Estoy corriendo.

I have discovered something while taking care of my COVID patients these past two weeks. As I have previously mentioned, the COVID patients I am taking care of are those whom have already survived the COVID storm and are in the long process of convalescence. As my colleagues continue to help those battling in the ICU, the step-down unit lends itself to a whole different front of discoveries and understandings stemming from the pandemic.

As a surgery resident in an academic medical center, one learns quickly about territory and the importance of respect of territorial boundaries. In other words, it boils down to who “owns” a patient. Is the patient a surgical patient? A medical patient? An ICU patient? And respect of those territorial boundaries involves respecting who owns the patient and makes the ultimate decisions concerning the patient. For example, vascular surgery is very frequently a consulting service on medical patients. In order to take a medical patient to the operating room “respect for the primary team” would consist of communicating the vascular plan with them and coordinating orders, etc so that the patient is appropriately pre-op’d and ready to go to the OR at the agreed upon time. Usually this consists of a chill exchange between surgery resident to medical resident… surgery resident: “hey, we are going to take patient Q to the OR tomorrow. Is it okay if I put in preop orders?”  medical resident: “sure, no problem.” Really quite painless, as long as the respect to the primary team is paid.

I have found that this ownership over COVID patients does not exist in its typical forms. Rather than a service… they are owned by the hospital. It was born out of necessity not choice. The surgical COVID team is perfect example of that.  We were the fifth team created by our hospital to manage COVID patients, not because COVID patients needed a surgeon, but because they just needed a doctor and a nurse and anyone willing and available was provided. The hospital mobilized its resources and owned its COVID admissions. Now the hospital is mobilizing again. ICU patients have been reassigned bed placement in effort to empty and close the makeshift ICUs that were created. As these patients are hospital owned rather than service owned, these movements have been administration-driven (rather than physician-driven) and the respect of territorial boundaries is non-existent. For example, I came into work the other night with a new patient name showing up on the board as pending arrival. My sign-out from my co-resident leaving for the day was that the patient was supposedly from a medical resident run ICU, and when he had reached out to them, they were unaware of any plan to transfer the patient and had no intention to create such a plan. I had wanted to leave the mystery of the new patient name at that… but alas, was wishful thinking.  Much time was spent on the phone being transferred among different people who didn’t know anything, but instead wanted to refer me to someone else. In the end, it was administration trying to consolidate patients, making more efficient use of space and personnel. Unfortunately, no one had actually communicated this plan with the patient’s current team, or future team (us), nor actually had the patient’s transfer approved. More time was then spent tracking down a physician who actually knew the patient and could sign the patient out to me allowing for a safe transfer.

I can’t say this form of hospital ownership is good or bad, as it was and is still needed to handle the COVID patients. It just lends itself to loss of individual ownership over patients when the Cardiologist works next to the Surgeon works next to the Anesthesiologist, none of them doing what they specialty trained to do.

Much Love and Prayers.