Interns on the Float caserooni #4

[sozme]

Case 4
Link to Case #3

SO these 2 little cases are derived from 2 real life examples. I will give you the scenarios, and then I'll tell you what the terns actually did. If it seems like there ain't lots of info, thats because there usually isn't.

Case 1 - 56 year old female in cardiac telemetry unit for ACS rule-out. Serial enzymes have been negative, as have serial ekgs. No telemetry events. Nurse calls intern at 0300 complaining that patients BP is 184/110. Other vitals normal. Nurse further reports the patient is asleep, so this is just the info coming from the auto-BP monitors that are running q3-4h or w/e. Patient is to have stress test in the early morning.

Case 2 - 71 year old man admitted for ACS rule-out. Same story as above. Serial enzymes negative, etc. Nurse calls because patient is complaining that he is short of breath. This is the 4th time this evening he has complained. PAtient had recently been taken off BiPAP. He has concomitant COPD (mild stage per PFTs 2 months ago) and takes inhalers as prescribed. His vitals are all normal.

Case 1 response - Intern woke up patient from sleep. Did neuro exam, which was essentially normal. Patient was pissed off being woken. Intern subsequently gave Vasotec and Clonidine. Outcome unknown.

Case 2 response - Intern went to room. Patient was bitching and moaning at the nurse about how they were not taking him seriously. SpO2 is 91% on 2 L/min LFNC. Other vitals essentially normal. Exam revealed nothing other than angry man able to speak in full sentences without SOB, no retractions/flaring, etc. Intern calls senior resident who comes in and finds same thing. They put him on BiPAP. CXR was ordered, which was unremarkable. Resident subsequently called RT, who comes up from the ICU bitching about being called for the same guy for the 4th time today. RT says she is going to put him on BiPAP regardless of what the resident says because she, "Can't keep being called every 2 minutes."

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[cbrons]

Case 4
Link to Case #3

SO these 2 little cases are derived from 2 real life examples. I will give you the scenarios, and then I'll tell you what the terns actually did. If it seems like there ain't lots of info, thats because there usually isn't.

Case 1 - 56 year old female in cardiac telemetry unit for ACS rule-out. Serial enzymes have been negative, as have serial ekgs. No telemetry events. Nurse calls intern at 0300 complaining that patients BP is 184/110. Other vitals normal. Nurse further reports the patient is asleep, so this is just the info coming from the auto-BP monitors that are running q3-4h or w/e. Patient is to have stress test in the early morning.

Case 2 - 71 year old man admitted for ACS rule-out. Same story as above. Serial enzymes negative, etc. Nurse calls because patient is complaining that he is short of breath. This is the 4th time this evening he has complained. PAtient had recently been taken off BiPAP. He has concomitant COPD (mild stage per PFTs 2 months ago) and takes inhalers as prescribed. His vitals are all normal.

Case 1 response - Intern woke up patient from sleep. Did neuro exam, which was essentially normal. Patient was pissed off being woken. Intern subsequently gave Vasotec and Clonidine. Outcome unknown.

Case 2 response - Intern went to room. Patient was bitching and moaning at the nurse about how they were not taking him seriously. SpO2 is 91% on 2 L/min LFNC. Other vitals essentially normal. Exam revealed nothing other than angry man able to speak in full sentences without SOB, no retractions/flaring, etc. Intern calls senior resident who comes in and finds same thing. They put him on BiPAP. CXR was ordered, which was unremarkable. Resident subsequently called RT, who comes up from the ICU bitching about being called for the same guy for the 4th time today. RT says she is going to put him on BiPAP regardless of what the resident says because she, "Can't keep being called every 2 minutes."

1 - Is she in any pain? What is her baseline BP? What is the purpose of adminsitering those agents? I cannot think of many things that cause acute elevated BP during sleep in an asymptomatic patient (but arousable) with no neurologic symptoms other than some kind of sleep breathing disorder (OSA, etc.).

2- Is 91% his baseline at that flow rate? Different story if he went from 100 to 91 suddenly. So people can complain of SOB for a lot of reasons, and in the hospital acute dyspnea is more worrisome esp in someone like this with multiple risk factors. I suppose the first thing I would want to know is if (other than bitching) he has any obvious signs of respiratory distress. Tachypnea, cyanosis, brady/tachycardia, accessory muscle use, etc. Absent that, perhaps he is just early septicemia but I would expect him to have some of those same exam findings, perhaps +/- febrile hypotension. In the absence of obvious exam findings, I would probably still worry about things like PE, etc. The first thing I would do though is turn up the flow rate to 3 or 4, which supposedly gives you ~3 or so +% FiO2 per L/min and see if it improves him. I would think chest x-ray is appropriate. Does he have IVFs running? If euvolemic and no signs of sepsis, I would have them turned off. In my very limited experience people in their 70s with true septicemia are rarely vigorous enough to have normal vitals and fight with the nursing staff. One thing I also just thought about - perhaps this is some kind of manifestation of dementia (sun-downing) or delirium? Do you know if he has dementia? In these situations where you are a brand new physician expected to cover 50+ patients and come up with solutions quickly, it seems pretty easy to forget to check about these things, and from my observations, the nurses will not always tell you or even know themselves.

