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Last night was just full of surprises from ED. After seeing the NSTEMI patient, we were referred this patient.
She's a 70 year old lady from HLC NH (Are we seeing a trend here guys? Are we??). Her relevant history is she's bed bound and requires full hoist transfer due to multiple sclerosis but is apparently cognitively quite well. She has had a productive cough for the past 24 hours and was found this morning unrousable and with a temperature of 32.2 degrees. On admission to ED, she was hypoxic, hypoglycaemic and hyperkalaemic.
Please note that at this point, I asked my registrar, "Is this patient palliative?" The reply?
"No, not at the moment. ED has already discussed with the family and they've made her NFR and not for ICU but the family want to trial medical management for now and re-discuss tomorrow".
"OK, so what's her renal function and pH?"
"Well, I can't remember what the exact pH was but the ED consultant said she was a bit acidotic and her renal function isn't actually that bad."
OK, fair enough. Since my registrar was busy admitting another patient, I went over to say hi to our next customer. Let me just say, when I walked in my first impression of the patient was not good. She had the classic "O sign", was tachypnoeic at at least 35 resps per minute, her sats were 89% on 15L via non-rebreather, she was tachycardic and hypotensive. She did not look well at all. In front of me lay her sequential VBGs. A quick glance at her latest VBG was worrying to say the least. Her pH was 7.069 and her lactate was 10. Ohhhh...kay... Really? Really??? We're going to treat this lady for one night to see how she goes?
So I spoke to the ED consultant. "Look, I'm just about to do the admission paperwork for this lady but can I just ask where are we going with her? I'll have to talk to my registrar but have you talked to the patient's family about palliating the patient tonight?"
"Yeah, we're just waiting for the other daughter to come in, she's the power of attorney."
Cool, so as long as the patient's in ED and my registrar's busy, I guess it's the ED's job to have these discussions with the family. Guess I won't interfere. In my admission notes: "Needs review by medical registrar later. As per discussion with ED consultant, patient likely for palliation given severity of sepsis and refractory nature of hypoxia, hyperkalaemia and hypoglycaemia. ED will discuss with patient's family when POA arrives."
Just then, a MET call was made upstairs. We went upstairs, fixed the patient and came back down to ED half an hour later. Patient had died already. She didn't even make it out of ED.
Should this patient have been referred in the first place? From the get-go, I feel this patient should have been palliated given her pre-morbid level of function and how severe her sepsis was. My kind-hearted partner argues that if you were in ED's position, you have to refer the patient at least for palliative measures. Who knows how long the patient will hang on for? You can't have a patient like this sitting in ED overnight. My argument is even without the power of attorney, ED should just have discussed with next of kin and palliated the patient after she failed to respond to the first round of treatment. Then the patient would have died before we could even see her and she would have been more comfortable in the end.
She's a 70 year old lady from HLC NH (Are we seeing a trend here guys? Are we??). Her relevant history is she's bed bound and requires full hoist transfer due to multiple sclerosis but is apparently cognitively quite well. She has had a productive cough for the past 24 hours and was found this morning unrousable and with a temperature of 32.2 degrees. On admission to ED, she was hypoxic, hypoglycaemic and hyperkalaemic.
Please note that at this point, I asked my registrar, "Is this patient palliative?" The reply?
"No, not at the moment. ED has already discussed with the family and they've made her NFR and not for ICU but the family want to trial medical management for now and re-discuss tomorrow".
"OK, so what's her renal function and pH?"
"Well, I can't remember what the exact pH was but the ED consultant said she was a bit acidotic and her renal function isn't actually that bad."
OK, fair enough. Since my registrar was busy admitting another patient, I went over to say hi to our next customer. Let me just say, when I walked in my first impression of the patient was not good. She had the classic "O sign", was tachypnoeic at at least 35 resps per minute, her sats were 89% on 15L via non-rebreather, she was tachycardic and hypotensive. She did not look well at all. In front of me lay her sequential VBGs. A quick glance at her latest VBG was worrying to say the least. Her pH was 7.069 and her lactate was 10. Ohhhh...kay... Really? Really??? We're going to treat this lady for one night to see how she goes?
So I spoke to the ED consultant. "Look, I'm just about to do the admission paperwork for this lady but can I just ask where are we going with her? I'll have to talk to my registrar but have you talked to the patient's family about palliating the patient tonight?"
"Yeah, we're just waiting for the other daughter to come in, she's the power of attorney."
Cool, so as long as the patient's in ED and my registrar's busy, I guess it's the ED's job to have these discussions with the family. Guess I won't interfere. In my admission notes: "Needs review by medical registrar later. As per discussion with ED consultant, patient likely for palliation given severity of sepsis and refractory nature of hypoxia, hyperkalaemia and hypoglycaemia. ED will discuss with patient's family when POA arrives."
Just then, a MET call was made upstairs. We went upstairs, fixed the patient and came back down to ED half an hour later. Patient had died already. She didn't even make it out of ED.
Should this patient have been referred in the first place? From the get-go, I feel this patient should have been palliated given her pre-morbid level of function and how severe her sepsis was. My kind-hearted partner argues that if you were in ED's position, you have to refer the patient at least for palliative measures. Who knows how long the patient will hang on for? You can't have a patient like this sitting in ED overnight. My argument is even without the power of attorney, ED should just have discussed with next of kin and palliated the patient after she failed to respond to the first round of treatment. Then the patient would have died before we could even see her and she would have been more comfortable in the end.
Yeah, I know right. Often times the family members find it hard to let go at the cost of the patient's comfort. So there is always this concept of trial of antibiotics for 24-48 hours when things might already seem futile.
But there rarely are also cases where patients are palliated and miraculously picked up too..and ended up lingering on the ward. Even palliated patients are admitted under Gen Med here..
temperature 32.2?! omg.