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.

Hypotension Causing Nursing Hypertension

Hypotension Causes: Three Cases Of Severe Hypotension and Their Dramatic Response To Treatment.

I’m almost going to print this up and drop it in a couple of hospitalist’s mail boxes as they completely buggered their management of the hypotensive patient.
So here’s the story…
50-odd year old dude comes in with bilateral foot wounds, both medicine and podiatry are seeing him.  They start antibiotics and aggressive debridement of the said foot wounds.  To complicate matters, dude is “fluffy”.  Y’know, 400+ and we can’t tell if he is edematous or not.  It’s all fluff.  Instead of thinking sepsis, they’re thinking he needs to be diuresed.  Considering a history of CHF, not a bad idea.  But as he’s getting massive doses of IV Lasix, we’re talking drip rates in the 40mg/hour range here, his urine output starts to drop.  It dwindles, then nearly completely stops.  Bad sign, right?

As this is happening, his pressures are following the exact same path, dwindling down to nothing over nothing.  We’re talking 60/doppler and his pulse is dandy.   But here’s the thing:  he is completely alert and oriented, talking a mile a minute watching the Food Network.

This goes on for 4 days and 5 nights.  Yes, 5 fucking nights.  The nursing staff would call the the on-call staff, explain the situation and be rewarded with, “Oh, uh, turn off the Lasix.”  or “Uh, um…give him a 500ml bolus of NS.” The staff leave detailed notes in the progress notes about the situation so that they can be reviewed by the next day’s docs, but still nothing is done.  Maybe some more piddly-ass boluses that do a whole lot of nothing, but produce no net effect.

Finally on Day 5 (yes, Day 5) as his kidney function is truly in the shitter (creatinine is like 4.0), his ‘lytes are all wacky, his H/H is crap, he barely has any albumin, he hasn’t made urine in 4 days and has been getting goofy at night needing higher amounts of O2, someone decides to actually DO something.  2 units of packed cells, albumin q8, a couple of decent fluid boluses and dopamine.  Finally.

And as if by magic, he gets a blood pressure.  A real blood pressure, like 120’s/80’s.  He slowly starts to make urine.  His O2 need starts to go back to baseline and he’s no longer goofy.  Podiatry decides that now that he is stable it is time to do surgery to lop off the now gangrenous foot and get on with definitive care.

Here’s the thing:  we could have fixed him on night 1 had the on-call doc been willing to look and realize something was not right.  Could we have called a Rapid Response?  Yes, but he wasn’t truly in need of it.  He was relatively stable, with the exception of no blood pressure and no urine.  Besides, we figured that we could manage him on the floor without the ICU.

No one seemed to be cognizant of the fact he was in septic shock from those nasty feet of his.  That is until a prog note was written post-surgery that basically said, “acute on chronic renal failure and septic shock.”  Finally someone got it.