Or end the shift. Been there, done that, got the poster.
A code last week reminded me that the biggest problem with classroom ACLS is that it is too clean, too managed, too un-chaotic. Here’s a couple of recommendations to the AHA for inclusion in the next set of guidelines for ACLS curricula.
1. More people, smaller rooms. Codes almost never happen in big rooms, so you end up with 20-30 people cramming into a 10×10 (or smaller). I swear besides the code team, everyone else tends to show up. Housekeeping, dietary, looky-loo nursing staff with nothing better to do, extra docs not involved in the case, maybe a couple of pharmacists and an administrator. To best simulate that feeling of claustrophobia and having to work under such conditions, the schools hosting the classes should hire extras to crowd around you so there is barely enough room to work.
2. Auditory competition. It’s usually a cacophony of noise as people are barking orders, shouting back values, yelling at each other and general noise in a code. ACLS mock codes are just too quiet, like a quaint afternoon tea in the country. They’re full of thoughtful contemplation, “Hmmm…we gave Epi, CPR is in progress, let’s see what the next step should be.” Where usually it is, “What!!! Did you give EPi yet?!!!” and “GET ON THE CHEST!!!!” To solve this, using the extras mentioned above, have them loudly carry-on conversations to provide a sort of white noise effect and teach students to think with 10 different voices giving you information all at once.
3. Smell-o-vision. Think it through.
4. Realistic dummies that either poop, pee or vomit during the code. Ever done CPR while trying to keep your scrubs out of vomit? Yeah, it’s difficult, the hands slip off of their position as the gloves slide over the vomit on the chest so it’s kind of like hitting a moving target. Also, the training should incorporate identification of emesis into the H’s & T’s differential diagnosis. Maybe call it T-H-Es? We’re trying to look for a causative reason, ID’ing dinner might be a good start, it’s usually easily viewed. One of the extras could smear chocolate pudding on the dummy with each rhythm check to add that extra layer of realism. To make it better, the manufactures of the dummies could add an optional module that uses the force of the compressions and triggered by breaths to spew liquid material out of the dummy’s mouth.
5. Re-organize the algorithms by using a drunken dart toss for each step, say every 2 minutes. Many times the actions are just so random it is like that. This way by using the toss method, random changes to the procedure would be accounted for and awaited thus allowing practioners to think ahead. Besides, wouldn’t playing darts in ACLS be awesome?
6. Teach clean-up as part of post-recusitation care. We’ve all seen rooms after a code. Wrappers everywhere, boxes from meds strewn about, random pieces of detrisius tossed to the side of the bed, pieces for the intubation tray lodged in the computer keyboard, sharps hiding under piles of plastic and the puddles of body fluid. What should be taught is that everyone goes on break, leaving one person to clean up the mess. That job should be assigned with as much if not more importance than the compressors to ensure the rest of the team gets to take a break post-code.
If the AHA would consider incorporating these elements into ACLS training, it would make the providers so much more capable in handling the realities of the true in-hospital codes. Just sayin’.
editors note: your results may vary, data is compiled from triple-blinded, beer-goggled, non-placebo, peer un-reviewed observation of events on medical/telemetry/geri-psych nursing floors over a 5 year period of time.
You’re talking to the patient, carrying on a normal conversation whilst finishing some mundane task. Abruptly in the middle of a sentence they stop talking to you. You turn in time to see their eyes roll back in their head and them slump lifeless back into the bed. What goes through your mind?
First, denial: “Maybe they’re just messing with me.”
Sternal rub and nothing.
Second, more denial: “Oh Hell no, they better not be playing with me now. Wake the Hell up!”
Third, even more denial: “That was a twitch…ahhhh shiiiiit.”
Slam the head of the bed down, take one more attempt at noxious stimuli. Nothing, nada, zip.
Finally, acceptance: “Someone call a Code!!!!!”
All in less than 10 seconds, probably only 5. The longest 10 seconds of the night.
I know this has been discussed ad nauseam already, but I had to weigh in.
