You're in clinic and this patient appears... what you do?

[woopedazz]

Real-world case.
Want to know how you guys handle these cases as something along these lines happens to me at least once a week.

Scenario: Pick up the clinic chart for the last patient of the day. A patient in their mid-30s getting an endoscopy the following day. Booking form states "Low-risk"

Context:
You work at a tertiary centre that is the only major hospital in the state.
Nearest interstate major centre is 1500 Miles away (direct flight) - and it's not fantastic. The nearest decent hospital is either the one you work in, or, ~1900miles away.
>50% of your patient cohort attends from regional/remote centres within a 1000mile radius.
This cohort (majority indigenous) has a predisposition towards extreme poverty and poor health literacy.
Minimal/nil access to nutritional foods.
Minimal/nil access to primary care.
High risk of neglect from health practitioners/carers.

The Patient:
- 30s Female.
- From remote community - community inaccessible by road due to flooding (typhoon season); and will not be accessible for weeks.
- T/F via charity helicopter for this endoscopy - on waitlist for 3 years.
- Not booked for a bed in hospital - staying at Christian boarding house tonight; then has charity helicopter return flight booked for the next day. Can't miss the flight.

# Type 2 DM - On protaphane (only medication)
- Not hypo-aware.
- Last admission was for what is presumed to be a hypoglycaemic seizure a few months ago.
# Blind - due to repeated retinal detachments.
# Deaf - due to chronic, untreated otitis media since childhood.
# No English.
- Consent by the state has already been provided for anaesthesia...
# Wheelchair bound due to bilateral BKAs secondary to diabetic foot ulcers (3 years/5 years ago).
# CKD: Anuric
- AV fistula never used; on peritoneal dialysis in remote community for ~4 years.
# Malnourished
- weighs ~30kg
- Endoscopy for ?gastroparesis/malignancy as cause for severe weight loss and anorexia.
# COPD
# Everything else you can imagine.

Exam:
- As you would expect from the above.
- Nothing else interesting/pertinent.

Investigations:
- Bloods are what you'd expect for a chronic PD patient; nothing outlandish.
- ECG = known LBBB.
- CXR (last admit) = aspiration pneumonia; now resolved (assumedly).
- No other investigations available.

Issues:
- BGL management +/- other stuff.
- Surgeon is only in town tomorrow and cannot rebook for months.
- Transport is only available tomorrow.
- Hospital is "at capacity" on first inquiry.

What you do? Cancel? Proceed? Call the Christian outreach re: insulin dosage? What dose you gonna give? Is that safe? Beg hospital admin to admit?

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[chessknt]

A few ways to approach but the strict answer is should be doable as an outpatient.

Bigger question is who the hell thought this was a good idea? If its a malignancy how would she get chemo (and what would she even qualify for given her extremely poor functional status)? If its gastroparesis (100% chance it is) then what the **** are they going to do different, start TPN in the place where cars cant get to? Enteric nervous system is already destroyed why do an EGD to prove it? She needs a stat palliative care consult with her guardian--->hospice. She is young but I have had people that age with cirrhosis die all the time. It's sad but she has advanced essentially terminal disease.

 

[woopedazz]

A few ways to approach but the strict answer is should be doable as an outpatient.

Bigger question is who the hell thought this was a good idea? If its a malignancy how would she get chemo (and what would she even qualify for given her extremely poor functional status)? If its gastroparesis (100% chance it is) then what the **** are they going to do different, start TPN in the place where cars cant get to? Enteric nervous system is already destroyed why do an EGD to prove it? She needs a stat palliative care consult with her guardian--->hospice. She is young but I have had people that age with cirrhosis die all the time. It's sad but she has advanced essentially terminal disease.

Agree wholeheartedly.

For interests sake let's say we discuss the above with the surgeon who suggests that the endoscopy is required.

We can all manage them on the day... but what to do with her sugars overnight? The bed manager says no admission available.

 

[chessknt]

Agree wholeheartedly.

For interests sake let's say we discuss the above with the surgeon who suggests that the endoscopy is required.

We can all manage them on the day... but what to do with her sugars overnight? The bed manager says no admission available.

I'm guessing her baseline sugars run in the 300s given the extent of damage already. I would recommend discharge rather than pointless insulin optimization that is about 10 years late.

If you felt compelled however you would need to review her outpatient records to get a better understanding of her compliance and resources, fasting sugars, post prandial sugars, and po intake consistency before making any long term changes. This is done on poorly controlled diabetic outpatients all the time albeit not under such challenging circumstances.

 

[DocVapor]

As long as she doesn't die in her sleep the night before she's fine for the upper GI. Keep her as close to her physiologic normal as possible, and tell the clipboard nurses that want all the numbers to be "normal" to go pound sand.

 

[IlDestriero]

Agree with all of the above.
Unnecessary procedure on end of life patient.
Don’t bother optimizing much as she’s never optimized based on her condition. You just need to keep her alive during the egd.
Prop, scope, can of ensure, have a nice flight.
+/- a bit of insulin if her sugar is 300+.

