Pooling for Patients

Since we’re a cardiac floor we have a large contingent of frequent flyer patients.  Most common are our CHFers and chest paineurs, along with the occasional COPDers.  Some of them are very nice folks, they’re respectful and pleasant, others just downright nasty.  You learn their quirks.

One guy who has “adopted” us as his new tune-up clinic is actually one of the nicer of our bunch.  He’s a CHFer who has very tenuous grasp on the idea of a low sodium diet, which invariably leads to his admission for fluid overload/CHF exacerbation.  We’ve tried really hard to teach him that eating at Wendy’s, eating bacon and movie theater popcorn is not the best elements of a low sodium diet, but it doesn’t seem to stick.  The last time he was in though we decided to have a little fun.  Looking back at his previous admission I looked to see what is BNP level was.  BNP, or brain natriuretic peptide is a protein secreted by the ventricles of the heart due to excess stretch brought on by fluid overload of the myocardium.  It’s a good indicator of the fluid status of a patient in acute decompensated heart failure.  We use it to determine how bad the failure may be.  It’s not always the best nor the most accurate, but it works pretty well.  If the level is under 100pg/ml it is considered normal.  Values above that show increasing levels of heart failure.  Our daignostics cut-off at 4500pg/ml, but at that point, the number really is maningless:  it’s high.

Looking to have some fun I announce, “OK, Larry is in the ED, I’m pretty sure he’s going to get admitted.  Anybody want in on a pool for his BNP level?  It’s a buck to buy in, the closest gets the pot.”

“Who?” asks Charlie, “Do I know him?” she continues.

“Yeah, he’s the one with the crush on Tanya.” I said.  Which wasn’t far from the truth, he’s a young guy and when he’s admitted and Tanya is on, he comes and hangs out by the nurses station.  He usually lives inthe 1500s range when he’s admitted.

“He’s the one who eats at Wendy’s right?  Put me down for 1850.”  Charlie says.

I put in for 1500.  No one else wanted in.  I think they kind of thought it was a bit weird that we were pooling on our patients.

Sure enough Larry comes up.  And his BNP?  1225pg/ml.  I won, being the closest, but I didn’t have the heart to take Charlie’s money.  Maybe next time.

Ebola in the Congo

AFP: Ebola epidemic kills nine in central DR Congo: report

Ebola fascinates me.  In fact most viral illnesses like this (especially the emerging infectious diseases) I find totally intriguing.  There is something near-beautiful about these guys. The simplicity.  The minimal code that makes up these natural predators.  Many folks freak out over Ebola thanks in part to Hollywood (remember Outbreak?), but the reality is that until Ebola goes airborne, standard universal (and contact) precautions can protect anyone in contact with patients infected with it.  Many people point to Ebola as a good biological weapon, but the reality is that smallpox is far more deadly and virulent, and there are many more stores of smallpox available, and in some cases (like the former Soviet Union) possibly unsecured.

My inner cynic says we are more likely to see an attack with smallpox, anthrax or other weaponized agent than Ebola.  But that’s just the pessimist talking.

It’s Never “Private”

Our EMR has a function where we can view the patients arrving inthe ED viewing chief complaint, time arrived, length of stay and the doc and nurse assigned.  Usually we view the board to look for possible admits, giving us the chance to make adjustments to staffing and sometimes rooming assignments inorder to be able to absorb a possible admission to the floor.  Call it thinking ahead.  We can see our frequent flyers arrive and which doc is on (Dr. Milion Dollar work-up then Admit or other docs).

Sometimes though, it is a source for entertainment.  I love seeing why people come to the ED.  It never ceases to amaze me why people decide at 3am to show up.  I’ve seen the usuals, abdominal pain, chest pain, nausea/vomiting/diarrhea, fever, back pain, suicidal/homicidal ideation.  Every now and then there are the ones you go, “WTF?’  Like sunburn, sick and spells.  But I saw a new one not too long ago that really piqued my interest.  All it said was, “Private.”