Thanks to an article out on Medpage Today, Rapid Response Teams Sign of Poor Bed Management, the whole idea of Rapid Response Teams has been brought into the spotlight. The article’s premise is that poor bed management is the cause for Rapid Responses to be called. Bullshit.
Code Blog sums it up nicely by saying,
I don’t believe RRTs are called because the patient was already in bad shape and assigned to a low level of care. I think they are called because stable patients just stop being stable sometimes.
Are there times where over-crowding and poor bed management are the cause? Yeah, if it is crazy busy, the nurse might miss subtle signs or the patient is sent to a floor of lesser acuity, but these are the exception rather than the rule. I can count on my hand the number of times I’ve called an RRT, of course now I’ve now jinxed myself, but each time it was from a rapid change in patient condition. There have been times where I could have called an RRT, but managed it with judicious use of critical thinking and calls to the doc. I think that some nurses use them as a crutch instead of critically thinking a situation through, but not because a patient was wrongly placed. Like I noted above, there are times when the patient is placed wrong. When our observation unit opened we had several times where they went from Obs to the Unit in a very short amount of time. But again, these we patients who rapidly de-compensated – and a couple that never should have gone there, but those are the exception.
Have the authors forgotten that a hospital is an acute setting? It’s not like these folks are healthy! And thanks to the rise of observation (outpatient in the hospital) those who are admitted in-patient are the sick of the sick. Having a resource to get help quickly is a godsend. Sometimes all you need is some stat meds, or imaging and labs , or just someone to look and say, “Yeah, they’re sick!” And sometimes you just need to have the ability to transfer to a higher level of care without jumping through hoops.
Even if we have the best patient flow possible, appropriate bed placement each and every time and proper resource management, there still would be a need to the Team. Patients crump. The article never addresses that simple fact. It’s far easier to point out structural issues than the reality – of course structural issues are somewhat easier to fix. Schedule better to make better use of the nurses you’re already overworking. Staffing plays an important role in this as well. A nurse that is stretched too thin can’t take the needed time to adequately assess their patients. When you 5, 6, 7 or more patients at a time, you’re running and even the most perceptive, mind-reading nurse can catch a patient decline if they’re stuck cleaning and doing a massive dressing change because the wound is saturated in stool of a 400lb quad with the 3 other nurses on the floor because it takes at least 4 to move the patient safely. That’s when the easy things to fix fall through the cracks, hence why we need a team to “rescue” the nurses.
It’s a complex multi-layered issue to which there are no simple and easy answers. It impacts staffing, scheduling, patient flow and the vagaries of the human condition. But would I choose to work somewhere without the back up of a RRT? Not easily.
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…
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By the time I got home the adrenaline was finally starting to wear off, the shakes trailing off. I don’t really remember the drive, it was an automatic drive home. I was aware, but detached as the images of what happened to my patient just minutes earlier kept running through my head. Those images were accompanied by the snippets of conversation, the shock and fear, the cool, clammy sweat sticky back of my t-shirt as it clung to my back. Numb, but not comfortably.
How quickly things can change with our patients. One moment you’re waking up not feeling well, but OK, waiting for surgery, the next you’re vomiting up copious amount of blood and huge chunks of clots. How strange it must be to not understand what happened because you went totally unresponsive right before you vomited. Did you hear your nurse yell out in fear “Can I get some help in here?! Someone call a Code!!!”
How odd it must be to open your eyes and see 15 people swarming your bed, frantic in their energy asking questions, asking you how you’re doing, sucking something out of your mouth. Do you feel it when you vagal out, go asystolic, vomit more blood and have someone start pumping on your chest? And when you ask, “Did I throw up?” the the nurses tells you that you did, but all you can worry about is that you might have lost control of your bowels. What goes through your mind when the nurse who has taken care of you for the last 2 nights is asking you to “Stay with me!” Do you know when your blood pressure is 60 palp? That you’re pale, diaphoretic and ashen?