In the absence of any obvious respiratory distress, I think I would he still warrant a stat chest x-ray, ABG, BMP, CBC. That is just my inexperienced guess. The ABG would have to be compared to something probably, like maybe he has a baseline hypercapnia just from being a COPDer. But if that was essentially normal, I don't think he would warrant a CT angiogram. And certainly I think a detailed mental status exam and physical exam is warranted before those tests (the CTA, not the other stuff). I don't think going back on BiPAP immediately is necessary. But then you did say he was taken off BiPAP and then started complaining again. I know hypercapnia can make you dyspneic, but I would think you'd have some other perturbations in vital signs to accompany it.

I guess what I am saying is, it is hard to say what to do, and I am very interested in hearing what the real doctors have to say about these types of situations.

 

[TooMuchResearch]

Case 4
Link to Case #3

SO these 2 little cases are derived from 2 real life examples. I will give you the scenarios, and then I'll tell you what the terns actually did. If it seems like there ain't lots of info, thats because there usually isn't.

Case 1 - 56 year old female in cardiac telemetry unit for ACS rule-out. Serial enzymes have been negative, as have serial ekgs. No telemetry events. Nurse calls intern at 0300 complaining that patients BP is 184/110. Other vitals normal. Nurse further reports the patient is asleep, so this is just the info coming from the auto-BP monitors that are running q3-4h or w/e. Patient is to have stress test in the early morning.

Case 2 - 71 year old man admitted for ACS rule-out. Same story as above. Serial enzymes negative, etc. Nurse calls because patient is complaining that he is short of breath. This is the 4th time this evening he has complained. PAtient had recently been taken off BiPAP. He has concomitant COPD (mild stage per PFTs 2 months ago) and takes inhalers as prescribed. His vitals are all normal.

Case 1 response - Intern woke up patient from sleep. Did neuro exam, which was essentially normal. Patient was pissed off being woken. Intern subsequently gave Vasotec and Clonidine. Outcome unknown.

Case 2 response - Intern went to room. Patient was bitching and moaning at the nurse about how they were not taking him seriously. SpO2 is 91% on 2 L/min LFNC. Other vitals essentially normal. Exam revealed nothing other than angry man able to speak in full sentences without SOB, no retractions/flaring, etc. Intern calls senior resident who comes in and finds same thing. They put him on BiPAP. CXR was ordered, which was unremarkable. Resident subsequently called RT, who comes up from the ICU bitching about being called for the same guy for the 4th time today. RT says she is going to put him on BiPAP regardless of what the resident says because she, "Can't keep being called every 2 minutes."

1. Have the nurse get an actual blood pressure. Tell them you'll come see the patient. Then change nothing.

2. Give him prn albuterol. He'll feel like someone listened and will stop bothering the nurse. If this fails, put him on BPAP overnight for his combined copd/osa he probably has.

I'm not an upstairs doctor, though.

 

[lymphocyte]

Case 4
Link to Case #3

SO these 2 little cases are derived from 2 real life examples. I will give you the scenarios, and then I'll tell you what the terns actually did. If it seems like there ain't lots of info, thats because there usually isn't.

Case 1 - 56 year old female in cardiac telemetry unit for ACS rule-out. Serial enzymes have been negative, as have serial ekgs. No telemetry events. Nurse calls intern at 0300 complaining that patients BP is 184/110. Other vitals normal. Nurse further reports the patient is asleep, so this is just the info coming from the auto-BP monitors that are running q3-4h or w/e. Patient is to have stress test in the early morning.

Case 2 - 71 year old man admitted for ACS rule-out. Same story as above. Serial enzymes negative, etc. Nurse calls because patient is complaining that he is short of breath. This is the 4th time this evening he has complained. PAtient had recently been taken off BiPAP. He has concomitant COPD (mild stage per PFTs 2 months ago) and takes inhalers as prescribed. His vitals are all normal.

Case 1 response - Intern woke up patient from sleep. Did neuro exam, which was essentially normal. Patient was pissed off being woken. Intern subsequently gave Vasotec and Clonidine. Outcome unknown.

Case 2 response - Intern went to room. Patient was bitching and moaning at the nurse about how they were not taking him seriously. SpO2 is 91% on 2 L/min LFNC. Other vitals essentially normal. Exam revealed nothing other than angry man able to speak in full sentences without SOB, no retractions/flaring, etc. Intern calls senior resident who comes in and finds same thing. They put him on BiPAP. CXR was ordered, which was unremarkable. Resident subsequently called RT, who comes up from the ICU bitching about being called for the same guy for the 4th time today. RT says she is going to put him on BiPAP regardless of what the resident says because she, "Can't keep being called every 2 minutes."

