Emergencies in Inpatient PMR

[pmr222b]

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Hi there I'm a third yr. med student hoping to apply for PMR next yr. Can anyone shed some light on the nature of inpatient PMR emergencies. Let's say a patient has acute renal failure or a COPD exac. do rehab docs treat the patient on the rehab floor and keep them there or are they stabilized on the rehab floor and then sent to the ER or internal medicine care. Has anyone seen anything crazy/stressful!
Thanks all,

 

[Disciple]

I've participated in codes on rehab floors, but for the most part, rehab units don't have monitored beds or the nursing staff to closely watch acutely ill patients.

Medical Directors generally frown on keeping acutely ill patients on the rehab unit.

 

[lobelsteve]

From 2001-2004 at a low end program, from parts unknown:

1. NSAID, Prednisone induced GI bleed. Able to transfer to ICU, died next day
2. Pericardial effusion/tamponade s/p CABG 1-2 weeks prior). Dx made by PMR resident (PGY3), it was a slow leak, but threatening to do pericardiocentesis in a CT surgeons patient (while still in his global period) gets things to happen fast. Surgeon on rehab floor in 5 minutes, patient in CT scan in 10 minutes, and drain placed by CT surgeon in Radiology in 20 minutes. Patient tx to CCU x 3 days then back to rehab. (CVA post CABG)
3. Admission GCS=8, Temp 103.5, no discharge summary or outside consultant notes with transfer.

MI's happen all the time- especially in AKA's with DM and severe PAD. Getting these vasculopaths up and walking is often too stressing for their heart (board question- how much cardiac demand increase from 1 AKA, how about 2?). Treatment: MONA, EKG, call IM and get them 23hr tele bed + restratify.

Just cause its PMR does not mean we didn't , don't still play doctor.

 

[SSdoc33]

automonic dysreflexia, PEs, MIs.

also, your 5th dump patient at 6 pm on a friday night. thats the worst emergency you can get....

 

[pmr222b]

Wow! So should I make my intern year as benign as possible as recommended by some or do a hardcore intern year.

 

[phoenix0610]

Wow! So should I make my intern year as benign as possible as recommended by some or do a hardcore intern year.

Dude, learn your medicine. I'm just a med student and I can tell you that. I rather become proficient and never use it than to be caught unprepared.

 

[JerseyTomato]

Wow! So should I make my intern year as benign as possible as recommended by some or do a hardcore intern year.

My experience in polling the residents who have done easy transitional years is that they feel just as prepared. I personally found a prelim program that is a happy medium...solid medicine that's not q4 call and a good number of elective months to balance things out.

 

[PMR 4 MSK]

Just know when it's an emergency and who to call. You miss a PE and the pt dies. You miss an MI, the pt dies. And residents do get sued.

Make friends with the IM guys - you help them with their problems, they help you with yours. Get and keep your ACLS certification - I ran several codes as a resident until the code team got there.

 

[fozzy40]

Had a patient go into adrenal crisis the morning after late afternoon admission. Our pharmacy was closed and no hydrocortisone to be found anywhere.

 

[Xardas]

Hi there I'm a third yr. med student hoping to apply for PMR next yr. Can anyone shed some light on the nature of inpatient PMR emergencies. Let's say a patient has acute renal failure or a COPD exac. do rehab docs treat the patient on the rehab floor and keep them there or are they stabilized on the rehab floor and then sent to the ER or internal medicine care. Has anyone seen anything crazy/stressful!
Thanks all,

Inpatient emergencies are fairly similar to what you'd see on med-surg units. You just get a lot less than a med-surg floor because you take patients that are more stable. Just about anything can and will be seen. But overall its not bad.

What I always teach is, know your medicine no matter what field you go into. It will come up time and time again. Failure to know your basic medicine will get you in trouble even if you do outpatient stuff..

 

[scifiMD]

Wow! So should I make my intern year as benign as possible as recommended by some or do a hardcore intern year.

I think that my intern year was the best of all worlds: 4 months medicine, 4 months surgical (trauma/ortho/neurosurg), 2 months neuro, 1 month rad, and 1 month peds. I won't tell you that living 4 months of q3 surgery call won't make you clinically depressed, but what it will do is teach you about medical emergencies AND surgical emergencies. You learn the lingo of both ends of the spectrum and that is a bonus come rehab time.

I guess what I'm saying is don't do a cake intern year. But maybe it's just b/c I'm jealous.

 

[Pontifex Maximus]

COPD exacerbations classify as emergency?

 

[ml2001]

COPD exacerbations classify as emergency?

Depends on how severe they are I guess. I'm in my intern year currently and have admitted way too many COPD exacerbations to ICU floor because Medicine attendings send these pts in anticipation of intubation even though intubation may not be the best possible option in them....

-ML

 

[PMR 4 MSK]

COPD exacerbations classify as emergency?

Work an ER and you'll see hundreds of them per month coming through, especially in this colder weather.

Remeber, part of COPD is often reversible airway Dx, i.e. asthma. Asthma can kill - we often don't give it the respect it deserves.

Can't breathe = can't participate in PT/OT/SP, D/C back to acute service.

 

[Pontifex Maximus]

Work an ER and you'll see hundreds of them per month coming through, especially in this colder weather.

Oh, I'm sure. But going to an ER doesn't exactly make it an emergency 😉

I just would classify it as a little less acute than say, the forementioned adrenal crisis.

 

[RuNnR]

This depends on your PMR program you match in and the services offered at various sites. And how good of a doctor you want to be.

Do you really want the nurse to call you w/ tachycardic pt, or short of breath, or hypoxic, ect and YOU do NOT know what to tell her? no. And you have to act fast.

I recommend an internal medicine year. YOU have to know it. You can do electives in ER and in surgery. I did 3 ICU months, 4 medicine, 1 ID, 1 ER, 1 ortho outpatient, and.....crap I forgot the other two.....hum.

ANYWAY, the BEST residents (efficient, effective, respected by all services) are the ones who did medicine and know it well. You know how to take care of patient at THAT instant.

What if you get called and your patient is unresponsive? know CPR, know the work up. SOMETIMES internal medicine or rapid response can't make it ASAP and that's what THE PATIENT NEEDS.

You will learn your level of comfort w/ various medicine issues but all inpatient rehab is medical.

Surgery? Well, surgery is internal, internal medicine. It's the SAME pathophysiology. You can do an elective. An as rehab you won't go the OR. You can learn post op care in a week on rotation. that's easy. AND each surgeon has their OWN restrictions, idea, knowledge, and what they want for the patient. Surgery is notorious for not dealing w/ medical issues well. the ICU MDs and IMs are called. This is the case everywehre from northwestern to hopkins. it's the basics of the training.

Our surgery only trained residents are not good at all & spend a lot of extra hours on the floor getting help from teh attneding and taking forever w/ the signouts. They aren't used to dealing w/ it. and that's ALL you do!

PM me w/ questions but i tell everyone to do an internal medicine year and learn as much as you can!!! you'll be great if you work hard and you'll start off rehab w/ a bang.

RuNnR

 

[BusterDouglasDO]

also, your 5th dump patient at 6 pm on a friday night. thats the worst emergency you can get....

Ha! so true...

...non-verbal, from outside, without a D/C summary or med list.

 

[2006MD]

Learn as much medicine as you can, I did this by admitting 10 patients or so q3nights while on my medicine rotation and then getting pimped about them the next morning w/o any sleep.

I'm glad to have amassed it during internship, b/c I've been slowly tapering my IM knowledge since starting residency...