26 August 2006

Listen to your Gut (literally)

"Doctor, we need you in Room 15, right now!"

The call came from an experienced ER nurse and I knew better than to hesitate. It was near the end of my shift, but I put down the matter I was handling and hurried over to see the new patient. As I walked in the room, I could see that it was Something Bad [tm]. The patient was supine and rather grey-looking. The red numbers on the automatic blood pressure monitor read 54/30.

That's low. Really low. Low enough that you shouldn't be conscious, but as long as she laid flat, she said she felt OK.

It was an odd presentation. She really had no complaints -- just felt faint when she sat up. She had felt perfectly fine till a couple of hours ago -- no chest pain or fevers or trouble breathing or anything. Except maybe, she conceded, some mild abdominal pain, and maybe had diarrhea once. The list of Bad Things [tm] in the abdomen started subliminally cycling through my head as I pushed on her belly -- ruptured Aorta, dead gut, perforated bowel, etc -- but her belly was soft and essentially non-tender, which would *not* be the case with a perforation. A quick look at her Aorta with the ultrasound was normal. I felt like there was something I was missing, but I was side-tracked by the *huge* peaked T-Waves on the ECG the nurse handed me.

Peaked T-Waves are a sign of a very high blood potassium level, an imminently life-threatening condition. So at this point I stopped thinking and leaped into full-on ER doc mode. Two IVs. Lots of IV fluids. Insulin and calcium to lower the potassium. Antibiotics . . . just on general principles. Full lab panels -- she's in renal failure, which explains the potassium, though not the low blood pressure. Dopamine for the blood pressure. Get a ICU bed for her and call the ICU doc.

"Whatcha got?" she asked as she strolls in.
"I'm not sure, but it's bad. A 77 year old female with unexplained shock, I presume septic, acidotic with pH 7.05, new onset acute renal failure. She looks better on pressors but I still don't understand the primary cause. She had some abdominal pain but it's pretty mild. Otherwise, she has no symptoms at all."
"Righty-ho," says she, "Send her up when the bed is ready and we'll sort her out. If you can, call nephrology and get her set up for urgent dialysis, will you?"
"No troubles."

So I start back to work on my other patients, pleased that I have stabilized and dispositioned an incredibly sick person in such a short time. It took maybe an hour, probably less. I look at my list of patients for the day - 21 in 8 hours. Damn, I'm really hitting my stride. Given that almost half of them were admits, and three to the unit, I feel pretty good about the efficiency there. I may even get to go home within an hour of the end of my shift.

But I'm bothered. I still don't really have a diagnosis on this last lady. Ordinarily, that wouldn't bother me. I like to say: "The goal of the ER doctor is to keep the patient alive long enough for them to become someone else's problem." And that is just what I have done. Mission accomplished, and I can go home, right? But there's something I'm missing here. I can't put my finger on it, and it's bugging me.

Then the nurse comes to me and tells me that the patient just passed some stool, and it was bloody. Eureka! I literally smacked my forehead with my hand. She has dead gut, which is to say that a segment of her small bowel has lost its blood supply (most likely a blood clot) and has died. That would completely explain the sepsis, acidosis, and renal failure. A quick call to the surgeon -- patient to CT scan, and off to the OR for exploratory laparotomy. Her odds are poor -- dead bowel is a Very Bad Thing Indeed. But had I let a couple of hours go by till the busy ICU doc got to see her and figure it out, the odds of survival would have been fast approaching zero.

I now realize the thing that was bothering me was that I *knew* all along that it was dead gut -- it was the second thing I thought of -- but I had gotten so distracted by the other stuff that I had just lost track of it. All it took was one random piece of data from the nurse to trigger that connection and it came up from my subconscious to the front of the brain. I'm glad it did. And I walked out of the ER exactly one hour after the end of the shift.

3 comments:

  1. Thanks for the story. It really helps on a Sunday morning when I'm slogging through Pharm and Pathophys.

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  2. Nice pickup. Close call. I'm guessing still not a good outcome...

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  3. The family withdrew care after about 24 hours in the hospital. Predictable course -- intubated, worsening shock despite max inotropes, too unstable for dialysis let alone laparotomy.

    It reminds me a little of my oral boards, though. I did get the diagnosis, but in the ER what really matters is I got the disposition right.

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