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Post a good case, dammit.
Started by RustedFox
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Well ****, been bitching all week about all the drug addicts and overdoses. What comes in right when I get here? A polysubstance abuse, intubated. I hate people.
I’m sure they’re super pleasant when extubated lol. What percent of them walk out AMA shortly after being extubated, I wonder…
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I really wonder if these pts would do just fine with a 1:1 nurse. I'm not saying they are always available.....but I had a 20 yo drunk girl who literally had a GCS of 3. She was only breathing and that's it. I couldn't get a single reflex out of her. I stuck a qTIP into the back of her nose and touched her brain and she didn't wince.
I told mom, I gotta do what I gotta do, and she said fine. Literally 2 hours later she was trying to pull the tube.
Just literally had an etoh’er who came in with GI bleed, variceal requiring banding, who got extubated this am, signout AMA
Prob more than we think. Prob is everyone is understaffed, easier to say f it, tube em and admit to the unit. I get it, it just blows.
Yea man it totally does
especially if You can't get them to the unit in a timely fashion. Then you are giving gobs of propofol or whatever else, their pressure becomes 90/60, and it's just a bullshiiiiit game.
I sit on these patients all the time, it’s rare that they don’t start showing signs of life after 3-4 hours. Saves an ICU bed.
Yea for these clear cut OD cases with no other red flags, I might just do this in the future. The RN has to be 1:1 (in California at least) for critically ill patients whether they are tubed or not tubed.
Come work at my hospital prease
Do you know how they ended up doing? I thought that the whole thing with rasburicase was to give it to prevent AKI in the setting of hyperuricemia/TLS.
Hha-come-uu work at my hopsitaburu, purrease.
I have no clue. I involved Oncology early and they continued to consult. If I saved the patient to my list, I'll find out.
Ya, it's called pseudohyperkalemia, you can see it in CLL where the cells are fragile and in the act of drawing blood you lyse them. My first time seeing it was on a newly diagnosed CLL where the K was >10 and he relatively fine with no EKG changes.
You can see it in ALL as well. My single experience it wasn't the lab draws that was lysing the RBC but the tubing to the lab and spinning them. Kid had a K of 12 with a normal EKG and the istat showed K of 3. For 3 days we had to run an istat everytime we sent lytes to the lab to keep everyone from freaking out.
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That sucks. Our techs were trained to catch those and request redraws in alternate tubes before releasing the result (and call the doc to let them know)
It was very strange, our lab claimed they couldn't run a whole blood potassium - ie without spinning the tube.
on a large analyzer that’s probably true. It’s mostly the point of care analyzers that do actual unprocessed whole blood. most of these that we saw were from CLL type patients and collecting paired serum and plasma tubes was sufficient to sort it out.
I’ve seen the same thing after giving intralipid, only POC labs are accurate.
36 yo F history TBI, mental illness and hereditary hemorrhagic telangiectasia (formerly Osler-Weber-Rendu syndrome) with chronic severe anemia from GI and pulmonary AVMs. Took care of her during an ICU rotation during my second year, eventually had to transfer her because IR wouldn't touch her AVMs.
Saw her again a year or so later, brought in by EMS with hematemesis. Pale as a ghost, HR 110, BP normal, awake and alert with her baseline bizarre affect. Blood looked like thin cherry Kool-Aid. Lab calls me and says the hemoglobin came back at 1.3, that this was incompatible with life and she would need to repeat the test before she could release the result into the EHR.
Me: "So you want me to take...more blood from this patient?"
Tech: "I can't release the result."
Repeat hemoglobin was 1.2.
Saw her again a year or so later, brought in by EMS with hematemesis. Pale as a ghost, HR 110, BP normal, awake and alert with her baseline bizarre affect. Blood looked like thin cherry Kool-Aid. Lab calls me and says the hemoglobin came back at 1.3, that this was incompatible with life and she would need to repeat the test before she could release the result into the EHR.
Me: "So you want me to take...more blood from this patient?"
Tech: "I can't release the result."
Repeat hemoglobin was 1.2.
You beat my personal record low Hgb of 1.9, which also looked like red Kool-Aid.
My personal record low was 3.0 -flat-.
I was a resident; I'll never forget the case.
Young lady with terrific fibroid uterus who refused hysterectomy again and again.
She looked "fine".
I walked back in the room to discuss results after not believing my own eyes.
Her family (I think it was her mom) was in the room and blurted out: "Tell him about the CHALK!"
She took 2 boxes of crayola-style blackboard chalk out of her purse and sheepishly admitted that she just takes it out from time to time to "smell it".
"Are... are you eating the chalk?" I asked, noting that several sticks were missing, like a pack of cigarettes with a few having already been smoked.
