How would you handle this case?

[dotcb]

The reason why we admit sepsis, severe sepsis, and septic shock patients to the hospital is that they reliably do not do well with outpatient treatment. It's not safe.

It's true – some would do okay with aggressive oral hydration and an oral antibiotic, but a lot would not. And some would die. Some end up having viral illnesses, but this easily could've been systemic Shigella, C-diff, or something else.

The fact that the patient returned eight hours later, was still hypotensive, and got admitted for 3 days -supports general practice guidelines that we're discussing here.

There's just no reason an emergency provider should ever need or want to try to tune up and discharge a patient like this. There are too many unknowns in the initial presentation (including the discovered red flags), and they end up needing more prolonged care than can be provided in the Emergency Department.

In our role as triaging "sick" patients from "not sick" patients and resuscitating, this patient was both sick and needed resuscitation. It just doesn't make sense to say that a patient is both sick, needs resuscitation, and then I'm going to discharge them?

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[Arcan57]

Ok, there's been a lot of bandying of terms about with an imprecision that's bordering on embarrassing. Clarification #1: Extraordinarily unlikely pt was in septic shock based on definition of septic shock as defined by hypotension not responsive to adequate fluid bolus. Clarification #2: With the possible exception of the OP, no one on this board has any idea about whether he would fall into the "severe sepsis with elevated lactate" category for which EGDT was shown to be so effective. Please provide references for the 20% mortality rate in severe sepsis, as all I can find for recent data is on only ICU patients which are clearly a different subset of patients than was being described in the original post.

Let's look at the argument here: pt has unstable vital signs and could be catastrophically ill, he needed workup and admission. Some of the posters are committing the heresy of assuming that it would be possible to have a conversation with someone who had resolution of VS abnormalities and wanted to go home about shared decision making and likelihood of sudden cardiovascular collapse. To be clear, that's no where near what actually occurred with the patient were a nurse sent him into the wind without a repeat eval documented.

With respect to the poster that claimed that the purpose of SIRS was to keep us from inappropriately discharging patients, I would argue it's much more effective as a SCREENING tool for indicating who we need to hunt for badness on. If you've never discharged someone that at some point in their ED stay met SIRS criteria than you suck as a physician. If you've NEVER discharged someone who met severe sepsis criteria at some point in their ED stay then you're either really new to the game or have been beaten to the point that you've lost any faith in your clinical instincts.

Come at me bro.

 

[Birdstrike]

Ok, there's been a lot of bandying of terms about with an imprecision that's bordering on embarrassing. Clarification #1: Extraordinarily unlikely pt was in septic shock based on definition of septic shock as defined by hypotension not responsive to adequate fluid bolus. Clarification #2: With the possible exception of the OP, no one on this board has any idea about whether he would fall into the "severe sepsis with elevated lactate" category for which EGDT was shown to be so effective. Please provide references for the 20% mortality rate in severe sepsis, as all I can find for recent data is on only ICU patients which are clearly a different subset of patients than was being described in the original post.

Let's look at the argument here: pt has unstable vital signs and could be catastrophically ill, he needed workup and admission. Some of the posters are committing the heresy of assuming that it would be possible to have a conversation with someone who had resolution of VS abnormalities and wanted to go home about shared decision making and likelihood of sudden cardiovascular collapse. To be clear, that's no where near what actually occurred with the patient were a nurse sent him into the wind without a repeat eval documented.

With respect to the poster that claimed that the purpose of SIRS was to keep us from inappropriately discharging patients, I would argue it's much more effective as a SCREENING tool for indicating who we need to hunt for badness on. If you've never discharged someone that at some point in their ED stay met SIRS criteria than you suck as a physician. If you've NEVER discharged someone who met severe sepsis criteria at some point in their ED stay then you're either really new to the game or have been beaten to the point that you've lost any faith in your clinical instincts.

Come at me bro.

http://giphy.com/gifs/reaction-applause-clapping-KzTO9ClEsxQSA

 

[Janders]

http://giphy.com/gifs/reaction-applause-clapping-KzTO9ClEsxQSA

Amen.

Forget check boxes. We see these ALL THE TIME. The have norovirus, and have hypotension, tachycardia, and ARF. But their bellies are soft, the stool is watery/non-bloody, and they perk up immediately with 2LNS with full normalization of their vital signs. Using my clinical judgement, I do not initiate a code sepsis, triple-lumen, vanco/zosyn bomb upon then. I don't begrudge you if you do, but my clinical suspicion is very high for viral etiology.

