Night Float IM Intern - Episode 1

[Dr_Rogers_Neighborhood]

(Some of these scenarios are based on real midnight calls from floor nurses to first year internal medicine residents. Patient names and identifiers are completely fictional).

“Hi, I’m calling about Bobby Jones on E3 (medical observation floor). He is a 23 year old guy with no PMH who is in because of acute gastroenteritis. His heart rate has just gone up from 100 to 130 in the past 2 hours but he isn’t SOB or diaphoretic and the rhythm is NSR. He is asking for something to slow his heart rate down because it is making him anxious.”​

1. What is your immediate response over the phone (what other info do you want, what orders do you want to give, etc.).
2. Do you go see this patient?
3. Do you call your senior resident for guidance? (or: which element(s) in this encounter would make you consider calling your senior resident?)

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[RustBeltOnc]

(Some of these scenarios are based on real midnight calls from floor nurses to first year internal medicine residents. Patient names and identifiers are completely fictional).

“Hi, I’m calling about Bobby Jones on E3 (medical observation floor). He is a 23 year old guy with no PMH who is in because of acute gastroenteritis. His heart rate has just gone up from 100 to 130 in the past 2 hours but he isn’t SOB or diaphoretic and the rhythm is NSR. He is asking for something to slow his heart rate down because it is making him anxious.”​

1. What is your immediate response over the phone (what other info do you want, what orders do you want to give, etc.).
2. Do you go see this patient?
3. Do you call your senior resident for guidance? (or: which element(s) in this encounter would make you consider calling your senior resident?)

see the pt.

 

[Dr_Rogers_Neighborhood]

see the pt.

You go see him.

He is an anxious but non-toxic appearing 23 year old male. The second you come in the room, he immediately asks, "Am I gunna be ok? Why is my heart rate so high?"

EKG shows sinus tachycardia with no other acute abnormalities.

Vital signs all normal save for HR 110-130 while you are talking to him.

Progress note from 5 hours earlier says patient was seen by infectious disease who believes his diarrhea and vomiting due to viral illness and no antibiotics indicated.

Nurse: "Can you please do something? He keeps friggen hitting his call button and it is driving me crazy!"​

 

[quickfeet]

I want to play the game.

I might be in the wrong here, but I assume this individual is just having a panic attack. And so long as he is hemodynamically stable and there is nothing at all that indicates to me that he is septic, I would order 2mg lorazepam PO.

Not sure if there's something I am missing here.

 

[Siggy]

(Some of these scenarios are based on real midnight calls from floor nurses to first year internal medicine residents. Patient names and identifiers are completely fictional).

“Hi, I’m calling about Bobby Jones on E3 (medical observation floor). He is a 23 year old guy with no PMH who is in because of acute gastroenteritis. His heart rate has just gone up from 100 to 130 in the past 2 hours but he isn’t SOB or diaphoretic and the rhythm is NSR. He is asking for something to slow his heart rate down because it is making him anxious.”​

1. What is your immediate response over the phone (what other info do you want, what orders do you want to give, etc.).
2. Do you go see this patient?
3. Do you call your senior resident for guidance? (or: which element(s) in this encounter would make you consider calling your senior resident?)

1. What is his blood pressure? Can you get a full set of vital signs for me and I'll be up in a minute.

2. Yes.

3. It depends. Day 1 of internship? "Hey, Bob, just a quick heads up, bed ____ is admitted for gastro and is tachy, I'm going to see the patient and keep you updated."
Day 365? Not yet.

 

[Siggy]

You go see him.

He is an anxious but non-toxic appearing 23 year old male. The second you come in the room, he immediately asks, "Am I gunna be ok? Why is my heart rate so high?"

EKG shows sinus tachycardia with no other acute abnormalities.

Vital signs all normal save for HR 110-130 while you are talking to him.

Progress note from 5 hours earlier says patient was seen by infectious disease who believes his diarrhea and vomiting due to viral illness and no antibiotics indicated.

Nurse: "Can you please do something? He keeps friggen hitting his call button and it is driving me crazy!"​

"All normal" doesn't cut it. Any trends? Any prior episodes? What, exactly is his blood pressure? What is his past medical history? I&Os for the day? What are his labs? AKI? The things that takes less than a minute to look up on any decent EMR.