"No... but I thought about it."
My personal record is "Doc, we don't have enough cells in the sample to give an accurate Hgb." 34 yo minimally responsive, pale as a ghost, dropped off by friends who mention something about hematemesis and take off. No other hx provided. He's hypotensive, HR of 150, RR of 50. Blood looks like just serum w/ a single drop of food coloring. Abdomen is swollen. His hgb was 2.0 after 4 units of pRBCs. I kept that guy alive for 10 hours, stayed 3 hrs after my shift. Mass transfusion protocol, 20 u pRBCs, 10u Plts, 10u FFP. Blakemore tube. GI won't scope. IR won't touch the pt because he is too unstable and INR is >10. His lactic acid was 45. His pH was 6.7. I waited about 2 hrs before intubating him because I felt that intubation would be an immediate death sentence, as there was no way I could match his minute ventilation on the vent, but he eventually started looking a bit better after about 10u pRBCs, so I figured that was my time to intubate. Put him at a RR of 36 on the vent, with a tidal volume of 800 (he was a small guy), just to try to somewhat match his MV. Initial NG tube placed puts out 2L of blood from his stomach. Blakemore tube then placed, but not much improvement. ICU admitted him. Blood bank eventually ran out of blood to release. The patient died a few hours later.
Whoaa.
That's a crazy case, and I'm going to take this in a slightly controversial direction. With the labs you're describing and the general clinical course, I don't know if this was "heroic measures" or "waste of resources."
To be clear, I'm not criticizing your care. Sounds like this was entirely by the book and I don't know that I would have done anything different in the moment.
But retrospectively, with a BT in place, no improvement in how the patient is doing, all specialty interventionalists refusing to do anything for definitive management and a coagulopathy with an INR > 10 and a lactate of FORTY FIVE.... I feel like those 20 units of blood (plus whatever was given upstairs) might have been better used elsewhere.
Am I just being a callous jerk here? No offense taken if the consensus is yes.
That was my thought afterwards, and if we are talking about the greater good, you are probably right, but I would do it again even for a slight chance of saving a 34 year old.
Did you ever follow up and figure out what the original etiology was? Alcoholic cirrhosis, or other liver pathology? I feel like 34 is pretty young to get full on cirrhosis and esophageal varices. But this may be the ignorant med student in me talking...
I'm speechless.
My call to my intensivist buddy was simply: “34 yo GI bleed, sickest patient I have ever seen that is still technically alive, please come help.”
Also, we got a CT abd/pelvis prior to ICU transfer that confirmed cirrhosis w/bleeding esophageal varices. He was bleeding briskly enough that they could see extravasation of contrast on a regular ole CT abd/pelvis venous phase despite a Blakemore in place.
Holy cow man, how much does one have to drink to get to this point?
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Roughly 1+ Liters of hard alcohol daily is where I've seen this. I don't see a ton of drug use in my neck of the woods. Occasional fent ODs. No meth to speak of. TONS of alcoholism though. I also trained somewhere where we saw a LOT of liver patients so the idea of a 30 yr old cirrhotic with varices is unfortunately not surprising.
Another classic case of interventionalists who refuse to do their job. “He’s too unstable to give him the treatment that will stop him from being unstable.”
Dude. That guy is dead. Even if by some miracle the guy doesn’t die (and it would be a miracle), he has stroked out. He is already infarction several organs.
It is a lot easier to just say that patient is too sick to benefit from my xyz procedure than to discuss with consulting doc that we all agree patient’ condition is terminal and any further treatment is unwarranted.
You can't stop bleeding like that with a scope. Patient won't survive IR procedure. There's nothing to be done for patients like that except have ICU talk about palliation and withdrawal of active treatment after a certain point.
I disagree. I've been part of these kinds of procedures. If they go to gi, you give them a whiff of basically anything and they code. I've had patients just crash after being given a drop of prop. Then they get intubated, lined, tons of pressors, gi scopes and there's too much bleeding to see anything and you can't get source control if you can't find the source.
Then these guys go to icu if IR says no or to IR and you're basically emptying the blood bank for a guy who will officially "die" after a week of wasted resources in ICU. If by chance you happen to get to the point where they miraculously walk out of the hospital, they will go home, drink again, bleed again and the same thing will happen a few weeks later. The long term prognosis is horrible for this self inflicted, irreversible illness. It's better to say no from the beginning.
I'm inclined to agree with our Cards/GI posters here.
We're all stuck in the same legal boat here, playing a strange game of hot potato.
We're all stuck in the same legal boat here, playing a strange game of hot potato.
Not strange.
