Lessons on Patient Care Learned at Home

Ross Perko, MD
Published: Friday, Sep 28, 2012
I am a second-year pediatric oncology fellow at St. Jude Children’s Research Hospital in Memphis, Tennessee. So, I am far from an experienced care provider. I have been married to my wife, Rachel, a pediatric oncology nurse, for about 3 years. So I am also far from an experienced husband. But in this time, I have gained a new perspective from what she has taught me involving patient care and doctors’ interactions with nurses. This has also made me aware of the ways I can enhance the care I give pediatric oncology patients, as a fellow and in the future as an oncologist. I think some of these insights may help other fellows as well.

I met my wife when I was a pediatric intern and it was far from a scene in a medical television series. Rather, I was post call in mid-December trying to finish my progress notes, leave the hospital, and complete my Christmas shopping. Due to the high number of respiratory infections on our service, I was short on rest and would likely have been a hazard to others and myself on icy Minnesota roads if I had driven to the mall. She offered to give me a ride that evening and while driving and shopping, we soon realized we had much more in common than caring for children. We held similar interests in music, sports, and shared a love for running. One of our earliest dates (her idea) was a nationally televised college basketball game and takeout Chinese food; and it could not have been better!

A first-year oncology fellow is a newly minted, board-certified pediatric physician, capable of starting or joining a practice. For many, only days before beginning a fellowship, they might have been overseeing a complex pediatric inpatient service. Then the gears suddenly change and they are submerged again, in new patients, new diseases, new faculty, mid-level providers, nurses, and cafeteria food. As a fellow, the expectation is to know the most about every patient and then some. At times, the process of gaining this information takes place outside of the patient room, leaving less time for the interactions that we who care for children crave. Deeper relationships with patients and their families can get lost in learning how to correctly enter and then retrieve information from the computer medical record.

Rachel has pointed out to me many times that doctors are not always the best communicators. Shocking, I know. Thankfully, with computer order entry in most hospitals, far less time is spent interpreting handwriting now. Prior to meeting Rachel, I didn’t understand the difference between TID and Q8H and I don’t think I am alone when I admit I have no idea what volume of heparin is used to lock a central line. However, I also discovered that many nurses are unaware of the level of activity a resident or fellow is responsible for while they are on call, or with the current
duty hour system. In a profession in which 2 individuals work so critically together to ensure the health and safety of a shared patient, much of each other’s job is surprisingly poorly understood. Learning more about the other’s job not only improves the workplace, but also elevates the care we can all provide to our patients.

I had never heard of, or even thought of, “flushing” prior to meeting Rachel, but it is especially prevalent among teenage patients. I had assumed that what was recorded in the patient chart was the absolute truth. “Flushing” is when a patient forgets to tell their nurse when they void and the event is not recorded, which gives the appearance that the patient is fluid positive. For a resident or fellow, this can lead to unnecessary diuretic use and fluid mismanagement, especially when cross covering numerous patients overnight. To the patient, this might seem like a trivial thing that nurses ask them; however, it leads to improved decision making of the primary team when the correct information is understood.

I used to think doctors were the only ones with stressful jobs (trust me, that thought lasted only a few days). I never fully understood how busy a single patient could keep a nurse until I learned the steps that occur after a medication order has been entered. For the medication to have its proper effect, it might need a premed, a fluid bolus, specific urinalysis parameters prior to and during administration, and/or specific monitoring at 15-minute intervals. These steps have one thing in common: they all require a nurse to be present in the patient’s room.

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