Assuming no chronic kidney disease (I don't care that he's 23, young people get sick too, just not nearly as often), a liter of LR or NS and recheck in 30 minutes. (day 1 intern checks in with senior. Day 365 intern does not).

As a side note, day 1 intern and day 365 intern are both interns. However, the capabilities of day 365 is drastically different than day 1.

 

[Dr_Rogers_Neighborhood]

"All normal" doesn't cut it. Any trends? Any prior episodes? What, exactly is his blood pressure? What is his past medical history? I&Os for the day? What are his labs? AKI? The things that takes less than a minute to look up on any decent EMR.

• Vital signs (8:00pm; 12:00am; 12:03am per your request for new ones)
  • BP 110/73; 112/68; 111/70
    
  • RR 13; 12; 14
  • Temp 101.3; 101.3; 100.7
  • HR 111; 107; 128
• I/O
  • Intake: 3,200 mL
  • Output: 2,800 mL
• Laboratory (from 5:00am this morning)
  • CBC with automated differential: within normal ranges
  • CMP: within normal ranges
• Best Physician Health System (BPHS) EMR ("Saga") shows only encounter for this patient being his admission by hospitalist service from E.D. yesterday AND one encounter from 8 months ago for a a single outpatient visit with BPHS Psychiatry Outpatient service for Obsessive Compulsive Disorder.
• Note from hospitalist from earlier in the day is just a pasted template with numerous spelling errors where words were inserted between template fields and no real narrative.
• Note from I.D. physician as previously described.
  
• Saga's "Synopsis" screen shows:
  • Medications
    • Paroxetine 40 mg - 1 PO QAM [Last given: 15 hrs ago]
      
    • Acetaminophen 325 mg - 2 PO Q6H PRN [Last given: 8 hrs ago]
  • Drips and Infusions
    • Current: None
    • History:
      
      • NaCl 0.90% infusion - 100 mL/hr [Completed: 22 hrs ago]
        
      • NaCl 0.90% infusion - 100 mL/hr [Completed: 5 hrs ago]
• Saga's "Problem List" shows:
  • Hospital Problems
    • Acute Gastroenteritis (principal hospital problem)
    • Febrile illness, undifferentiated
  • Non-hospital Problems
    • Anxiety
      
    • Obsessive Compulsive Disorder

 

[Siggy]

So we've got a guy which is, by definition, septic (pulse/temp = 2/4, source), only 400 mL positive since admission (and Os are always questionable outside of the cathed patient, but it is what it is), who probably has poor to no oral intake. Liter of solution of your choice (I'm going on an LR crusade), hair trigger for liter number 2. If the patient has abdominal pain, treat that. Assuming heart/lungs/abdomen exam has nothing special/new (let me know if it does), reeval after fluids.

...and for the med student, this is why you don't give sedative orders over the phone in these situations.

 

[cbrons]

So we've got a guy which is, by definition, septic (pulse/temp = 2/4, source), only 400 mL positive since admission (and Os are always questionable outside of the cathed patient, but it is what it is), who probably has poor to no oral intake. Liter of solution of your choice (I'm going on an LR crusade), hair trigger for liter number 2. If the patient has abdominal pain, treat that. Assuming heart/lungs/abdomen exam has nothing special/new (let me know if it does), reeval after fluids.

...and for the med student, this is why you don't give sedative orders over the phone in these situations.

Assuming that you took all the steps you already outlined, do you think it is reasonable to give him ativan anyway?

 

[Doctor4Life1769]

Are we sure it's just gastroenteritis? It very well could be, and it may not be.
I don't see physical exam findings in this thread. If there is, then let me know.

 

[Dr_Rogers_Neighborhood]

I don't see physical exam findings in this thread. If there is, then let me know.