Sure, most of these get admitted (they are OLD, they are INFIRM, they aren't taking PO well). They go to a tele bed.
Some of them I just keep in the ED for 6-8-10 hours. 4L NS, Zofran, enforced PO challenge, and repeat BMP to show renal function improving and electrolytes improving (Heck, I'll replete that K+).
Have I ever sent one straight home after 2L NSIVF? Probably not with a Cr >2.5 (that is normally 1) and an initial pressure that low. But via shared decision making, I think it could be REASONABLE.

 

[BuzzPhreed]

But via shared decision making, I think it could be REASONABLE.

My impression from my "hypothetical" conversation I had with this "hypothetical" patient ex post facto was that there as precisely -zero- shared decision making. And that might have been the biggest part of the problem.

Interesting discussion, though. He "hypothetically" continued to crap his brains out for at least the following 24 hours. Why they didn't "hypothetically" let him go home after admission Day 2 probably had to do with the fact that he announced he was a lawyer when he returned to ER a couple nights before.

I don't think he met the criteria for septic shock either. Not entirely wrong to err on the side of caution, though. Just my opinion as a gas passer. I've taken care of my fair share of abdominal catastrophes in the OR. First things first: resuscitate, and be certain your resuscitation has worked (or is working). Secondly, try to get a diagnosis while you're doing the first thing. I don't think that happened here.

 

[emergentmd]

I think we are all splitting hair. Keep it simple. If this patient presented 100 times. I would guess that

50% of the time he would have done well and you were right that it was all due to dehydration
40 % of the time he would have come back sicker and required a longer hospital stay and left the hospital back at baseline
5 % of the time he would have had a longer stay and had some chronic issue b/c of this,
5% he would have been found dead.

These are all made up numbers but you get the idea. Whoever cared for this patient would have alot of blood on his/her hands if they kept up this practice.

Bottom line. I don't care what the outcome was. It is poor medicine

 

[Rendar5]

Gotta chime in and agree with xaelia and bird strike.


... Sepsis has run amok and everyone has gone from too liberal 10-20 years ago to so conservative that they've lost the ability to clinically reason.
The guy had diarrhea. Really, diarrhea. That is it. Not HUS, not pancolitis, not septic shock. (And yes he meets severe sepsis just like someone with a kidney stone and a creatinine of 1.5 does) do they not even teach the concept of hypovolemia anymore? Do they now teach you that children dying in the 3rd world are dying from septic shock and not diarrhea? And that all those children need is 30cc/kg of fluid plus a lactic plus a central line plus an icu plus blood cultures plus an X-ray plus a urine culture plus vanco and zosyn.

Now does the guy need a night of iv fluids And a repeat set of basic labs in the am, sure. Maybe a dose of cipro or flagella while you're at it. Hypovolemia shock is much simpler physiologically than septic shock and doesn't need the kitchen sink


This is a youngish person with plenty of physiologic reserves. Save the overuse of labs and resources for the elderly, immunosuppressed and others without reserves.

 

[Rendar5]

Btw to the op,
The case was managed questionably by the first person, not the second. Your friend should probably be asking not to pay the first provider's charge, not the second one. Take rvu's from the person who screwed up, not the doc that did the right thing. And a complaint letter should be sent so whoever was involved gets educated.

 

[deleted109597]

Jesus. You people are the same people that make all of the flu patients instantly ESI 3 instead of the ESI 8 they should be (hyperbole for the slow).
Fever and tachycardia already gives you 2 SIRS criteria. Couple that with the cough, or runny nose, or whatever and they instantly have SEPSIS.
Forget that 75% of people with SIRS criteria don't even have bacterial infections (my patients are often tachypneic and tachycardic just from walking in from the parking lot).

So while this case looks from the outset as bad medicine, we really don't know much about it other than what the OP said. This is similar to everyone who second guesses the cellulitis patient that bounces back. We can't admit all of them. Pick the ones likely to do well as an outpatient and let them be outpatients.
ORT should be the practice for everyone. It's part of ACEP's choosing wisely.

 

[Boatswain2PA]

I agree with the training differences, in theory, but the differences in competence are irrelevant. The ideal midlevel/physician-extender/PA/NP (or whatever term you want to use) depended on the practice setting. In the CMG or employed ED setting, it is one who,

1-Does not increase your workload, and

2-Is 100% medical-legally independent (so you're 0% legally responsible) always.