We were not so busy at the time that one popped up so our imaginations ran wild.  As you could assume the ribald variey was the most common. What most of us figured was that it was a stuck object or something similar.  We never did find out but it sure gave us a couple of laughs!

Dedication

A couple of nights ago we admitted one of our fine upstanding citizens after a fall on the ice.  He admitted to drinking 2 24oz.  beers to fortify himself for the trek to the local corner store to replenish his supplies while there was a lull between the snow and ice.  On admit to the ED he was lethargic, but woke on command and talked, albeit with slurred speech.  Not apparently that drunk and considering the large lump and laceration on his forehead, maybe he was still a little dazed.

They did the standard work-up as the sutured (poorly..) his laceration, including labs and a head CT.  The CT was negative for any acute process, but did show some atrophy.  Labs with one exception were relatively normal, kind of.

Any guesses what his ETOH level was?

A.  >10
B. 223
C.  499
D.  156

Not to mention issues with his ETOH level, he also had end-stage liver disease, status-post TIPS with esophageal varices and a history of seizure disorder.  Not exactly the most well-kempt of individuals mind you.  You could smell him in the hallway and he was far too lethargic to have him shower.  But back to his level.

If you guessed C., you would be correct.  Yep, 499.  Based on an online calculator, he would have had to drink 15 12oz. malt liquors in 1 hour to get a level that high.  2 big beers my ass.  He was dedicated.  Dedicated to destroying his young life.  And that was the kicker, he was only 38.  It’s sad and sick all at the same time.  The worst was that he had been doing this for many years to achieve the level of liver damage he was experiencing.  Unfortunately it seemed like the wasn’t going to stop and that the social safety nets in-place were either burned away or had completely failed.  And no matter what we as health care professionals did, he had continued to do this for years and probably wouldn’t stop until he ended up dead.  Which maybe was his ulterior motive in it all.  Now, when I crack open a beer I think about this case and realize how lucky I am.

Sun-upping

Anyone who has worked in the hospital or similar care facility has dealt with the syndrome we know as sundowning associated with Alzheimer’s.  Simply put, a relatively normal person with dementia starts to exhibit increasing confusion, agitation and other negative behaviors when the sun goes down.  I can’t even begin to count the number of times where I have gotten report and the off-going nurse says, “Oh they’ re such a sweet little old lady.  She’s a little confused at times but harmless.”

The sun goes down and that previously “sweet little old lady” turns into demon spawn.  Trying to impulsively climb out of bed, pulling at lines and tubes, telling us to “get out of my house you bastards”, and generally acting like a possessed person.  They can be draining to help and keep safe.  You spend more time in their room than anything else through the night.  Then they wake up after sleeping for awhile and have returned to the sweet little old person.

What really weirds me out is when the phenomenom is reversed.  Sometimes you get a patient whose circadian rhythm is totally swapped, they sleep all day and are awake and crazy all night.  Then you get the occasional one who is peaceful all night and then when the sun comes up, they start to go nuts.

We admitted a patient not too long ago with acute on chronic renal failure and hyperglycemia.  He was normal, if a little odd on admit.  Then right about 0630 he walks out of his room, fully dressed and looking for trouble.  Long story short, he gets combative and ends up face down in his room with cuffs on while being placed on a 2 MD hold (for being medically unstable and unable to make informed decisions).  Evidently he has a history of extreme paranoia and showed up the ED with a 9mm handgun, a can of Mace and a large multi-tool, and he looked ready to use anything he could get his hands on when he made a break for it.  He got some meds and ended up being very pleasant for the rest of the day and into the night.

But what happens at 0630 the very next morning?  The exact same thing.  He tears off his tele box and leads and starts swinging them around like a flail trying to brain anyone who comes close to him.  And the outcome is pretty much the same as well.  Face down and restrained getting meds on-board.  Then alter on in the day he returned to a normal dude.  But it was like clockwork , hell, you could probably have set your watch to it.  And he did it the next morning too.

Theoretically it was probably due to the meds that had stabilized him during the day wearing off and that was why he would flip out and sun-up, but it was kind of weird nonetheless.