Does riding in a bed moving like the furies are after it down the hall cause motion sickness? I’m guessing that the worried looks, the terse simple descriptive language the nurses and docs are using, the speech of people under pressure must worry you. Does your mind rebel at the unfairness of it all? Did realizing you had stomach cancer make you mad? You were a healthy guy. Sure you drank, but you sobered up years ago. Yeah, you smoked, but otherwise, healthy. No chronic medical conditions, just some elevated lipids. In fact your doc at your last yearly check-up said you were about the healthiest 80 year old he had seen in a long time. Or is the only thing you’re thinking about is your wife of 50 some odd years and whether you’re going to see her again?
I know that when you got to the ICU you vomited more blood and clot chunks. You looked incredibly pale, blood pressure barely registering. There was blood all over the floor, all over you, all over the bed. I wish you could see the cluster of docs outside your road, the 7 nurses around your bed, the cluster of medical knowledge all focused on saving you. I wish I could tell you that it was going to be OK, that we’re going to take care of this, but deep down I know I can’t. You’ve lost a lot of blood, it’s got to be close to 3 liters, blood and huge gelatinous chunks of clot, like something tore loose inside of you. But you were in the best place and I was in the way.
It was the fastest 30 minutes I can remember in a long time. The adrenaline was still surging as we brought the bed back upstairs but as I began talking to my colleagues the shakes started. I knew they would, was waiting for them. The shakes, the weakness in the knees, the self-doubt came crashing down, barely held back by an iron will. It’s odd how I can remember bits and pieces, little flurries, but not a seamless narrative of the whole thing. Maybe it’s a protective thing. I remember the looks on my co-workers faces, the awe, the respect, the one who said, “I want you in my code, you were so in control.” If they only knew.
If they knew that I spent the drive home going over every little bit of the previous 12 hours. Could I have done anything differently? Should I have checked your vitals at 4am instead of letting you sleep? You had been rock-solid stable all day, all night, no sign that anything was amiss. I know rationally that this was a quick thing, bright red blood spewing out is a rapid thing. The clots? Well the EGD pics were beyond nasty, huge masses of clot on the wall of the stomach. It is like something broke open. Still I wonder if there had been a sign early, if there was something I missed, or if it just came down to when you went unresponsive and started to vomit up blood. You should know though, that I went home, and even though I’m not a religious guy, said a prayer for you, knowing you needed all the help you could get.
I just looked down at my hands, the shakes are gone. Finally.
I looked up from my charting that night as an incessant stream of words kept drawing my attention.
“Mrs. Smith? Mrs. Smith? Can you hear me? C’mon open your eyes for me!” incessant pleading, repeating quicker, voice rising in timber and urgency.
I look over at tele, nothing ringing, nothing out of the ordinary. As I walk across the nurses station I see two colleagues at the bedside of one of our new admissions. Like a tag team they’re trying to get Mrs. Smith to respond. And it isn’t working. She is just laying there, limp, barely moving any breath into the shriveled shrunken chest. I start to get that sinking feeling in the pit of my stomach. Something is definitely not right.
“Hey, what’s going on?” I ask walking into the room. Looking around I see a manual BP cuff, fluids up and going, oxygen on, but no purposeful signs of life.
“She’s not responding to us.” says Not-so-New-Nurse (NsNN). She’s good, a little lacking in confidence in herself, but usually when she asks a question these days she already knows the answer, but is not yet confident to believe she has the correct answer.
“Merly was trying to get some vitals but the Dynamap isn’t reading so I came over from my patient in bed 2 to help her out.” she continued. “Now she’s not responding to us.”
I look around, Merly is nowhere to be found. Not surprising. It always seems that when her patients are going bad she finds reasons to step out. It’s “Oh I need this”, or “I went to call RT.” She’s been at this a long time and is a very competent nurse, she always seems to disappear at the worst times.
Outside the room another charge nurse and the house supervisor have come over. “Do you need anything? Want us to call the RRT?” they ask, worried looks directed my way. They both know my reputation as a black-cloud.
