anything else

[100YardDash]

I apologize in advance for the long post.
Im an intern at a categorical PM&R program. I'm currently rotating at a private rehab hospital for the month. I have a patient who I admitted at the start of the month an 87 y/o F w/ PMH of CHF, COPD, DM, HTN, PVD, AS, mild dementia admitted for debility 2/2 pneumonia/CHF. Medicine is following pt too. She has a PEG tube due to oral dysphagia/anorexia although SLP cleared her for puree diet after VFSS so she consumes half her calories PO. She is on Lovenox. She started going south on Monday from UTI. Today in the afternoon after all my attendings left for the day, I got a page stating that she is complaining of sudden SOB which began suddenly during PT. When I went to see the patient, it's very obvious that she is tachypneic. She reports CP, but has a very low threshold for pain and always reports pain around her PEG site. Her O2 is 99% and she is tachy. Her lungs sound bad.. I order CXR, EKG (our lab does not run cardiac markers so if you want them, they have to send it to my univ. hospital down the street which takes 2 hrs!!). I page my upper level who is a 3rd year. My upper takes a look at her suggests she go to the nearby ER. I call my attending and he tells me to send her to the ER.
I'm an intern and going through the normal stages of feeling completely incompetent! Anything else I could/should have done/ordered? The private world is different and this hospital is small w/o an MRI and CT machine so has a low threshold for sending patients to the ER. I have done it three times this month (possible stroke and acute abdomen) and fortunately they were false alarms but of course this adds to my feelings of being totally incompetent whever the patient rolls back in the next day. Normal? Man that was a long post! sorry about that.

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[padresp]

You did fine. Sounds like everything worked out. Intern year, for PM&R residents, in my opinion, should be about the following:

- Learn what is sick and what isn't sick (develop an instinct)
- Learn when to call for help (e.g. your senior resident, attending, etc) if you're not sure. That's OK.
- Last, learn the basics of medicine (CHF, pain medications, delirium, chest pain, etc.)

That's about it. I feel like once you get those down, you can start learning the nuances. I didn't start to feel comfortable until well after my intern year, so don't let that get to you. You will make mistakes, just learn from them.

My personal opinion about your particular scenario is that you have a lady who is tachypneic with sudden-onset shortness of breath. When you looked at her, did you think "this might be a PE?" or "this might be an MI?" If you think it's a reasonable likelihood, then she needs to be in a better-monitored setting than a rehab hospital.

 

[Taus]

Without getting into all the mediciney specifics....

You are already on track to develop the key elements (IMO) that you need to get out of intern year when going into PM&R

-knowing when you are in over your head and when you need to get help
-knowing how emergent the need for help is (sick vs. not sick.... send to ED NOW vs. okay order tests/treatments/consults/etc)
-knowing the major medical differentials and first line workups/treatments

-some of the above are subtle things that just become easier and better able to recognize with time and experience

What's worse... sending someone out and having a false alarm or being wrong and having that patient crump or even die? You may catch flak for sending someone out unnecessarily (and sometimes rightly so)..... but it will pale it comparison to the world of **** you'll get for sitting on a crashing patient.

Welcome to inpatient rehab

 

[oreosandsake]

you send 3 sick looking people out, and they came back safely. "false alarm" no true harm, no foul.

you don't send the 4th one out, they have a massive PE, and pass away on the rehab unit while you are on guard.

(shudder)

 

[cbest]

First of all, don't feel bad about sending patients out if they get sick in acute rehab. Obviously, do your best in terms of prophylaxis and being thorough on rounds to hopefully catch things early if they do pop up. However, the large majority of pts in acute rehab can be pretty damn sick and are not easy to manage partly because they're complicated and partly because, as you mentioned, the facility may not be equipped to work up the acute issues in a timely fashion.

With regard to your pt and other pts you'll deal with during your inpatient rotations, read up on the SIRS criteria and sepsis. If they meet criteria, send their ass out ASAP because 1) sepsis should be treated in an ICU setting and 2) they can tank on you quickly. Based on your description, your lady sounded like crap and if she didn't turn the corner quickly, I would have sent her to the ED or back to the acute hospital setting in a jiffy.

So far in my PGY-2, I've had great stretches with weeks and weeks without a transfer and a couple weeks where I've sent multiple pts to various ICUs. For example, in one week I sent a lady to the CCU with new onset AFib and bilateral saddle PEs (all appropriate DVT PPX in place), a dude to the MICU for sepsis 2/2 PNA, and two to the neuroICU - vp shunt infection and status epileptics. I went through the charts over and over, poured over them with my attending, and went through them with a couple rehab residents and my buddy who is IM to see if I was missing stuff or if I'd screwed up. Nothing - just a really crappy week with some sick as hell pts.

Be conscientious, ask for help, and get the pt to the appropriate setting - you'll sleep better at night knowing you did what you felt was best for the pt!

 

[Gauss]

aspiration pneumonia, acute decompensated CHF, ARDS from worsening pneumonia....
with her AS & CHF I wouldn't be suprised if albuterol gave her chest pain
sick patients crash easily and there's nothing wrong with being safe and getting a higher level of care involved

 

[100YardDash]

That post might of came off wrong.. I don't feel bad for sending the patients one bit. Thanks for the advice. I guess what I should have asked was at what point did you really start to feel comfortable in residency? 2nd year?

 

[Taus]

That post might of came off wrong.. I don't feel bad for sending the patients one bit. Thanks for the advice. I guess what I should have asked was at what point did you really start to feel comfortable in residency? 2nd year?

Later in intern year after my ICU and ER rotations. Much more peace of mind with general floor issues after that.

 

[RUOkie]

That post might of came off wrong.. I don't feel bad for sending the patients one bit. Thanks for the advice. I guess what I should have asked was at what point did you really start to feel comfortable in residency? 2nd year?

I was comfortable with the sick/not sick assessment in my PGY3 year. After a LOT of mistakes.

But when someone is sick, I'm still not comfortable after 17yrs. But I now know what I don't know. And that is the most important thing to learn.

 

[Jitter Bug]

After completing my intern year, I felt really solid about sick/not sick. I didn't know a damn thing about rehab for another year or two...

When you think you know it all, and nothing catches you by suprise, and nothing fazes you, it's time to retire before you screw up big time and get sued.

 

[100YardDash]

Thanks for the replies. The patient ended being admitted for acute decompensated heart failure causing respiratory distress.

I actually started my ICU rotation this month and follow w/ medicine wards for the next 5 months. It's been 3 days in the ICU so far and the way things are going and how steep the learning curve is here at the ICU, Im sure Im going to feel that much more comfortable managing a patient like the one above. Appreciate all the input guys. Take care