Physical Exam (performed by you):

General appearance: alert, mild distress, non-toxic, cooperative, appears stated age
Head: normocephalic, without obvious abnormality, atraumatic
Eyes: conjunctivae/corneas clear. Pupils equal, round, reactive to light. Extraocular Movements intact.
Neck: supple, symmetrical, trachea midline, no adenopathy, no Jugular Venous Distention
Lungs: clear to auscultation bilaterally, normal to percussion bilaterally
Chest wall: no tenderness
Heart: accelerated rate, S1, S2 normal, no S3 or S4, no murmur, click, rub or gallop
Abdomen: normal findings: no scars, striae, dilated veins, rashes, or lesions, no organomegaly, no bruits heard, liver span normal to percussion, spleen non-palpable, abnormal findings: hyperactive bowel sounds
Extremities: normal, atraumatic, no cyanosis or edema
Neurologic: alert and oriented X3.
Mental status: alert, oriented, thought content appropriate.​

EKG (taken by nurse 30 seconds before you arrive at bedside):

Computer read-out: Sinus tachycardia, Unremarkable EKG

 

[gutonc]

Trollololololololol.

 

[medrest]

Sinus tax due to fever. Dehydration, anxiety, septic from ?infectious diarrhea contributing. Give IVF bills like 500ml NS. Tylenol to bring down temp. May need 0.5mg Ativan as he has psych history. Recheck vitals. This is what I would do. Always see a sick patient. Consider d-dimer to rule out PE.

 

[medrest]

bolus*

 

[PinkLithe]

D dimer useless here. It was only validated in the outpatient/ED setting. In someone with possible SIRS/early sepsis D dimer gonna be positive anyway, PE or not.

Basically,
1) Bolus IVF 500cc - 1 L.
2) Recheck vitals in 1-2 hours.
3) Tylenol for fever.
4) R/o other potential septic sources and do some bloodwork-- CXR, urinalysis, BC x 2, vBG, lactate. If still having diarrhea, consider repeating stool cultures/Norowalk/C diff toxin.
5) If clinically worsening, cover over night with broad spectrum antibiotics.
6) I'd hold off on the Ativan for now. Treat the medical issues first and if patient still anxious, baby doses. Explain this to patient so he doesn't irritate the nurses with frequent call bell ringing.

 

[Doctor4Life1769]

Ya I wouldn't give ativan

I'd just go ahead and give a 1L bolus
Agree with work up for infectious cause
Consider CT if focal abd symptoms
d dimer is pointless, just jump straight to CT-PE
Tylenol and motrin prn fever
procal

 

[engineeredout]

At this point, 1L bolus, CBC, BMP, lactate, acetaminophen for temp. With a benign abdominal exam except for hypo active bowel sounds I don't see the utility for imaging the abdomen at this time. If a CXR was not obtained thus far I would get one. UA if not already obtained as well.

Any recent abx use or exposure to hospitals (C. Diff risks?)

Definitely not giving benzos as mentioned above.

 

[Dr_Rogers_Neighborhood]

Ya I wouldn't give ativan

I'd just go ahead and give a 1L bolus
Agree with work up for infectious cause
Consider CT if focal abd symptoms
d dimer is pointless, just jump straight to CT-PE
Tylenol and motrin prn fever
procal

Note above -

Progress note from 5 hours earlier says patient was seen by infectious disease who believes his diarrhea and vomiting due to viral illness and no antibiotics indicated.

 

[Dr_Rogers_Neighborhood]

If a CXR was not obtained thus far I would get one. UA if not already obtained as well.

Urinalysis (done on admission):

You tell the patient you are going to send him for an x-ray. After 2 minutes of talking to the patient, you notice his HR has gradually decreased from the 130s to the 110s. He appears more calm and reassured.

You ask him:

Any recent abx use or exposure to hospitals (C. Diff risks?)

"No man, I ain't never stayed in the hospital one night my whole life and I only take that depression pill."​

When you tell him he is going for a chest x-ray, his HR again becomes elevated.

"Wait, why do I need that? Am I ok? Am I going to be ok? Is there something wrong with me? Why is my heart beating so fast?"
​

You notice the patient obsessively focused on his telemetry monitor.

 

[TraumaLlamaMD]

This patient clearly has a problem with anxiety, but a baseline rate of 110 when more relaxed is still too high for me to leave it be or throw Ativan at it. How's he look after the bolus?