 

[GassYous]

What is "clinic"?

 

[IlDestriero]

What is "clinic"?

Maybe they mean Preoperative Home?

 

[GassYous]

Why would you need to admit or give insulin for a 5 minute procedure? Just spray the back of her throat with some local and hold her down for the scope. Use a pedi size.

 

[Blockit]

Sadly, in the GI world unnecessary procedures are very common. At my last place we did an urgent upper endo on a hospice patient who had reported a black stool. Stage 4 lung CA, no further treatment. Was heme negative on exam. You start to recognize that there are certain types of physicians that go into certain specialties, because of their desire to fill their wallets as much as possible. GI can be one of those specialties.

That being said, your patient should do just fine. Short of you losing her airway during the procedure, there’s not a whole lot that your quick blast of propofol can do to harm her beyond her baseline poor condition.

 

[dhb]

What is "clinic"?

A place where i can make 300€/h

 

[deleted697535]

hold on a second, do you practice in subsaharan africa?

 

[coffeebythelake]

Sadly, in the GI world unnecessary procedures are very common. At my last place we did an urgent upper endo on a hospice patient who had reported a black stool. Stage 4 lung CA, no further treatment. Was heme negative on exam. You start to recognize that there are certain types of physicians that go into certain specialties, because of their desire to fill their wallets as much as possible. GI can be one of those specialties.

That being said, your patient should do just fine. Short of you losing her airway during the procedure, there’s not a whole lot that your quick blast of propofol can do to harm her beyond her baseline poor condition.

A major aspiration event could shorten this patients life a bit. These cases aren't as risk free as u make it sound. Horrible diabetes probably also mean horrible gaatroparesis

 

[DrOwnage]

If I have confidence in the GI doc I’m working with I will almost never cancel an endoscopy unless the patient is having an active MI, or their hgb is low as balls and hasn’t been replaced appropriately (in that case, delay).

 

[Blockit]

A major aspiration event could shorten this patients life a bit. These cases aren't as risk free as u make it sound. Horrible diabetes probably also mean horrible gaatroparesis

Well I guess I should’ve been more specific when I said “losing control of the airway“. I put a significant aspiration event into that same category.

 

[nimbus]

hold on a second, do you practice in subsaharan africa?

More likely Australian outback.

 

[woopedazz]

Why would you need to admit or give insulin for a 5 minute procedure? Just spray the back of her throat with some local and hold her down for the scope. Use a pedi size.

My issue was the fasting requested by surgeons for the presumed gastroparesis. I just said "no insulin tonight/ tomorrow" and let her run high

 

[chocomorsel]

hold on a second, do you practice in subsaharan africa?

With the use of the words "indeginous" and "typhoon", most likely not. If he/she were in Africa he wouldn't call the people "indigenous". and we don't have typhoons in Africa. That's usually way East. I usually see this word typically used for the much smaller native population that has been decimated by the conquerers over hundreds of years, i.e NZ/Australia/other Pacific Island communities with the aboriginals and North America with the Native Americans.
Suspect he/she is somewhere in the Pacific with the British spelling he/she uses plus we don't use miles. We use ***.

Edit: Then there's the whole "consent by the state", "Charity Helicopters" "AV fistula" "thousands of miles">>very large country.
All that point to Australia. Ain't no "state" approving surgeries like that in Africa with Charity Helicopters etc. It's the "state" trying to make amends for all the crap they did hundreds of years ago to the aboriginals. But since I am not allowed to comment on sociopolitical threads, let me get off my soapbox.

 

[abolt18]

With the use of the words "indeginous" and "typhoon", most likely not. If he/she were in Africa he wouldn't call the people "indigenous". and we don't have typhoons in Africa. That's usually way East. I usually see this word typically used for the much smaller native population that has been decimated by the conquerers over hundreds of years, i.e NZ/Australia/other Pacific Island communities with the aboriginals and North America with the Native Americans.
Suspect he/she is somewhere in the Pacific with the British spelling he/she uses plus we don't use miles. We use ***.

Edit: Then there's the whole "consent by the state", "Charity Helicopters" "AV fistula" "thousands of miles">>very large country.
All that point to Australia. Ain't no "state" approving surgeries like that in Africa with Charity Helicopters etc. It's the "state" trying to make amends for all the crap they did hundreds of years ago to the aboriginals. But since I am not allowed to comment on sociopolitical threads, let me get off my soapbox.

Wait, what do you call "AV fistulas"? That's the turn I'm most familiar with here in the U.S.A.

 

[anbuitachi]

proceed.

lido , prop, done.

 

[chocomorsel]

Ok Wait, what do you call "AV fistulas"? That's the turn I'm most familiar with here in the U.S.A.

You aren’t getting it. It’s the fact that they even have an AV fistula.