“Not quite yet, let’s see what’s going on.” I say.
I step up to the side of the bed, grab a frail limp wrist feeling for a pulse. It’s there, thready weak, fluttering away under my fingertips. “Mrs. Smith…” I say squeezing on her nailbeds. Normally I would be rubbing my knuckles along her sternum, but as I look I can count the ribs, I might snap them if I rub too hard. Mrs. Smith is a dictionary definition of cachectic, eyes sunken, skin a wan yellow almost waxy pallor, thin stringy hair, the look of someone who has not eaten much, if not anything in a long time. She had come in right before shift change with a diagnosis of hypokalemia and failure to thrive, or otherwise malnutrition.
As I’m thinking this through I’m inflating the manual cuff, fingers still on the radial artery. I watch as the dial creeps lower, lower, still not feeling the tell-tale pulse, then faintly it comes. 64 palp. Not a good thing. As I’m feeling I’m watching her chest rise and fall. Shallow halting breaths.
“I think it’s time, call an RRT will ya!” I holler out the door.
Merly’s back, dragging the Code Cart. “Tell me what’s been happening,” I say as the overhead page goes out, “Rapid Response 5NW.”
“I don’t know. I checked her at midnight and came back to check on her fluids and she wasn’t responding to me.” Merly says as the code team starts to fill the room. Furniture is disappearing out of the room as we make room for the extra bodies.
Fave ICU charge nurse is first in, “Hey Wanderer” she says. We’ve been through this before more times than I would like to count. I look around, Merly has disappeared once again. “Uh, 78 year old female, found unresponsive, BP 64 palp, pulse weak and thready, resps shallow…”
“Uh Wanderer, she’s agonal…” Fave ICU nurse says, “Call a Code!” she hollers out the room.
I look over, Mrs. Smith is surely agonal breathing. Erratic, shallow breaths separated by pauses that are far too long. I kick the brakes off and pull the bed away from the wall. Someone tosses me a BVM, I pull it out and crank the O2 up. I’m looking for RT as they are just slightly territorial, but no one’s here yet. Head tilt, good seal on the BVM while I start to bag, hearing the code page go out in the background. Now people are streaming in. It seems that with RRTs they don’t go balls out, they move fast, but not like when you call a code. RT arrives and offers to take over the airway which I gladly let them. I’ve seen RTs fight each other over managing an airway and I know they would just run me over so I leave it to them.
The ICU residents have arrived and not surprisingly, Merly is gone.
Once again no one steps up to talk, NsNN stands silently in the corner, fixing up IV fluids so I jump in. “Uh, yeah, 78 year old female, admitted toady with hypokalemia, failure-to-thrive, we found her unresponsive with a BP of 64 palp. She then began agonal breathing and we called a code.”
Mrs. Smith is just laying there, not even fighting the bagging. We get her on the code cart’s Lifepack, and the monitor comes up showing sinus tach in the 130s.
“Let’s get some labs, draw a rainbow. Anyone know what her K was on admit?” the resident starts giving orders. We’re lucky tonight, Dr. And actually wants to go into critical care and has her act together. “You guys think we need to tube her?” she asks the RTs bagging her.
“Yeah, she’s not even fighting us nor helping a bit.” one of them says.
“How about some fluids?” says the resident.
“NS up and wide open.” says NsNN.
“Y’all need to leave her alone!” I hear from the other side of the curtain. Then I realize that her neighbor has been adding her own commentary to the proceedings. “Hey NsNN, can you talk your patient down a bit?” I ask knowing that we’re only starting to rile up her demented roommate. The comments she has been making would be funny in any other situation, but not tonight.
“Do you guys want to tube her or should I?” asks Fave ED doc as he enters the room. “Go for it.” says Dr. And. Fave ED Doc grabs some gloves, tosses his stethoscope in the corner and starts talking to a freaked out looking guy in a short white coat that came with him. “Normally I would let you try, but not right now. I’ll show what we’re going to do though.” A visible wave of relief spreads across the poor guy’s face. Tubing someone is one thing, tubing some one in front of an audience of hundreds is another.
