Random Filler

Been working a lot with our EMR roll-out, trying valiantly to hold in “there!! right fucking there! that button right there!” from coming out of my mouth, but I did run across a couple of interesting things in the last couple of weeks.

Chief complaint: suicidal, constipation.  Which came first?  Maybe it was “I’m so constipated I want to kill myself.”  I don’t know.  Don’t want to know.  Don’t even want to go there.

Chief complaint: rectal pain.  On the same night as the World Naked Bike Ride.  Coincidence?  Maybe?

And bringing up the end, possibly the highest glucose reading I’ve seen: 1056mg/dl.  Patient noted he rarely checks his sugars as they’re always high.  Too bad the HgbA1c wasn’t back when I left.  That probably would have been a winner too!

Record Setting Month

I’m glad August is OVER!  What is normally a shit month in my life was a shit month at work too.  Low census, poor staffing, sick-ass train-wrecks and all the goodies of a urban tele floor.

But truly I’ve had some records shattered.  We see far out and funky lab values all the time, but these were some doozies this month.

And the Winners are:

HbgA1C:  14.6!  Also had a 13.9 as a runner-up.  Both patients with Type I diabetes, both young, one with OK support, one with none.  We worked the diabetic educator to the bone trying  to teach these young’uns to not end up destroying themselves.  For those playing along with the home game, <6 is good control for diabetics.  And when you translate that to eAG (estimated Average Glucose) you get 372mg/dl and 352mg/dl.  Bad mojo.

Worst Case of Thrush EVER:  Candidal Esophagitis, from the oropharynx to just above the lower esophageal sphincter.  And in a twist, the patient was not immuno-compromised.

Highest WBC in a non-cancer patient:  68.8.  Yes, 68,800!  And it had jumped from 48,000 less than 12 hours earlier.

Lactate:  10.8.  Of course what do I say?  “Last time I saw a lactate that high we were coding the patient.”  Sure enough the patient did expire (they had the nasty white count).  They were sick with a capital “F”.

Dumbest idea of the month:  dude comes in drunk and complaining of nausea and vomiting.  After being triaged he goes to the bathroom and pops a couple of poppers, promptly turns grayish-blue with  a pressure of 50 and a raging onset of methemoglobinemia.  At least he was in the ED when he did it.

Oh, and for two Fridays in a row, had rapid responses at shift change…a helluva’ way to start the shift!

I hope September is better…

Friday’s EKG Answer

I want some answers!!!

Well, we got ’em.  Last week I posted an EKG quizzer.  Funny looking 12-lead right?  Prolonged QT?  Dilaudid, Verapamil?  Remember?  No?  Go check the link to refresh your memory:  Friday 12-Lead.

Go ahead, I’ll wait.

Back yet?

OK, so we have signifcant QT prolongation.  Or do we?

Is it me or does that T-Wave look kind of funny?  Kinda’ looks a little flat-ish.

How about these two?

Hmm…I see a little bit of notching in the T-waves here.  Almost like this isn’t just the T-wave we’re looking at.  Maybe this will help a little bit:  the patient’s potassium level when drawn was *drum roll please* 1.9mEq/L.  Yes, 1.9mEq/L.  She had gotten some replacement during the days, but obviously it was not enough.

What we have here is actually a QU segment as the U-wave from the hypokalemia has merged into the normal T-wave.  More examples of this can be seen thanks to Google’s Book Search from Understanding Electrocardiography.  It notes that you start to see dominant U-waves that merge with the T-wave when serum levels of potassium below 3.omEq/L, most notable in leads V2-V6 (as shown above), with the U-waves actually becoming larger than the T-waves when the levels drop to around 1.0mEq/L.  Adverse events related to hypokalemia include AV blocks, torsades, V-Fib and cardiac arrest, which is not a surprise knowing how potassium works in the cardiac cycle.   Typical causes of hypokalemia include diuretic use, alcohol abuse, loss through the GI tract from vomiting or suction (think NG tube) and some antibiotics just to give short list.

Electrolyte imbalances are also relatively common with pancreatitis, especially when you have vomiting.  Our patient was pretty much past the vomiting stage having been NPO for 3 days.  Combine that with having NS going at 250ml/hr for the last 2 days and we were flushing her K+ out of the system.  Fluids were changed to add K and the rate was reduced.  She got several K+ riders during day shift as well.  Thankfully the on-call doc didn’t freak out and have us turn the dilaudid PCA off as that would have caused just a bit of a problem based on her usage.  Even better was we never had to talk to the EP doc.  Small things.

