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Case 1: Shortness of Breath
Case 2: Fever
Case 3: Overdose
Case 4: Motor Vehicle Collision
Case 5: Knee Pain
Case 6: Respiratory Arrest
Case 7: Ankle Injury
Case 8: Cough
Case 9: Abdominal Pain
We spent the last post focusing on reviewing the documentation, now we can turn our attention to the medical decisions. We’ll spend the first part addressing the decisions made by the first doctor when the PE was missed, and the second part addressing the decisions made during the visit 18 days later when the patient coded and died. The goal here is to point out a few general points and direct readers to some #foamed resources, rather than trying to do a complete literature review of all the minute points. The best teachers inspire students rather than spoon-feed each individual point, and I hope this case will inspire you to learn more and be a better doctor.
Tachycardia at Discharge
Discharging tachycardic patients is usually a bad idea. If you’re going to do it, you better have an excellent and clearly explained reason why you’re discharging them. It’s a recipe for disaster. If you want to discharge a patient and find out they’re still tachycardic, it should be a mental trigger to stop and think if you’re missing something. As discussed in this excellent post from emDocs, “In one study, abnormal vital signs occurred in 83% of unexpected and related to proximate ED visit deaths, with tachycardia occurring in 83% of those cases”. Working fast is good in EM, but only up until a certain point. We all need to be willing to slow down and do some hard thinking when required. This is one of those times.
Right test for the right patient
At the risk of sounding too obvious, if you are legitimately worried your patient has a PE, and you can’t rule it out with PERC or a d-dimer, they need to have a CT scan. We have a responsibility to help care for all patients who come to the ED. While roadblocks may exist in taking care of obese patients, it is our responsibility to find a way around these roadblocks and help them get the care that they need. The easiest way in this case would have been to transfer the patient to another hospital that had capacity to obtain this patient’s CT scan. The judge clearly laid this out in his instructions to the jury.
Cognitive priorities
Another point is about the cognitive error of focusing on a toe when a patient comes to the ED with shortness of breath and chest pain. It is difficult to tell the physician’s thought process given the lack of good documentation, but I suspect that the care he provided for the patient’s erythematous toe distracted him from the workup and diagnosis of pulmonary embolism. Rather than doing the hard work of thinking about a PE, he replaced it with the cognitively easier task of addressing the patient’s toe. Doctors all feel a need to take care of patients, but we have to be careful that we’re not just doing something for the sake of doing something. Don’t fill your capacity for action with things that are irrelevant.
Lysis for Suspected PE Code
Why not attempt lysing this patient? Its clear that the doctor had an excellent idea of what was causing this patient’s arrest. The history of shortness of breath coupled with a long recent car trip will make nearly any doctor think about PE, and furthermore, at the end of his note he even writes that he suspects it was a PE! The patient regained pulses a few times but was mostly coding. There’s really no good reason to not try lysis in this situation, with a recently dead patient and a great story of PE. Try 50mg of tenectaplase or alteplase and keep going for 15 minutes. There’s different recommendations on dosing from different sources and no clear consensus as to the right way to do this, but in my opinion its definitely worth a try. I won’t delve into the details because ALiEM already did a better job than I would: https://www.aliem.com/2013/03/whats-code-dose-of-tpa/
Intubation in the Coding Patient
The risk/benefit of intubating coding patients has been debated. Most studies break this down by out-of-hospital cardiac arrest vs in-hospital cardiac arrest. In this case the patient coded just as he was being transferred from pre-hospital care into the ED, so it’s not clear which category he would fit into. The physician describes how he rapidly got to the head of the bed and intubated the patient. There are certainly studies suggesting that early intubation may be associated with less ROSC, less survival to discharge, and less good functional outcomes as discussed in this Core EM post: https://coreem.net/journal-reviews/intubation-cardiac-arrest/ This is an issue that is still a topic of much debate that will likely continue.
End Tidal CO2 in the Coding Patient
A positive thing about this cardiac arrest was the use of ETCO2. Its clearly documented that they were using ETCO2 to monitor the patient. A sudden rise in ETCO2 may correlate with return of pulses and it can help monitor quality of CPR. Unfortunately, in this case it never got above 15, even though the patient reportedly got pulses back at several points. Its also worth noting that feeling for a pulse via digital palpation may not be reliable given the subjective and subtle nature of the test, which is interesting given the fact that it drives much of the decision-making in cardiac arrest. There’s some great information about ETCO2 in cardiac arrest here, down toward the bottom of this post: http://rebelem.com/beyond-acls-cognitively-offloading-cardiac-arrest/
Ultrasound in the Coding Patient
Another point of discussion is that the physician used ultrasound to aid in his management of cardiac arrest. Towards the end of the code an echo showed no sign of large effusion or tamponade, which would be a finding that could be rapidly intervened. The only possible criticism here is that if there had been an effusion, you would have wanted to know that at the beginning, not waiting until the end of the code. Cardiac activity on ultrasound is associated with higher likelihood of survival to discharge, and can help identify other interventions that may help the coding patients: http://rebelem.com/reason-trial-pocus-cardiac-arrest/ However, there are certainly some challenges with using POCUS in this situation:
- Its hard to get doctors to define “cardiac standstill”: http://rebelem.com/can-we-agree-on-cardiac-standstill/
- Ultrasound may increase length of pause in chest compressions: http://rebelem.com/impact-pocus-cardiac-arrest-resuscitation-compression-pauses/
Hopefully seeing some real-life examples of these teaching points will make them memorable and useful to you and your patients.
More hospitals should consider having CT scanners that can accommodate larger patients. It’s not a long term solution to the real underlying issue of obesity, but it might prevent delay of care and untimely deaths as illustrated in this case. Thank you for presenting this case, it’s an education.
I wonder if you could suspend someone from a Hoyer lift or two and take only part of their weight, the lift acting as a counterweight, reducing the net weight on the table when that is the rate-limiting factor.
Maybe better, place the patient on a tarp, have four people with lead on the four corners (two on either side of the ring) and have all of them keep about 20-30 pounds of traction on an upward vector.