Leukocytosis

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gutonc

gutonc

No Meat, No Treat
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The next resident who consults me from the ICU for an urgent bone marrow biopsy for persistent leukocytosis in a critically ill patient on high-dose steroids is getting kicked in the groin.

3 in 3 weeks. I expect this in July but c'mon.
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Check your pager, I got a guy with thrombocytopenia with your name all over it. ITP??
 
gutonc said:
The next resident who consults me from the ICU for an urgent bone marrow biopsy for persistent leukocytosis in a critically ill patient on high-dose steroids is getting kicked in the groin.

3 in 3 weeks. I expect this in July but c'mon.
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We have a 60yo male for 3rd ICU admission in a month with empyema in the chest and septic (previous 2 admissions were peri-anal abscess and groin abscess). Peripheral film was said to have left-shift but no blasts and blood count showed leukocytosis. Yes, he is on steroids too. Can I get a bone marrow please? Our I.D. guy is convinced this guy has underlying leukaemia.
 
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gutonc said:
The next resident who consults me from the ICU for an urgent bone marrow biopsy for persistent leukocytosis in a critically ill patient on high-dose steroids is getting kicked in the groin.

3 in 3 weeks. I expect this in July but c'mon.
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Don't worry that guy also has a troponin of 0.04. I'll meet you there.
 
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Instatewaiter said:
Don't worry that guy also has a troponin of 0.04. I'll meet you there.
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His hemoglobin is also down, and even though there is no evidence of GI bleeding, we all know the only cause of anemia is from GI blood loss.

Why dont you cath him, Ill do the EGD/colon, and Guton can do a bone marrow simultaneously.
 
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See...by the time you 2 get done dicking around with him, his WBC will be trending down and I'll get another page to the effect that they think he can go home and just follow up with me in clinic.
 
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gutonc said:
See...by the time you 2 get done dicking around with him, his WBC will be trending down and I'll get another page to the effect that they think he can go home and just follow up with me in clinic.
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Don't worry. I'll cause some pretty bad anemia with my RP bleed. They'll be reconsulting both of you.
 
Why dont you cath him, Ill do the EGD/colon, and Guton can do a bone marrow simultaneously.
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wait, GI offering to scope somebody clearly in ACS?! what world is this
 
GI: This patient is too unstable to scope. Stabilize and supportive care first.
Cards: Likely demand ischemia. Treat medically. Too unstable to cath.
Heme: Probably in DIC. Treat underlying cause.
ID: That central line you placed is a potential infection source, as is that foley, A-line, and ET tube. Please remove them.
Renal: No urine output. Could be FSGS. Need renal biopsy once you stabilize. Order these urine studies despite patient having no urine output. And when do you want those CRRT orders?
Endo: the sugars are running too high. You need to start a drip now.
Rheum: the high dose steroids will mask everything. Here are some labs you can check, they are send-outs and will take 4 weeks to come back.
Pathology: You're depleting our supply of prbc and platelets.
Palliative Care: Can I help? :help: :thinking:
 
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group_theory said:
GI: This patient is too unstable to scope. Stabilize and supportive care first.
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2AM:
[medicine intern] "Hey, GI? Yeah, we've got this guy down here that seems to be having a pretty brisk GI bleed. Could you come take a look at him and maybe scope?"
[GI] "Is he stable?"
IF YES: "Ok, since he's stable, then the scope can wait until the morning."
IF NO: "Ok, well we can't scope him if he's unstable, so get things calmed down and we'll scope in the morning."
 
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Is this also thread where we can talk about parking all of your procedural **** ups and 4th line chemotherapy neutropenics in the MICU, while someone else tries to keep them alive when you all go home and sleep?
 
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gutonc said:
Absolutely.
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Kirk-McCoy-TheNod.gif
 
We don't park our problem children in your unit until the weekend. We think dropping recommendations for ICU evaluation on all our admitted cirrhotics at around 4 on friday is basic strategy (like always splitting 8s and doubling on 11). They are all chronically critically ill and you have to take em. They usually dribble back out but you smart ICU doctors don't really need our help, so we'll pick em back up when they get back to the floor (aka Monday).
 
Sounds about right. Though, honestly, unless I'm slammed with hyper acute patients taking care of a liver dump isn't the end of the world - where I'm finishing my training, liver doesn't even have their own service (even though we do transplant), so I'm totally past any righteous indignation (no one cares).

When they get really annoying is when they need a whiff of pressor to keep their MAPs above 55, sometimes you can get them weaned with midodrine, but as long as anyone needs a bit of norepi, they sit, until they find some poor bastards willing to transplant them or they die.
 
Pull the levophed for hrs paper and see what they did (IV diuretics too!), then try to get us to explain why we just want the Levo without the lasix. The Midodrine data is terrible too.


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Gastrapathy said:
Why did someone with GI in his name like a post that involved a 2am phone call from an intern. Call me in the morning.


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When I was a fellow, we had a GI attending give us a GI bleed lecture....I **** you not, the lecture included highlights such as


Don't consult us without a legible h&p's on the chart
Consult us between the hours of 10a-2p, everything else can wait till the morning
Already have our consents done because yes....we will want to scope them
I know what the textbook says on IVs in GI bleed...but if we're going to scope, you should have a central line placed for us
There is really no reason EVER to do a scope in the middle of the night...we do it simply because we are a teaching program and the fellows need to take call
Remember, that h&p's better be legible,
If a bleed comes in at 2am I will want a bleeding scan, if that's positive, consult surgery at. 4 am after the test finally gets done....and then we will scope in the am....so don't forget the consent...
 
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