 

[PinkLithe]

Did his HR come down because I was talking to him, or did it respond to the fluid bolus?

Either way, at this point I'm more reassured that he's got an anxiety-mediated tachycardia. I'd explain to the patient that his heart rate is intimately linked to his psychosomatic state and that being anxious will cause his heart rate to increase. So calm down, relax, we're around to rule out the big bad things, which you most likely don't have but we'll rule out anyway, give a touch of ativan +/- sleeping pill and say good night. Oh and I'd follow up on what I've ordered of course (CXR, bloodwork etc.)

With respect to the incidental elevated urobilinogen, I'd add in a hemolytic screen, liver enzymes + function tests for the morning bloodwork and have the team follow up on it.

This patient clearly has a problem with anxiety, but a baseline rate of 110 when more relaxed is still too high for me to leave it be or throw Ativan at it. How's he look after the bolus?

But he's still anxious. And infected. And had a fever. 110 is safe enough to just watch overnight. Someone should reassess in am, but it's nothing to hover at the bedside about. In fact, trial some Ativan. If HR settles and so does patient you're assured it's all anxiety. Minimal harm with potentially a deal closer.

Edit: I just realized he is on telemetry. D/C that ****. I don't see why he needs it. He's a healthy 23 yo with an anxiety problem.

 

[dyeguy21]

Duh.

Plus it's pretty easy to play a game of "gotcha" (which is inevitably what this will turn into) when you control the flow of information.

PS - no one cares about bowel sounds.

100% correct, BS are present or not and that's about it. Even then people don't actually do them right.

At this point, (so we don't get a freaking trickle of information) Pan scan, pan labs, pan culture, total body EMG, consult all specialties (even OBGYN), request all records from all doctors previously seen, break into his home a la "House," call all sexual partners, move him to the unit with every medication ever invented on standby. Problem solved.

 

[Doctor4Life1769]

I agree, this case sounds pretty pointless.

 

[Siggy]

Get a set of stable vital signs and this becomes a day team problem.

 

[RangerBob]

100% correct, BS are present or not and that's about it. Even then people don't actually do them right.

At this point, (so we don't get a freaking trickle of information) Pan scan, pan labs, pan culture, total body EMG, consult all specialties (even OBGYN), request all records from all doctors previously seen, break into his home a la "House," call all sexual partners, move him to the unit with every medication ever invented on standby. Problem solved.

Ouch. I'd throw in a whole body MRI while we're at it. Probably right before the EMG--that way the patient is anxious about being stuck in a tube for a couple hours, and worrying about the upcoming electrocution/human pin-cushion test coming up.

Don't forget your holistic medicine. The telemetry monitor seems to be making him anxious, so I'd scrape off some of the plastic on the monitor, dilute it with a liter water, then take that sample and dilute it with another liter of water, take that sample and dilute it again, and then administer 3 drops to his tongue. Then check his lifeline and horoscope. We may need to call the newspaper to change his horoscope for the next day if things are looking critical (defined as an unfavorable statement or wrong lottery numbers from a fortune cookie)...

After that I'd prescribe a box full of puppies--if that doesn't cure depression or anxiety, then there's no hope...

On a side note, there are two things I wish I could do as a resident:
1) Actually prescribe someone a box of puppies (or kittens)
2) Diagnose someone with "Walking Corpse Syndrome!" I love how that shows up at the top of the diagnosis list in Epic... It sounds much better than Cotard Delusion, and by using the quotations, some programmer at Epic was able to justify listing it first so we'd all see it all the time, but never utilize it.

 

[Dr_Rogers_Neighborhood]

Duh.

Plus it's pretty easy to play a game of "gotcha" (which is inevitably what this will turn into) when you control the flow of information.

PS - no one cares about bowel sounds.

I apologize for offending you. This was a real case though with a few things modified.

I'll tell you what really happened. The patient was an otherwise healthy kid 23-24 (forgot which) who developed vomiting after eating what he thought was bad sour cream at a restaurant the night before. He was staying at his parents house (was on break from college or grad school) and he went to an immediate care center which sent him to the E.D. because they thought he was septic (he wasn't). The ED physician did not want to admit him, but his primary care physician (fresh out of residency) insisted (don't remember why or even if I ever knew exactly).

