT intern has many other pts to worry about, and still has to leave the hospital once in a while to beat the 80hours
 
this is another thing, the intern on the CT service can have up to 20-30 pt ADMITTED to their service, with 10 or more consults, for the intern to take care of ALONE. Second, most consultants lay their plan down in their daily note and dont reround on the patient untill the next day. It is the PRIMARY teams job to properly manage the patient and optimize their care, not the consultant, especially when the pt is in the ICU and not admitted to the consultants service. Thats unreasonable to expct the intern to manage the vent when they are not on the primary team, that is certainly stepping over boundries. Its not about ignoring the other teams managemnet its just about not being there. The CT intern has many other pts to worry about, and still has to leave the hospital once in a while to beat the 80hours

I don't think Tired was saying the consultant needs to manage every issue a patient has, but it is a good idea to talk with the primary service at least once a day (not via the chart) to find out the current plan. When I've been the consult resident, I've always made sure to talk with the medicine team taking care of the patient or someone on the surgical team (in preop holding/PACU, surgical floor, ICU, etc...) about the patients for whom we are jointly caring. There are always busy services, and I think the point Tired is trying to make is you shouldn't make excuses just because you have a lot of patients.
 
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