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Morbidity Rounds 3rd September 2009

Morbidity Rounds 3rd September 2009. David Hadley MD. 3 cases of poor outcomes None with obscure diagnoses All with “difficult” patients All errors made were due to incorrect conscious or unconscious assumptions. He’s just drunk She’s one of those chronic pain patients

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Morbidity Rounds 3rd September 2009

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  1. Morbidity Rounds3rd September 2009 • David Hadley MD

  2. 3 cases of poor outcomes • None with obscure diagnoses • All with “difficult” patients • All errors made were due to incorrect conscious or unconscious assumptions

  3. He’s just drunk • She’s one of those chronic pain patients • She says she doesn’t drink but that restlessness is either DTs or BDZ dependence • Bed 29 had a full workup. If there’s no DVT she can go home

  4. Down’s patients often behave oddly • Those raised LFTs are d/t EtOH abuse • He’s uncooperative • Those bruises are traumatic • She’s on the hospitalist so I needn’t get involved

  5. Assumptions • Easily done • Can allow shortcuts in workup and treatment • But!! Dangerous if made subconsciously and not challenged

  6. Goals • Identify assumptions made at each step • Identify where facts were ignored or made to fit pre-existing conclusions • Accept that these kinds of mistakes are made recurrently by all of us

  7. Case 1 • 62 y.o. female • Hx chronic fatigue, chronic pain, fibromyalgia & depression * • Chronically takes T3s, Gabapentin, Lorazepam and Immovane *

  8. 20h00: EMS called for c/o R knee pain • Severe pain in R leg w swelling of R ankle to knee. • No recent trauma, injury or illness • Normal vitals • Triaged CTAS 3 to EMS stretcher

  9. EMS stretchers • EMS care for 4 hours • VSS throughout • Occasional increases in pain (8/10) treated with morphine. • R leg warm to touch • Emesis x 1 treated with gravol

  10. To WR • 00h10 downloaded to WR • given warm blanket • VSS, afebrile • No distress noted

  11. To Bed 29 - 01h00 • Ambulating fine to bed 29 * • Pain everywhere. Vague symptoms • Moans & groans w every movement • R ankle swollen, cool to touch. PPP

  12. Bed 29 • 37.5 106 102/75 20 94% RA pale • Required assistance with everything but can do same when encouraged

  13. 02h35 • Pt quiet in chair. Moving about independently but moans w ambulation • 37.5 107 96/P 22 98% RA * • Now also c/o L wrist pain

  14. 02h40: Initial EP Assessment • Has chronic pain • Dx w FM in late 80s • Usually pain all over. F/U by GP. • Increased pain / swelling R calf / ankle • No DVT / PE risk factors • Denies EtOH abuse: 2 drinks / week

  15. Physical Exam • Small woman, dishevelled, restless • 106 100/palp 99% RA • R leg swelling __ ankle, no pitting. • Pain R calf. • L leg no swelling

  16. Initial Plan • R/O DVT • Chronic pain issues • ? EtOH withdrawal * • ? BDZ or Narcotic dependence *

  17. Treatment • IV fluid • Morphine 2.5 mg prn • Gravol / Maxeran

  18. 03h40 • 102, 98 / P, 26 95% RA • Pt ++ dramatic. * Able to ambulate to BR. States passed a loose stool. • IV bolus, Morphine 2.5 mg, * Maxeran 10mg, Tinzaparin 9625 units SC • States zero relief with morphine. Medicated again. *

  19. Investigations • Na 126, K 3.3, Cl 88, CO2 19 * • Cr 142 Glc 4.8 • WBC 26.5 PMNs 19.1

  20. Investigations • INR 1.4 • ALT 198, Alk Phos 278, GGT 149, Bili 30 • EtOH < 2.2 • APAP, ASA negative

  21. Assumptions • Look for possible infection - CXR, urine • EtOH related hepatitis • Revisited issue with patient who admits did drink a few years ago during divorce

  22. 04h45 • Returned from xray, crying in pain • Pt declined offer of ativan as was on it before with no success * • Morphine 2.5 mg * • CXR no acute process

  23. 05h30 • Vitals unchanged • Still c/o ++ pain • Pt feels morphine doing very little, requesting ibuprofin * • D/W EP who will reassess

  24. 07h00 • EP reassess: Increased swelling / bruising to R ankle, L wrist. Both tender, both appear traumatic * • “Patient likely abusing EtOH, has abnormal LFTs. Lives alone at home. Appears to be withdrawing. No ___(wbc 26) ** • Awaits doppler and wrist xray *

  25. 07h30 • 38.1 118 81/47 24 96% ** • Ongoing wrist / ankle pain. Quite drowsy -states from morphine * • leg edema, cool, bruising to dorsum • Transported to U/S • On hospitalist list ** • EP handover **

  26. 08h37 • Doppler U/S report: No evidence of DVT to the level of the popliteal vein • Ongoing severe pain • Bands 6.9 *

  27. 09h53 • L wrist -ray: No convincing evidence for a # or dislocation. • R ankle: Moderate soft tissue swelling overlies lateral malleolus. No effusion. No evidence of # or dislocation

  28. 10h00 • 38.0 122 132/54 22 95% • Ongoing 8/10 R leg and L wrist • Moaning w movement • Given Ativan and thiamine *

  29. 11h00 • 37.1 118 86/56 20 92% • Unable to sit up in bed, moaning • ++ unable to keep eyes open • Pain 7/10 • NS bolus *

  30. 12h37 • Pt drowsy, unable to sit upright • Pain 9/10 • Blisters noted to L heel and ? R lower leg *

  31. 12h50 • Pt incontinent of stool • 2 person transfer • ++ bruising L buttock • Serosang drainage from R heel • EP paged to see pt

  32. 13h55 • EP #2 assesses pt. * • Concern re necrotizing fasciitis • Pip / Tazo, Clindamycin, Vancomycin • Plastics to see • Sepsis protocol started

  33. 15h08 • Plastics / ID / ICU involved • Prep for OR

  34. 17h30 • OR - prepped for exploration of ? nec fasc to R lower extremity • Cardiac arrest pre induction • Pulse restored post RSI, epi etc

  35. OR note • +++ purulence from above and below deep fascia of lower leg. Unhealthy muscle • Through knee amputation • Similar findings to L forearm • L upper extremity amputation • Pt dies < 1 day post op from overwhelming sepsis

  36. Timeline • 19 hours in ED • 8 hours on hospitalist list • 44 hours in hospital • Multiple false assumptions • Multiple clues not detected / acted on

  37. Learning Points • Be aware you are making assumptions • Challenge all assumptions • If pieces of the puzzle don’t fit, don’t force them

  38. Learning Points • Make the solution fit the pieces, not the pieces fit the solution • Treat pain appropriately - not just w 2.5 mg • Vital signs don’t lie • Be aware of dangers at end of shift when attempting to have a neat package for handover

  39. The End!! • I assume

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