Anyway, he had a profound obsession about his heart rate (would check his pulse sometimes up to 40 times per day as well as his BP). His father later told me he had bought 3 blood pressure machines from Walgreens over the past few months. He frequented emergency rooms (though not the one he was hospitalized in for this incident) thinking he was having a heart attack when in fact he was just having recurrent panic attacks. Some really severe anxiety disorder.

Anyway because of his infection he had an elevated HR and this obviously made him more anxious. The nurse actually called and asked if she could give him digoxin (I'm not kidding). Not knowing much about his history though, his isolated tachycardia in the absence of any other scary findings (coupled with his constant pulse checking while literally being attached to a telemetry monitor) made me think it was completely anxiety mediated. This patient had also been prescribed clonazepam for panic attacks, but he wasn't taking it because it lowered his HR when he would check it at home. Anyway, that is exactly what I gave him and he slept the rest of the night and was discharged in the morning.

But of course when you are an intern and all you have is an annoyed nurses' report plus some vaguaries listed in Epic, you start to get really worried (or at least I did).

If this was a dumb exercise, I can stop, I just thought it might be fun and helpful since one of the hardest things about PGY-1 night float is getting those pages where you are expected to make a decision quickly with little to no information.

 

[PinkLithe]

I think that it's a useful case, primarily for the purpose of practicing triaging. I'm a Canadian IM resident so things may be different up here but when you're on call at night you are BUSY. The ward pagers are constantly going off with this kind of stuff, and you're also trying to do consults in the ER. The hardest part as a PGY-1 for me was appropriately triaging who to see, who to manage over the phone and who to be really worried about. This is a case that I realistically would have managed over the phone -- complete set of vitals, fluids, basic septic work up if I was worried, trial of Ativan. May have swung by the ward to make sure he's ok if I wasn't busy. You realistically don't have hours and hours to just sit there and work him up for everything -- that's not your job on night float. Your job is to make sure no one is gravely mismanaged overnight.

I'm PGY-2 now, but I still think these cases are good for the juniors to learn when to freak out and when to just deal with the obvious.

 

[Siggy]

On a side note, there are two things I wish I could do as a resident:
1) Actually prescribe someone a box of puppies (or kittens)

https://twitter.com/emergencypuppy

 

[ratherbefishing]

I liked this case. I don't know why people on this forum take offense to some posts. Also, Ativan? Do we just throw medicines at problems at night?

 

[IJL]

I liked this case. I don't know why people on this forum take offense to some posts. Also, Ativan? Do we just throw medicines at problems at night?

Uhh, yes?

 

[Crayola227]

What bothered me most were seeing words like non-toxic, normocephalic.

Those are idiotic terms most often used in the ED first, surgery likes them too.

I never see any self-respecting internist or intensivist use them, usually because they tend to use more words, hopefully ones with real medical meaning.

(I'm poking fun at EM but really)

 

[Wordead]

Man, yall are pretty liberal with benzos....

 

[evilbooyaa]

Man, yall are pretty liberal with benzos....

I'm inclined to agree. Benzos over the phone or on initial presentation would be a pretty bad answer. I'd say liter bolus of fluid + tylenol and re-assess. I think sepsis gets thrown around far too often by the medicine folks (basically every single SIRS in the world insta becomes sepsis, BC, broad spectrum abx for 48 hours, etc).

 

[alpinism]

Agreed.

As one of my IM attendings liked to say "I get severe sepsis every morning when I go for my 3 mile run."

SIRS/Sepsis guidelines are only useful when used in the right clinical context (i.e. history or exam suggestive of a systemic infection)

nursing home resident with AMS and tachycardia = absolutely
healthy 23 yo with gastro and tachycardia = highly unlikely

Hate to monday morning quarterback, but the first thing I would have done is asked about the basics:

pain, nausea/vomiting, fluid intake?

either way would probably have gotten a liter and tylenol then re-assessed.

