Morbidity Rounds 3rd September 2009

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