D
deleted52758
refused by our MICU. pH 6.95, HCO3:3, glu 600
amazing.
amazing.
I sincerely wish that the 'public' read posts like these. When I tell my friends and family about the crazyness that goes on, and how dangerous a lot of this is for patient care, they are absolutely shocked and amazed - and yet things like this are a regular, every day occurance. Not sure what public outrage would do, but some kind of reform has to come down the pipe... this is just a terrible way to run a system.
Both highly inappropriate, neither of which would fly if they were brought up for review. Work avoidance is dangerous. So is downplaying of how sick DKA patients can get, since they "see it all time".
I accept your assertion that this is not always about work avoidance. However in my ER I only have 22 beds. They're usually all full as is the hallway, the other hallway that's full of chairs, the fast track and the waiting room. I will usually have 3 to 5 EMS crews trying to offload patients to God knows where and 4 more inbound. That doesn't even address the helicopters. So I'm not real keen on keeping a patient who clearly needs to be admitted in the ER for a few more hours.I'd like to provide an IM perspective here, because I take issue with the presumption that refusing a patient like this in the MICU is due to "work avoidance." At Duke we only have 16 MICU beds and it's a totally closed unit. We quite often have 14-15 ventilated patients in various states of critical illness, many of whom are sick transplant patients or neutropenic cancer patients...
So we'll often request that the patient in the ED be given a few more hours of fluids and the insulin drip in the ED to make sure they're headed in the right direction before the patient comes to the wards...
Does this change your perspective on keeping these patients in the ED for longer periods of time? I'm curious to hear your thoughts.
I'd like to provide an IM perspective here, because I take issue with the presumption that refusing a patient like this in the MICU is due to "work avoidance." At Duke we only have 16 MICU beds and it's a totally closed unit. We quite often have 14-15 ventilated patients in various states of critical illness, many of whom are sick transplant patients or neutropenic cancer patients. In order to take someone with DKA we typically have to literally move a patient. Sometimes this is possible...the least sick patient can sometimes go to the SICU, neuro ICU, or CCU if they have a bed, but the MICU team would no longer manage them, and sometimes that affects quality of care just due to different levels of familiarity with the types of conditions treated in these different units. As such, the MICU residents and fellow will sometimes refuse to accept DKA patients even with a pH below 7.2, or 7.0, if we think it would be unsafe to transfer anyone out of the unit to make a bed for that person. Granted, if the patient with DKA is sicker than our least sick patient, we'll do everything we can to make the transfer, but this is usually not true. Clearly, this is NOT work avoidance. If anything, it makes more work for us to do what we think is the right thing, but from our perspective it has nothing to do with the length of time a patient is in the ED. Refusal to admit a patient is typically not about avoiding work, and it's unfair to assume this. In fact, more time in the ED for a patient like this is what we feel to be the best thing for the patient, but sometimes it means a 4-8hr stay down there, unfortunately.
Our medicine floors are practically step-down units in many senses...they'll run insulin drips and the like, so we can actually manage DKA quite well in most settings on the floor. So we'll often request that the patient in the ED be given a few more hours of fluids and the insulin drip in the ED to make sure they're headed in the right direction before the patient comes to the wards. This makes good sense, I think, if we don't have room in the ICU but we also don't want someone potentially unstable going to the floor. Frankly, the ED is much better equipped to provide both levels of care and transition between the two, whereas the floor staff would be grossly unprepared for an unstable patient. I agree, it's not optimal, but given how sick patients are these days and the growing bed shortage, this is what we're forced to do for the time being. With ever-increasing waiting room times though, I can certainly understand your frustration about patients being kept in the ED for this long. I'm just not sure what a safe alternative would be.
Has anyone else experienced this dilemma? Does this change your perspective on keeping these patients in the ED for longer periods of time? I'm curious to hear your thoughts.
docb makes an excellent point. Tying up beds in an ED is unacceptable. There are way too many patients in the waiting room to tie up a bed, and while we may make the one person needing an ICU admission better, we may make 2 patients septic by delaying their evaluation and thus tying up even more resources.I accept your assertion that this is not always about work avoidance. However in my ER I only have 22 beds. They're usually all full as is the hallway, the other hallway that's full of chairs, the fast track and the waiting room. I will usually have 3 to 5 EMS crews trying to offload patients to God knows where and 4 more inbound. That doesn't even address the helicopters. So I'm not real keen on keeping a patient who clearly needs to be admitted in the ER for a few more hours.
...one thing that DID happen (which maybe doesn't anymore) was, although the MICU was a closed unit, the MICU house staff and attendings would also manage patients in other, open units (neuro ICU and CCU, mostly, with SICU and CVICU not so much).