There has to be a huge genetic component too- I’ve also seen many people who drink that much and are 65 before it gives them any trouble … sad when they’re in their 30s +/- small kids at home.
In my neck of the woods our biggest substance abuse issue lately has been fentanyl in the cocaine - true story I had a lady complaining because she was just “doing a couple lines for her Birthday” and “that jerk put heroin in it” 🤦🏻♀️
We’ll just have to agree to disagree I guess. If there’s no point of an intervention then there’s no point of sending to ICU and depleting the blood bank. You guys have clearly honed your skills to the point where you can prognosticate based on no history, some vitals and a lactate, I can’t say the same for myself.
That's harsh, dude.
I'm asking this out of a genuine curiosity, not trying to challenge you.
I understand GI probably cannot help much here because they will not be able to visualize given the pace of bleeding. It seems the patient probably truly is too unstable for a surgical procedure, and will code with the operation, but it seems IR is an option here.
Is doing an IR procedure any more destabilizing in this case compared to what the patient has already undergone (intubation, Blakemore tube, I presume aggressive vascular access such as a CVC and a line)?
I understand the prognosis here is VERY bad based on the data provided and most likely outcome regardless is death.
Several. Potentially changing to portable vent. Physically moving to Angio suite, which often involves an elevator ride. You are placing an arterial catheter in the femoral artery on a guy who can’t clot. You are also moving the patient further away from the “normal” supply of meds/drugs and put the nurses in a different environment. More chance for things to get messed up and for things to take longer.
I probably would have done the same with the 34yo. Give him the old college try. 20 units of blood is a lot, but certainly not drain-the-blood-bank level. That's a kid. You have to try. The regret level would be too high not to. And after 12 hours of trying, THEN you have the palliative talk.
Or you get me and my HPM hat involved. I had THAT talk with an angiosarcoma patient this last weekend. A loooong talk. (like several hours over several days.) She's young. She has a young family. It's horrible. But she's now ready to forgo further transfusions, which means it was worth it.
One of my buddies in residency had a cop struck by a fleeing suspect if I remember right, open book pelvis, nasty trauma, you know, the works. Worked all night to save the guy, 110+ units of blood products. (And I am now old enough that these were the days before we HAD massive transfusion protocols.)
Was THAT too much? In retrospect, maybe. But given that he was an officer, and given the situation, at the time, the guy got everything and no one regretted it.
Or you get me and my HPM hat involved. I had THAT talk with an angiosarcoma patient this last weekend. A loooong talk. (like several hours over several days.) She's young. She has a young family. It's horrible. But she's now ready to forgo further transfusions, which means it was worth it.
One of my buddies in residency had a cop struck by a fleeing suspect if I remember right, open book pelvis, nasty trauma, you know, the works. Worked all night to save the guy, 110+ units of blood products. (And I am now old enough that these were the days before we HAD massive transfusion protocols.)
Was THAT too much? In retrospect, maybe. But given that he was an officer, and given the situation, at the time, the guy got everything and no one regretted it.
Yea it's really sad. They probably didn't even put a note in either...so if this ever makes post-mortum rounds or given to the lawyers it just looks bad on them.
Our ICU sees a ton of cancer. Man, those young cancer patients are so freaking sad. You know their disease, you know the prognosis is 100% fatality. And then you just watch a 20-30-something waste away while their spouse and kids watch. Good HPM docs help with the comfort and emotional transition, but it’s still so sad.
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Did you train in Wisconsin?
It’s not a laughing matter, but this comically reminds me of when I had to contact on-call IR about some nonsense in a patient record. The APRN coordinating the telemetry unit wrote that she consulted with neurology about an AIS patient, CTA resulted in essential occlusion of M1 segment of MCA with distal reconstitution giving radiologist an impression of a high grade stenosis. Pt presented with NIHSS of like 15. GCS of like 12. Neuro told her to call IR for perfusion study and MT. She wrote that IR told her patient was not an MT candidate due to high grade stenosis. 😶 Ridiculous! I don’t know how she got put in charge of anything.
Neuro APRN on next day wrote basically the same thing. How is that even possible?
IR put no note on the consult in the patient record. I had to dig out of him later that he “felt like” he was looking at an atherosclerotic narrowing rather than a thrombotic occlusion, and MT is not used to deal with LVO due to large artery atherosclerosis.
I thought personally that the view sounded narrow, since folks have been studying the use of stent retrievers, asp catheters, etc. to rescue pts from AIS due to LAA since like 2014 at least.
This pt is still effed on follow up with outpatient neuro. I keep harping on documentation to people, but it’s not getting through much. It’s like there’s no concept of someone else reviewing the record.