Right now, as far as I'm concerned, the EM business model has pitted MDs and PAs against one another in an employed or CMG setting. Reason: working with a PA increases a doc's med-mal exposure, and realistically, any increased profit seen from the PA is likely to be skimmed by the employer and never given to the doc. In this set up, the PA is not the physicians assistant, the PA is the employer's assistant, by allowing them to profit off increased liability for the physician, with increased (or at best unchanged) case load at the same time. I'd much rather have an NP working independently without forcing me to co-sign or be liable for charts. At that point the responsibility of ensuring competence is not with the physician, it is with the employer and overseer of the midlevel, who is not the physician working side by side with them.

In a physician private-practice setting, however, a PA can actually function as a physician's "assistant" whereas he/she is selected, trained, hired/fired and employed by the physician(s) and practice. Any help or "assistance" is of benefit to the doctor, including decreased workload and increased collections.

****That's the whole thing that makes it worth the increased liability.*****

If, if, if.....

It's in a setting where any increased collections are funneled anywhere other than as a defined bonus to the doctor, or without a defined decreased in work load, then it's a net negative for a doctor to have a medical-legally dependent extender, regardless of how effective or competent they are. (In an ED setting, an extender will not ever in reality, decrease physician workload, since there's always an oversupply of patients in the waiting room and the work load is pre-set at a specific patients/provider/per hour; ie, any patient seen by the PA is not one less seen by the doctor, it just frees up the one behind them in line to be seen by the doc instead).

In the CMG or employed ED setting, the best mid-level is not the "best mid-level." It is a medical-legally independent one, regardless of any theoretical differences in training or knowledge base.

In a private practice setting, the best mid-level is precisely, whoever is the best midlevel.

This is something to keep in mind as ED practices shift away from SDGs to a more common CMG or employed model, where mid-level/physician ratios are pushed to increase employer profits, potentially to the detriment of the physician.

You bring up some great points, and points that have made me a little less vocal in my opposition about my profession seeking autonomy/independence. We have the nurses in one side pushing for their independence, and on the other side we have physicians who are gradually giving up their independence.

However your points ignore two important points.

#1 is what is best for our patients. I know, it sounds so idealistic, but we are supposed to remember that, right? PA education >>>>>>>> NP education (although, 5 years out, any difference in quality of provider is mostly due to personal drive and not a result of initial education), just like MD/DO education >>>>>>> PA education. If that isn't important for our patient outcomes, then why did you go to school for so long?

#2 your points are only valid in the environments you describe. Where I work, in rural America, the shifts I pull are shifts the local doc's don't have to work, so they can spend more time in clinic where they make their money. In rural America, the physicians are still in charge of medicine (for the most part). Furthermore, in some of the places I work I have more EM type training/experience than some of the FP/IM docs who I work "for". Lastly, none of the places I work could afford to pay a BE/BC EP to come and work there.

 

[deleted6669]

Agree with Boat above. a few issues. In democratic groups( I work for 2) the docs make huge bank off the PAs. the doc gets 50% of the RVUs on each chart they sign + 100% of their own, so a doc working with 2 PAs gets his base salary + 2x his base RVUs/hr (his own + 0.5 from each PA). in my situation it works out to > 30k of extra income/doc/yr. last time I checked. it's probably more now due to our vastly increased volumes. the docs also get to cherry pick more of the "fun" cases, leaving PAs more of the "scut" so the docs enjoy their working life more. not ever having to remove tampons left in for a week is worth something...some of our docs have not done an I+D in > 10 yrs. some almost never do pelvics at all. many probably don't even know where the slit lamp is as 100% of eye complaints get seen by the PAs.
also, as Boat mentioned, do you want a non-physician colleague who thinks "more like a doctor" and has more similar training or one who attended a part time program for 500 hours of clinicals?
My third job is at a very rural place that can't even afford 24/7 coverage with FP docs. they have one boarded em guy(the chief), a few moonlighting FP docs, and a bunch of very experienced em pas. when I was hired there (after applying every year for 10 years) I was the least experienced guy on staff with over 25 years working in the specialty. If they were mandated to have 24/7 doc coverage in the E.D. the hospital would close. the place is viable because they staff PAs 80% of the time.

