How to deal with this....

[roja]

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I worked last night... First black cloud night in a while.

and I had a rare case that made me want to go put a heavily clod boot into someones torso. 😡

I still turn into this 😡 when I think about it. I realize there are political concerns etc, but I don't know if my concious will allow me to say NOTHING to someone in an upper level.

Last night I got a 60 something NH patient (baseline, axo3, self dresses, feeds, etc uses a wheel chair 2 to bka.) DM, HTN, mild cirrhosis but gets aroudn talks to faimly, etc...

Came in as AMS around 3:45 am with a documented BS of 26 at 3am by the NH. apparantly someone gave him glucagon at some point but that was it. (the nh is 5 min from our hospital). Once I slammed a cordis in and pushed several amps of D50, got him tubed and sedated, I went through the NH papers. On the chart, is documented: BS at 1am 17. BS at 1:45 26. Glucagon given. BS at 2:15- 22 BS at 3am 19.

This guy basically sat hypoglycemic and documented for 2.5 hours.

Of course, his daughter calls me and wants to know how he si doing and what happened. I hedged.

I don't really know how to adress this... Do I keep quiet and live with the guilt of doing nothing? of saying nothing? do I say something to the department chair? the PD? any suggestions? 😕 😕

 

[deleted87716]

I don't really know how to adress this...

My recommendation would be to discuss it with your attending, and let them handle it. If it was me, I'd get in touch with whoever is the medical director for the nursing home, and let him or her know what happened. Chances are, they'll have better luck making sure it doesn't happen again than you will. IMO, this sort of thing always works better attending-to-attending.

Hope this helps,
Kent

 

[mikecwru]

I worked last night... First black cloud night in a while.

and I had a rare case that made me want to go put a heavily clod boot into someones torso. 😡

I still turn into this 😡 when I think about it. I realize there are political concerns etc, but I don't know if my concious will allow me to say NOTHING to someone in an upper level.

Last night I got a 60 something NH patient (baseline, axo3, self dresses, feeds, etc uses a wheel chair 2 to bka.) DM, HTN, mild cirrhosis but gets aroudn talks to faimly, etc...

Came in as AMS around 3:45 am with a documented BS of 26 at 3am by the NH. apparantly someone gave him glucagon at some point but that was it. (the nh is 5 min from our hospital). Once I slammed a cordis in and pushed several amps of D50, got him tubed and sedated, I went through the NH papers. On the chart, is documented: BS at 1am 17. BS at 1:45 26. Glucagon given. BS at 2:15- 22 BS at 3am 19.

This guy basically sat hypoglycemic and documented for 2.5 hours.

Of course, his daughter calls me and wants to know how he si doing and what happened. I hedged.

I don't really know how to adress this... Do I keep quiet and live with the guilt of doing nothing? of saying nothing? do I say something to the department chair? the PD? any suggestions? 😕 😕

If it were me, I would speak to the department chair. Although assuming that the NH wasn't providing the best of care is not a very far reaching assumption, I wouldn't put myself between the family and the NH until I had a lot more information and had discussed it with the chair. The chair can appropriately investigate and defer to legal, etc.

Not that it matters particularly right now, but what was this guys major malfunction? Was he OD'd, worsening his liver function, or was he septic?


mike

 

[AlienHand]

You're right to be angry about this situation. While I do believe there are at least 2 sides to every story, I can think of no excuse for the NH to sit on severe hypoglycemia for over 2 hours.

For the safety of this patient (assuming he/she survives), the family should be informed. They might want to consider moving the patient elsewhere. For the safety of the other patients at the NH, the medical staff of the NH should also be informed so that they can make sure this sort of thing doesn't happen again.

Now, as far as how to go about raising the issue, I think you might talk with a trusted attending within your residency program and go from there. Be prepared to take matters into your own hands (talk to the family and/or NH directly) if you get a tepid response from those within your program.

 

[ERMudPhud]

I worked last night... First black cloud night in a while.

and I had a rare case that made me want to go put a heavily clod boot into someones torso. 😡

I still turn into this 😡 when I think about it. I realize there are political concerns etc, but I don't know if my concious will allow me to say NOTHING to someone in an upper level.

Last night I got a 60 something NH patient (baseline, axo3, self dresses, feeds, etc uses a wheel chair 2 to bka.) DM, HTN, mild cirrhosis but gets aroudn talks to faimly, etc...

Came in as AMS around 3:45 am with a documented BS of 26 at 3am by the NH. apparantly someone gave him glucagon at some point but that was it. (the nh is 5 min from our hospital). Once I slammed a cordis in and pushed several amps of D50, got him tubed and sedated, I went through the NH papers. On the chart, is documented: BS at 1am 17. BS at 1:45 26. Glucagon given. BS at 2:15- 22 BS at 3am 19.

This guy basically sat hypoglycemic and documented for 2.5 hours.

Of course, his daughter calls me and wants to know how he si doing and what happened. I hedged.

I don't really know how to adress this... Do I keep quiet and live with the guilt of doing nothing? of saying nothing? do I say something to the department chair? the PD? any suggestions? 😕 😕

Once again I'm reminded of the high quality of NYC nursing home care. I used to get patients all the time there that I swore had been rotting from the bottom up for days. I see much less gross neglect now.