1. I need to know baseline BP, current antihypertensives, the actual BP, a brief cardiopulmonary exam in addition to the neuro exam, repeat EKG, and a BUN/creatinine to rule out end-organ damage. But even hypertensive urgency is not necessarily benign, especially in the context of high CV risk factors in this ROMI. And a stress test isn't going to help with the BP. Agree with the management (but thiazide vs CCB vs ACE-i vs tinkering with current medications would take a little thought requiring some more background information).

2. I don't quite understand this case. "Nurse calls because patient is complaining that he is short of breath." Exam demonstrated a man "without SOB." Some part of the story needs clarifying. History and physical exam are always the first step, including a mental state exam (e.g delirium 2/2 hypercapnia or hypoxia from hypoxaemia or other causes.). Needs an ABG as the next step in management more than a CXR.

The mental component of COPD is incredibly important, because dyspnea and anxiety are cyclical. So even a tiny physiological insult can trigger a disproportionate amount of dyspnea. Intervene early and reassuringly was what I was taught.

We had a patient with 12% lung function who needed a Coude catheter for acute urinary retention after a failed Foley's. Not pleasant for him. Visibly anxious. Became diaphoretic, tachypneic, with clinically evident increased WOB. The supervising urology resident stepped in, cranked up the O2, held the guy's hand and told him to focus on his breathing (pursed lip, long expiration). It worked quite well. In obstructive type respiratory pathology, the expiration time is probably one of the most important management parameters (that's certainly true when they're on the vent), but people are physiologically inclined to increase their RR, which just worsens everything. Don't forget to turn down the O2 after.

 

[Doctor Bob]

Both of these situations revolve around one of the big learning issues of intern year; what do you do when someone tells you about a problem that you don't see as there.
Patient 1 has asymptomatic HTN according to a monitor; so what? How often do patients check their BP at 3am when they're at home? So what do you do when a nurse/tech/whatever asks you to deal with something that isn't actually a problem?
Patient 2 has no objective findings but complains about something you can't prove or disprove. You can't pull the trigger on a $10k workup every time a patient complains about something subjective in the setting of an otherwise baseline exam.
You'll hear a lot about the notion of "attending gestalt"; when there are two patients who look identical, have the same complaint, and yet the attending feels the need to do a bunch of workup on one. You ask why, and they can't really give you an answer that wouldn't be applicable to the other person. So you ask why didn't they do the workup on the other person. And they can't give you answer that wouldn't be applicable to the first. The reason is some little voice in their head, born of years of experience, tells them that something just doesn't seem right about one of them. They can't put their finger on a reason, but that nagging feeling is there.

Once you develop that feeling, listen to it. It's not always right, but it's right a lot more than it's wrong.

But what's of interest to me in these situations is something nobody has touched on yet.

RT says she is going to put him on BiPAP regardless of what the resident says because she, "Can't keep being called every 2 minutes."

Regardless of what the resident says, that's not ok. Even when the RT is right. If a nurse or RT or tech or otherwise disagrees with a resident, they can't just do whatever they feel is right. If there is a disagreement at your level, you involve your senior. If there is still disagreement, then you call the attending; it's their license and ultimately their decision.

 

[cbrons]

How often do patients check their BP at 3am when they're at home?

This should be the first thing I ask the nurse when she asks to give IV hydralazine for that auto BP check at midnight

 

[libertyyne]

Is there any change in pain for pt 1 ? Was an EKG performed after the BP readings? Can people sleep through an aortic dissection?
Not a doctor or a med student but I stayed in a Holiday inn last night.

 

[Psai]

So where's the part where you tell us what they did?
I don't know why you post these and do zero followup

 

[cbrons]

So where's the part where you tell us what they did?
I don't know why you post these and do zero followup

Its actually in the OP....

Sent from my SM-N910P using SDN mobile

 

[Psai]

Its actually in the OP....

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Hm you're right, I was expecting more for some reason

 

[libertyyne]

Its actually in the OP....

Sent from my SM-N910P using SDN mobile

Outcome unknown is very unsatisfying

 

[Crayola227]

Hm you're right, I was expecting more for some reason

Outcome unknown is very unsatisfying

Some of the other cases offered a lot more.
Not sure I'm loving the "real-life" scenarios,
just that I'm not sure the follow up of "Night float intern barely did anything and we don't know the outcome" is packed with learning points.

("every patient is a good learning case" I was chastised once by an attending early on, so I never say otherwise now)
(also to never bitch when someone takes time for an attempt at your medical education....)

I was gonna say all of the above, except that I caught @Doctor Bob managed to drop some bomb pearls (see what i did there?) despite the case follow up being unknown

This not only proved the two bits of "wisdom" I was taught, but is ironic because of course as an ED doc, he's able to look at a nightfloat case, and discern the learning points irrespective of outcome or follow up. The need for the ability to do this, is frequently necessary for both situations, and others as a physician.

Despite all of the above, burying the unsatisfying outcome still sucked balls even as it tickled them.