This dilemma comes up all the time for us, and can sometimes become rather difficult to navigate without upsetting our ED colleagues. I remember a recent situation whereby an ED patient was placed on 100% facemask in the setting of pneumonia with tachypnea and hypoxia, and the MICU was called for admission. But there was no blood gas drawn, and the patient's sat was 98% on the facemask. He looked great, and when the unit team requested a gas his pO2 came back at over 200! As it turns out, the guy was easily weanable down to 4L NC,
A PaO2 of 200 isn't very normal for being on a NRB. Under 300 you're suspecting acute lung injury. Around 200, you're approaching ARDS (without knowing anything else about the patient.) This isn't taking into account respiratory distress, hypoventilation, or concern for sepsis. Depending on the patient, I may advocate for ICU or stepdown care, despite his ability to "wean to a nasal cannula."
I'm not suggesting that pts can't change or that we don't need to learn to deal with a scarce resource, but I'm just reminding you not to live and die by a blood gas.
mike
refused by our MICU. pH 6.95, HCO3:3, glu 600
amazing.
Sorry Mike, but I have to disagree. A PaO2/FiO2 ratio less than 300 (or 200) suggests lung pathology. In order to diagnose ALI/ARDS you have to meet 3 criteria:
1) P/F ratio less than 300 (200 for ARDS)
2) Bilateral Pulmonary Infiltrates
3) No evidence of elevated Left Atrial Pressures
this was classically done w/ Swans--now done with Echo
this is a very interesting topic.
We frequently run into this problem at our hospital too, however........
I feel DKA is a little bit of an interesting thing though.
DKA seems to almost ALWAYS be directly discharged from the ICU the next morning. They get their insulin drip, bunch of fluids, their gap closes in 6-10 hours, they get their lantus and they go home.
This is literally how fast DKA can turn around. So, frequently i understand why ICU doesn't want to take DKA'ers because they so frequently turn around and they often "look" great (ie patient eating, watching tv, stable vitals), but their labs look awful.
So, I can understand the IM/critical care guys perspective.
Even the guys with pH (which I never check) that is super low, give 'em their fluids and insulin and it goes aways pretty readily.
Problem at my place is that they WILL NOT do insulin drips on the floor so they HAVE to go to the ICU. This is a system issue and will hopefully change in the future.
So, many times the lab criteria are met for DKA, but the patients look sooo well.
I don't know how sick the guy looked with a ph of 6.9, but my guess is that his pH didn't stay that low for long after being resuscitated.
later
???
Um, how are you disagreeing?
#1 a PaO2 of 200 is not good on a NRB
#2 Refer to the "without knowing anything else about the patient" comment
#3 I know the other criteria for ARDS, I am sorry I didn't type them out.
I would also refer to the general sentiment of my post... don't live and die by a blood gas (similar to the "But the PCO2 is 40!" argument when a person is profoundly tachypneic and looks like crap.)
I'd like to provide an IM perspective here, because I take issue with the presumption that refusing a patient like this in the MICU is due to "work avoidance." At Duke we only have 16 MICU beds and it's a totally closed unit. We quite often have 14-15 ventilated patients in various states of critical illness, many of whom are sick transplant patients or neutropenic cancer patients. In order to take someone with DKA we typically have to literally move a patient. Sometimes this is possible...the least sick patient can sometimes go to the SICU, neuro ICU, or CCU if they have a bed, but the MICU team would no longer manage them, and sometimes that affects quality of care just due to different levels of familiarity with the types of conditions treated in these different units. As such, the MICU residents and fellow will sometimes refuse to accept DKA patients even with a pH below 7.2, or 7.0, if we think it would be unsafe to transfer anyone out of the unit to make a bed for that person. Granted, if the patient with DKA is sicker than our least sick patient, we'll do everything we can to make the transfer, but this is usually not true. Clearly, this is NOT work avoidance. If anything, it makes more work for us to do what we think is the right thing, but from our perspective it has nothing to do with the length of time a patient is in the ED. Refusal to admit a patient is typically not about avoiding work, and it's unfair to assume this. In fact, more time in the ED for a patient like this is what we feel to be the best thing for the patient, but sometimes it means a 4-8hr stay down there, unfortunately.
Our medicine floors are practically step-down units in many senses...they'll run insulin drips and the like, so we can actually manage DKA quite well in most settings on the floor. So we'll often request that the patient in the ED be given a few more hours of fluids and the insulin drip in the ED to make sure they're headed in the right direction before the patient comes to the wards. This makes good sense, I think, if we don't have room in the ICU but we also don't want someone potentially unstable going to the floor. Frankly, the ED is much better equipped to provide both levels of care and transition between the two, whereas the floor staff would be grossly unprepared for an unstable patient. I agree, it's not optimal, but given how sick patients are these days and the growing bed shortage, this is what we're forced to do for the time being. With ever-increasing waiting room times though, I can certainly understand your frustration about patients being kept in the ED for this long. I'm just not sure what a safe alternative would be.
Has anyone else experienced this dilemma? Does this change your perspective on keeping these patients in the ED for longer periods of time? I'm curious to hear your thoughts.