 

[DeadInside]

Birdstrike's post was thoughtful and dead right. I fully support independent practice by any and all practitioners. I do not need nor want 50% or even 100% of someone else's RVUs. My kids are not starving. I do not want to do a half ass job of seeing any patients, even the "easy" ones. I am OK taking out hundred year old tampons and doing my own I&Ds. That's my job.

 

[goodoldalky]

Birdstrike's post was thoughtful and dead right. I fully support independent practice by any and all practitioners. I do not need nor want 50% or even 100% of someone else's RVUs. My kids are not starving. I do not want to do a half ass job of seeing any patients, even the "easy" ones. I am OK taking out hundred year old tampons and doing my own I&Ds. That's my job.

Interesting take, although I personally disagree. There are simply not near enough docs, so an alternative has to be used in some capacity. A good PA or NP can be great to work with. However, emergency medicine is very difficult to practice well, and the only folks who should be doing it independently went to medical school and residency. In my humble opinion.

 

[Birdstrike]

Interesting take, although I personally disagree. There are simply not near enough docs, so an alternative has to be used in some capacity. A good PA or NP can be great to work with. However, emergency medicine is very difficult to practice well, and the only folks who should be doing it independently went to medical school and residency. In my humble opinion.

So if "the only folks who should be doing it [practicing EM] independently went to medical school and residence" then do you want to be held medical-legally responsible for the work of those who didn't?

 

[e30ftw]

I think the ED is a good place for midlevel utilization. There are so many esi 4/5 charts that are straightforward and it's simply math that at some point it makes sense to hire a midlevel to help out with volume. just run numbers of ED volume/365/provider hours. Once volume gets to a certain point it makes sense to add coverage and for single coverage shops at ~18-22k it probably makes most sense to hire a midlevel.

My issue is the growing amount of EDs staffed by CMGs who run 24hr single MD coverage then have 40 hrs of midlevel coverage on top in a 40k ED. Docs sign 4-5 charts / hr taking liability but receive little to no income from the CMG. That's BS. I don't think you should ever have more midlevels than physicians working a shift and it's only fair for MDs to receive some of the RVUs since they take medicolegal risk AND supervise.

 

[deleted547339]

I think the ED is a good place for midlevel utilization. There are so many esi 4/5 charts that are straightforward and it's simply math that at some point it makes sense to hire a midlevel to help out with volume. just run numbers of ED volume/365/provider hours. Once volume gets to a certain point it makes sense to add coverage and for single coverage shops at ~18-22k it probably makes most sense to hire a midlevel.

My issue is the growing amount of EDs staffed by CMGs who run 24hr single MD coverage then have 40 hrs of midlevel coverage on top in a 40k ED. Docs sign 4-5 charts / hr taking liability but receive little to no income from the CMG. That's BS. I don't think you should ever have more midlevels than physicians working a shift and it's only fair for MDs to receive some of the RVUs since they take medicolegal risk AND supervise.

Yea, but how many level 4/5 have you seen that ended up being a train wreck that triage entirely missed???

 

[Birdstrike]

Yea, but how many level 4/5 have you seen that ended up being a train wreck that triage entirely missed???

I've seen many, many. Haven't you?

 

[deleted547339]

I've seen many, many. Haven't you?

Exactly. I was saying that something triaged as a level 4/5 cannot necessarily be handled by a midlevel exactly for that reason.

 

[Boatswain2PA]

Exactly. I was saying that something triaged as a level 4/5 cannot necessarily be handled by a midlevel exactly for that reason.

Yet, in many places, we take care of those level 4/5s, along with the codes, the florid CHFer, the severe uroseptic nursing home pt, the unstable A-fibber, the multi-victim MVA....and are held to the same standard of care that you are. Matter of fact, I've taken care of all of these patients within the past month all by my lonesome.

I'm not saying PAs = MDs. But don't insinuate that we can't safely practice emergency medicine, because we can. And we do.

 

[deleted6669]

Boat and I both practice at least part of the time as solo providers in critical access hospitals. This is not an entry level position by any means. At my critical access gig I have the least experience of any of the PAs on staff with 28 yrs practicing EM and I have only been there for 2 years.

 

[leviathan]

Interesting case. From an internal medicine point of view this is pretty much a slam-dunk admission or at least a consult for us to weigh in. I wouldn't send someone home with an acute kidney injury and a SIRS/sepsis picture without at least seeing an improvement after IV fluids and a presumed source. With that creatinine he could very well already have an ATN picture that is too late to respond to IV fluids. As always there may be factors about the case we aren't aware of that could change the whole picture.