May I Take Your Order?

This morning I wrote a routine order in a patient's chart and suddenly thought of the warm, pink beaches of Bermuda. No one observing me at the time could have guessed that as I leaned over the nurse's station I was actually loping down the sandy dunes once again, squinting at mirror images of green sea and sky. What triggered this incongruous memory was an exchange between a tropical reveler and a barman that I heard while perched on a stool in the hotel's oceanfront watering hole:

"I'd like a glass of water, please."

"Yes ma'am...here you are."

"There's no ice in this glass."

"You didn't ask for any."

Looking at the scribbled cursive I had just placed into the chart, I let slip a subtle grin, for I knew the instruction just written would likely be followed precisely - and likely lead to an unhappy patient. Just like the confused Bermudian mixologist, most caregivers carry out orders with the precision of a military color guard, and in my experience following every medical command to the letter can sometimes produce a noticeable knitting of the kindly practitioner's brow. The pen frequently fails to translate the actual intent of an order hatched within the tangles of a doctor's mind, therefore he will allow a certain degree of laxity in its completion, all for the sake of efficiency. He must, however, constantly be on guard during the final decoding of said order, for it takes little effort to bungle the master plan when multiple tests and treatments are being juggled simultaneously in the course of a patient's day.

As an example I offer the order that evoked the memory of the unloved glass of warm water. The patient in question was a woman whose pain was not relieved by the oral medication oxycodone. The order began as follows:

"Begin morphine sulfate patient-controlled analgesia pump with 4 mg dose", etc. This means the patient will now be able to give herself a shot of morphine by simply pressing a button at the bedside. Beneath that was the accompanying order to discontinue the ineffective pill.

This looks like a fabulous bit of doctoring, except for one small problem. It takes hours for the morphine sulfate pump to be delivered and started, but only a second for the nurse to say to the patient "I'm sorry, but your doctor stopped your pain pill. You'll have to wait for the pump."

Like a chess master scrutinizing the board before him, I pondered the chart until I realized I needed to plan a good three moves in advance in order to ensure that my patient didn't languish while the pharmacy mixed up his analgesic concoction. Therefore, the actual order was written as:

"Discontinue oxycodone after morphine sulfate pump is started."

Simple, isn't it? All one has to do to keep on top of medical orders is to visualize them being carried out and then ask, accompanied by a cartoonish shrug, "What could possibly go wrong?" By taking the time to answer this question, the doctor may prevent any bloopers or frustrating gaps in data collection from occurring. In fact, this trick has led to the appearance of other classic orders such as:

"CT scan of chest in A.M. - to be done after patient has been seen by doctor." (No one likes to round on an empty bed).

"Old records to floor - please send all records, not just most recent hospital stay." (This assures that last year's sojourn in the ICU will be remembered).

"Please check O2 saturation on room air - and record results in chart." (Res ipsa loquitor).

Since the care given in most hospitals is exemplary, these examples, rather than revealing any lapse in patient care, serve mainly to illustrate the intricate workings of the mind of the physician infatuated with obsessiveness. Still, as they say, orders are orders, and if a rather compulsive doctor regards his or her orders as meaningful as the Ten Commandments, all the better for the patient. Therefore let the words in the chart go forth with clarity and pithiness - let no mishap occur due to order befuddlement, or conjecture of the author's intention. Let every order be written as if it were to launch the king's fleet itself - and hopefully in the right direction.