“Uh,” he says looking down, feeling the throat and jaw, “How about a #3 Mac and a 6.5 tube. Do we have drugs?”
“Yeah, here!” pipes up the pharmacist standing by the door, just on the edge of the chaos.
“OK, she’s what 50 kilos?”
“40, soaking wet.” I say.
“Right, let’s do 15 of etomidae and 40 of succs. Suction ready?”
I’m standing at the IV site, guarding it like it was the last beer in my cooler against a thirsty horde. The pharmacist hands me the bottles of meds and a couple of syringes.
“15 of etomidate, 40 of succs, right?” I ask, just to make sure. “Yeah.” comes the distracted reply. He’s face down with the scope looking into Mrs. Smith’s mouth. I glance over at Fave ICU Nurse and quietly ask, “Etomidate first, then succs, right?” I ask, then add, “It’s been awhile.” to qualify my question. She nods.
“Alright, every body ready?” Fave ED Doc asks. “Let’s do this.”
I push the first, “15 of etomidate in…” flush it wait a breath and push the next, “40 of succs in.”
A brief moment of action and then “Got it…someone want to listen?”
Fave ICU nurse and I, plus about 3 others start putting scopes on. “Equal bilaterally.” is consensus.
“Let’s get her packaged and downstairs to the Unit.” says Fave ICU nurse, “I’m going down to let them now we’re on the way.
Sometime during the preceding 5 minutes Merly showed back up, carrying a handful of supplies, fluids, tubes, IV miscellany. But at least she’s here. Since the start we’ve had about the same for blood pressure, in spite of the fluids . Her roommate is still muttering at us, telling us what to do and adding her own running commentary and answering questions along the way for her obtunded roommate.
Transferring a critical patient to the ICU is a exercise in logistics. We have an RT at the head of the bed breathing for her, trailing along is the residents, the IV pole, Merly and assorted other folks. And naturally the elevator that comes first is the small one. We fit. Barely.
We pull into the pod where she’s headed. This time I managed not to drive by feel getting the bed into the room. Thankfully Merly is here with us. One of the ICU nurses pulls her aside for report. We get Mrs. Smith over to her new bed. 40 kilos was a guess, but it was pretty damn close, she’s so light. I gather up the stuff that goes back with me upstairs and look over. They’re about to turn her onto her side to pull out the extra detritus under her and she pukes. She’s on her side quicker than one would think possible. “Suction!” someone yells. I get a glimpse of the vomit. It’s brown. It looks like poop. Then the smell hits me. It is poop. Really not good.
Knowing there is nothing else I can do I crib a page from Merly and disappear myself. NsNN and I are pushing the bed back upstairs, musing over what we just saw. “Merly and I are going to have a talk I think.” I say. “This isn’t the first time we’ve RRt’d or Coded one of her patients are she isn’t around.
“You did good though,” I say to NsNN. “It’s like I’ve been trying to tell you: you know what to do, you know the answer, but you just have to believe in yourself.”
“Thanks, I know, but it’s so easy when you’re around…” she says back.
Back on the floor I start relating what transpired on the way there. “That was fun wasn’t it?” I asked sarcastically. Then we all went back to what we were doing before. Because that’s how it is. We fix them enough for them to be someone else’s problem then go back to what we had been doing. It’s hard. You go over it in your mind, wondering what did we miss early on, did we do everything right, are they OK? And even though it wasn’t my patient I muse if it had been. She was where she needed to be.
I found out a week later when I came back to work that they took Mrs. Smith to emergent surgery the night we shipped her down. On opening her they found a belly full of poop and a perforated bowel. Evidently Mrs. Smith had undergone a gastric bypass-type surgery in the 70’s and they think her anastomosis had finally failed. With a belly full of poop she went into severe septic shock and came out of surgery maxed out on pressors while they searched for any family. Mrs. Smith had lived alone, we didn’t even know if she had family. Through some digging and a little bit of luck they were able to find some. She held on long enough for them to say it was OK to let her go. And then she was gone.
