Please elaborate. What makes it tough? Actually not being there to assess the situation yourself? Too many hospitals and patients? What?
1. Relying on other peoples skill set: You want a patient to get a central line with CVP monitoring and venous blood gas. "Oh, ED doc is busy and NP cant do CVLs. Is there something else you'd like." No, this septic patient with a history of cardiomyopathy needs a central line.
2. You dont know the staff the same way you know staff at your home institution. In this sense, they can be abusive. (Nurse)"Patient needs a fluid bolus." "Um, hi, this is Dr. Remy, why do you think this patient who i know absolutely nothing about needs a 'fluid bolus.'"
3. You are constantly witnessing and party to some less than average care. I have watched many many horrible intubations where my a$$hole was puckered from 1000 miles away. I have come on service to find patients on 10cc/kg TV + no PEEP.
4. In some instances, you do not get sign out. I have been alerted to many cases where there was a plan put in place by the daytime intensivist/hospitalist that, upon reviewing the chart, I did not agree with. Im not a genius nor the worlds smartest doctor. If i missed something, thats cool. But I would atleast like the opportunity to discuss the issue with the daytime provider.
5. Can have a set up where you are putting in trash orders all night. "Doc, can you reorder PO metoprolol, order fell off." I really dont enjoy doing that at 245am. Dont know about you guys
6. I have been put in situations where I have to have a goals of care discussion with patients families, again, from 1000 miles away. That feels icky. I dont like it.
7. This is just an aside, but I have seen a few instances where I camera into the room and the nurses are doing chest compressions. "Hi, this is Dr. Remy, how long have you been doing this, is there a doctor in the room?" "No, patient literally just came up from the ED." How in the F*ck do you send a patient from the ED so unstable that they literally code when they get into the ICU room. Thats unacceptable.
I think the idea of a central doc assisting in care is great. I think it would work for a particular health network where you know the staff. Not a situation where you are seeing patients from random hospitals across the country
OH, did I mention the EMRs. The E M Rs. the Log on passwords, tech support. It was never ending.
Very tough gig