 

[Crayola227]

So nurse calls, and by computer alone:
sounds like just w/ sign out & computer stalking the nightfloat guy gathered:

"young otherwise healthy kid (early 20s) PMHx sig for bad anxiety and OCD about pulse admitted with n/v
c/w viral gastroenteritis per ID, w/ assoc tachy" now w/ demands to "fix" tachy

PMHx
OCD
Anxiety

Meds
Paroxetine

All
None

SocHx
Claims no rec substances

FamHx
Noncontrib

Obj:
Vitals since admit:
Febrile ~101, Tach 110-130, BP 110s/60s, RR < 14, satting well
I/O +400 mL

PE per notes:
Remarkable for
Tachy, hyperactive bowel sounds, mild abd tenderness

Labs:
Standard sepsis w/u from from ED (but I look of course, so he had normal CBC, CMP, U/A 2+ urobil)
EKG nl sinus tach
Bld cx pend

No img

Consultant:
ID think viral GE and recs no abx

A/P
WITHOUT SEEING HIM:
I call nurse, and ask about the following: recheck vitals same as above, patient looks fine just freaked about pulse
No CP/SOB, skipped beats
Mild abd pain, min nausea, no vomiting, some diarrhea but not much, and not c/w upper or lower GIB
No calf pain/swelling

I consider:
PE/DVT, MI, AAA, arrthymia, PNA, pericarditis, hemo/pneumothorax, abd source infxn or perf or trauma or bleed, gallstones, ascending cholangitis, pancreatitis, c diff, UTI,
Low suspicion
Tachy but otherwise HD stable, CBC & CMP WNL, nl EKG
ddimer waste of time, per hx and data low pretest prob of most of above so if not done in ED I don't need LE doppler, spiral CT or trops or repeat EKG or CXR or abd XR or CT or abd U/S or lipase
Stool studies won't change management
Urobili 2+ could point to hemolysis or stones, still not convinced I need to work that up right now, as CMP (which would include liver zymes was WNL, could consider hepatitis w/u viral panel, drug screen)

W/o seeing him I can start by giving fluid & APAP and recheck vitals
Then I can add more fluids and benzo by phone
recheck vitals

I visit him if fluid + benzo doesn't solve the problem to check if he looks legit sick and exam because that would be the only thing to change management
Which would be repeat bld cx, lactate, & call senior, to see if we start abx, to report exam findings and what of any of the above w/u I get considering exam
Otherwise dayteam can decide if they want most of that testing

If I'm not that worried about delirium in elderly, inability to protect airway in this puking patient, tanking up and Ativan by phone should be fine to start IMHO even if that's not what's wrong with this guy

Fluids and Ativan should solve my problem without a bedside visit in this person, if there's more to it I can go bedside and do more, but for someone like this it's hard to go wrong with fluids, APAP, benzo, without looking at him

someone like this I've hardly harmed with Ativan even if I go bedside because that didn't take care of it and he needs abx & more w/u

Low dose benzos aren't particularly dangerous in young people protecting airway, in fact they can help with nausea

IVF are fine in young kid w/ no heart, liver, kidney dz, electrolyte disturbance, low albumin

The only reason not to give benzo blindly by phone are issues around MS, aspiration concerns, anticholinergic toxicity syndrome

(****, maybe this guy has serotonin syndrome from OD on Paxil, in which case benzos would be adjunct tx)

(****, does he have antocholinergic syndrome? In which case benzo bad)

(****, if he had hepatitis leading to UA urobili 2+ APAP and maybe benzo bad? Normal CMP and no one thinks he's boozed up right now so unlikely acute EtOH hepatitis, this is probably safe to throw at his liver and fever and tach)

Nah, I think I can throw fluids and a benzo and then f/u vitals before I need to see him

But I'm s/p ICU, 2 ward month, and 1 NF month, and I just explained the data I collected per chart and nurse w/in 5 min and thought process that led me to see if APAP, benzo and fluids would be safe to try before looking at him

I didn't jump to more sepsis w/u because he's had a good w/u for infxn and we're holding off abx

And what would make go bedside, and what I would think of and do depending on exam