By the time I came back that night, her potassium was edging up to around 3.5 and her QT had normalized out to around 420ms.  We get so tuned in to hyperkalemia that sometimes we forget that hypokalemia is just as significant.  We were able to keep the potassium within normal for the rest of the stay and to no surprise, her QT intervals stayed normal and there was no recurrence of giant U-waves.

That’s your answer.

Observation Lovin’

Our observation unit is lovingly called the Hooper Annex (Hooper is our local detox unit) as not a day goes by that we don’t have at least 1 in with ETOH-related issues.  But we get dumped on, a lot.  Usually it’s because the docs can’t or won’t make up their mind and end up passing the buck.

Can’t figure out what to do with grandma, but there’s really nothing medically wrong with her?  Admit to obs.

Oh, you’re drunk and it’s cold outside?  Admit to obs.

Gastropareisis needing dilaudid?  Obs.

I know that an observation unit is a place to send the patient if they just a little too unsafe to send home, but not sick enough to be admitted.  And it can be a great thing.  Take for example uncomplicated chest pain.  No family history, no pain at rest, pain resolved PTA, but you’re male, age >50 and smoke.  OK, perfect obs admit.  Grab some serial enzymes, an EKG in the morning, maybe a stress test and off you go.  Or when your troponin I jumps to 5.0, we can start beta blockers, integrillin and call the cath lab.  Either way, we’ve done the right thing.

On the other hand you get a patient that needs a little IV antibiotics for an upper arm abscess.  The labs from their PCP are borderline icky, not enough to say definitively one way or the other if in-patient admission is warranted.  What to do?  Based on old labs, because why would we pull new ones, just plan to admit them to obs.  Then maybe grab a few new labs to direct therapy.

But if things had gone the right way, y’know like accurately triaging the patient, doing a complete workup before sending the patient out of the ED, like with labs and stuff, we wouldn’t be looking at this trainwreck patient rolling by the desk looking at each other going, “Uh, oh.”

If you had drawn labs first you would have been floored by the lactate of 2.2, the WBC >18, a H/H in the shitter, mult. 4+ accumulations of gram-positive baccili and cocci and gran-negative baccilli growing from the wound culture you just did the in ED or the raging case of rhabdomyolysis with a CPK of 96,000!  Yes, 96,000.

Luckily for you,we queried this lack of workup where you found all of these values.   We had a funny feeling, y’know that gut-level, spidey-sense feeling that this patient is not going to turn out well without a higher level of care.  Thankfully you ended up placing the patient in the ICU so they could run pressors and hang lots of lots of fluid on his septic self, instead of on observation where we would have had to rapid response them to get them to the unit as they crashed before our eyes.  Yeah, good call.

How Low Can You Go?

As nurses we see wacky, off and plain old disturbing lab values.  But I think I saw a new record the other day:

Hemoglobin 3.2 mg/dL, Hematocrit 13.2%

The freaky thing?  The patient was doing fine.  Alert, well, they only spoke Russian, but they were fighting us.  Vitals were great, pulse in the 80-90’s, BP 140/80.  Maybe a little pale, but otherwise OK.  And refusing blood transfusion.

Figure she had been brewing this for quite awhile and had been able to compensate quite well for it.  After being told in no uncertain terms that, “You will die without blood.” she consented and received 5 units.

A True Professional

Nation & World | Driver registered blood-alcohol level of 0.708 | Seattle Times Newspaper.

RAPID CITY, S.D. — South Dakota authorities say a woman found passed out in a stolen delivery van last month registered a blood-alcohol content of 0.708 percent, nearly nine times the legal limit and a possible record for the state.

Some people are professional sportsmen, others professional poker players, some though are professional drinkers.  To end up with a BAC of .708 you kind of have to be a professional drunk.  While it may be outrageous, you kind of have to respect the dedication this would take.  Not to mention the cost involved.

Strong work!

Quite Possibly a New Record

I’ve seen some stinky ABGs. Probably not as many as some seasoned RTs or ICU type folks, but have seen my share. But I think this tops my list of worst ABGs. And the ED was wondering why they were a wee bit altered…

pH: 7.20
pCO2: 164 (yes, 1-6-4)
pO2: 177 (10L face mask)
HCO3: 62
Base Excess: 29.3

Looks like they’ve been working on this for awhile though. I heard they were still talking…