I would tell your department chair that you think a report needs to be made to the state health deparment and that the NH needs to change its protocals for hypoglycemia


As a side note. Why did he need a cordis and intubation? Was he hypoglycemic from sepsis or something? Most of those guys seem to get better with a peripheral line and IV D50. Although it can take some time if they've been left with a glucose of 15 for most of the night.

 

[roja]

I think I will tell the dept chair. He is a great guy and I imagine will bring it to the appropriate people.

Never would I get in the middle of family and an issue like that. you are just begging for trouble to do that.. talk about suicide!

I am sure you could figure which home it is here in NYC... its quite known to us for its apathy and neglect.

As to the side: no peripheral. nada.. he had baseline anasarca, and was so clamped down. Intern was putting attempting to put a triple lumen on one side and having a hard time. Cordis was what was handed to me and all I wanted to do was get access and get D50 into him. After the D50 he was still unresponsive and not protecting his airway. had crap for lung sounds and was hypoxic if not being bagged. Probably aspirated (NH said ? brown emesis). Also, figured if he was septic, then could use EGDT so just wanted a line.

I think there was an OD on insulin.. but not sure.. he was on a sliding scale. His NH3 was elevated. No fever, lactate normal, bp normal so I don't think sepsis tipped him over. Possibly his NH3 but doesn't really explain his hypoglycemia.. other than the fact that it sat there for almost 3 hours...<i>very</i> healthy for the brain

 

[Flopotomist]

Pre-med lurker here, but just curious - are there laws requiring mandatory reporting of elder-abuse? Wouldn't neglect this eggregious be considered abuse? Just wondering.

 

[SoCuteMD]

Nope, the only mandatory reporting in New York State is children.

At least that's what I was told by a geriatrician. Hope she was right!

 

[mikecwru]

Of course, the other thing to think about, although less common, is some kind of adrenal crisis in addition to or instead of sepsis. It's nice to send a TSH/cortisol for our medicine friends to ruminate over.

mike

I think I will tell the dept chair. He is a great guy and I imagine will bring it to the appropriate people.

Never would I get in the middle of family and an issue like that. you are just begging for trouble to do that.. talk about suicide!

I am sure you could figure which home it is here in NYC... its quite known to us for its apathy and neglect.

As to the side: no peripheral. nada.. he had baseline anasarca, and was so clamped down. Intern was putting attempting to put a triple lumen on one side and having a hard time. Cordis was what was handed to me and all I wanted to do was get access and get D50 into him. After the D50 he was still unresponsive and not protecting his airway. had crap for lung sounds and was hypoxic if not being bagged. Probably aspirated (NH said ? brown emesis). Also, figured if he was septic, then could use EGDT so just wanted a line.

I think there was an OD on insulin.. but not sure.. he was on a sliding scale. His NH3 was elevated. No fever, lactate normal, bp normal so I don't think sepsis tipped him over. Possibly his NH3 but doesn't really explain his hypoglycemia.. other than the fact that it sat there for almost 3 hours...<i>very</i> healthy for the brain

 

[GeneralVeers]

Was he on any kind of oral hypoglycemics as well? They tend to produce prolonged hypoglycemia.

 

[VA Hopeful Dr]

Nope, the only mandatory reporting in New York State is children.

At least that's what I was told by a geriatrician. Hope she was right!

Its required to report elder abuse in SC

 

[Febrifuge]

<< Its required to report elder abuse in SC >>

The question remains, though, whether it's "abuse" as defined by the NY state law, assuming there is one. Incompetence? Neglect? Mmmaybe, but in situations like this the thing is to stick with the objective info, and put it in the context of the legal definitions.

Which is why attendings, chairs, and hospital admin folks are the right ones to do it, not so much the front-line providers. Roja, it sounds like you're doing it the right way, and I'm glad you're doing it.

 

[SoCuteMD]

<< Its required to report elder abuse in SC >>

The question remains, though, whether it's "abuse" as defined by the NY state law, assuming there is one. Incompetence? Neglect? Mmmaybe, but in situations like this the thing is to stick with the objective info, and put it in the context of the legal definitions.

Which is why attendings, chairs, and hospital admin folks are the right ones to do it, not so much the front-line providers. Roja, it sounds like you're doing it the right way, and I'm glad you're doing it.

It actually doesn't matter whether it is abuse or not in NY State, because it's not mandatory to report in NY. Only child abuse.

In any case, I agree with Roja's approach as well.

 

[southerndoc]

I don't really know how to adress this... Do I keep quiet and live with the guilt of doing nothing? of saying nothing? do I say something to the department chair? the PD? any suggestions? 😕 😕

In many states you do not have an option. You must report this. Even if it is medically negligent, it is still a form of elder abuse as well.

 

[southerndoc]

Brown emesis and elevated ammonia? Did he have a GI bleed?

 

[casi]

It seems strange that New York doesn't have mandatory reporting. Definately make a call to whomever handles abuse agianst vulnerable adults. I would consider this neglect.

Honestly when the family asks what happened. I would simply say "Our report from NH states:____________ and we did ____________"

http://www.ocfs.state.ny.us/main/psa/ <-- check this out for reportting