Or, “oh shit! That VT isn’t stopping!”
I’m walking into the nurses station the other night when I hear the “oh shit!” alarm ringing in the tele cave. Y’know the one, that incessant, high-pitched dinging that is saying “Pay attention!” Reflexes trained by my years on a tele floor I look up expecting to see someone bradying down, or maybe some nasty artifact, but instead I see this starting – and it’s not stopping!
A.) Start screaming like a little teeny-bopper freaking out and run in circles?
B.) Shit my pants?
C.) Drop what I’m doing and high-tail it to the room in question?
Believe it or not, C is the correct answer. Sphincter slams shut as I haul ass down the hall. I bust in the room expecting to find a dude laying there, unresponsive, not breathing or generally not doing well. Instead I see dude and his nurse clamly chatting. I breathlessly ask, “Were you shaking the leads?”
“No” she replies, “What’s up?
Dude looks up and says, “Is my heart racing again?”
“Uh, yeah, he’s in VT.” I say, amazed that he’s sitting there calmly chatting. “Do you feel funny or anything?”
“Yeah, my heart feels like it’s going pretty fast. But I’m used to it, it’s happened many times before, no big thing.” he replies nonchalantly, basically amused with the gaping look on my face.
So we hook him up to the bedside monitor, and sure enough, there it is VT, rate in the 150’s, BP is 100/53, he’s pink (ok, kind of yellow), warm and dry. No light-headedness, no dizziness, he does admit to a little bit of chest pain, but in reality he’s in better shape that half the floor, except that he’s in this particular rhythm.
Prehospital 12-Lead ECG has a great quote on their wide complex tachycardia page, “If it’s a wide complex rhythm (fast or slow) it’s ventricular until proven otherwise!” And that’s how we were treating it. So we grab some labs, call the ICU team to come assess him and a 12-lead EKG. Should we have called a Rapid Response? Maybe, but we felt we didn’t have to. He was stable. He has had this many times before. And he was sitting there cracking jokes with us.
So here’s the 12-lead:
So what to do now? The ACLS algorithm for tachycardia with pulses starts with determining if the patient is stable. Check. He’s cool. Establish IV access. PICC line left upper arm. Check. Wide or Narrow complex? Duh. Obtain 12-Lead EKG. Check. Expert consultation advised. Check, ICU team is here now. Amiodarone if ventricular tachycardia or unknown, adenosine if SVT with abberancy. Oh, wait…he has a history of WPW and 3 failed ablations. Now what?
This is where expert consultation is really a good idea. In our case, he’s now cracking jokes with the ICU team as well. He’s still rolling along between 145-160 BPM. We grab some labs. Turns out his potassium sucked, magnesium sucked and his calcium critically sucked. The Team decides that amiodarone would be a good idea and getting his electrolytes sorted out might help as well. So we’re hanging amio, mag and they’re calling cardiology. Mind you this is 2130 on a Friday night. Do you think a cardiologist is going to come in at that hour? Nope. She says, “Oh, just have one of the ED docs cardiovert him and call it good.”
He gets packaged and ready to roll to the ICU, ’cause by this time he was pretty much a 1:1 and the nurse had 3 other patients she was already neglecting. Grab the defib off the code cart, because with our combined luck (this nurse and I have a history of codes/RRTs) dude will decide to stop having a pulse once we’re between floors in the elevator.
The rest is rather boring. A little bolus of propofol (yeah, we MJ’d him good!) and the judicious application of 100 joules of DC electricity fixed him right good. One shock and back into sinus. But it was a good thing he was in the Unit as they spent all night getting his ‘lytes repleted.
What could have been a very bad thing ended up being a very, well, fun thing. Too often on our floor a busy night consists of incontinence, wrangling demented patients back into bed 30 times an hour or chasing naked psych patients down the hall, so dealing with a true cardiac issue was a rather refreshing change of pace.
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.