Tuesday, July 17, 2018

Funky Lab

Asked to see a young man who had been admitted 5 days earlier with what appeared to be extreme alcohol induced hepatitis.  In addition to an extreme liver panel, but not so bad ultrasound, his proteins were very low for a young previously healthy man and his sodium was only 123.  The residents had the presence of mind to address the hyponatremia in the usual way.  Osmolality 335 in serum, 691 in urine, sodium 150 in urine.  This is pseudohyponatremia of extreme degree, though not recognized for that.  After some testing, his cortisol was low at 3.1 so they called me.  The original lab looked like there was some other substance restricting plasma volume so I had the residents repeat the serum osmolality which had come down to 290, still inappropriate to the sodium of 129.  Since his glucose, bun and proteins were not high, this is usually from a lipid problem.  Sure enough, the cholesterol was 1208 and ldlc 1098, by far the highest numbers I have ever seen.  I assume the liver dysfunction impairs some of the serum cholesterol disposal enzymes.

Not sure why it took 5 days to figure this out.

Tuesday, July 10, 2018

Unrestrained PRN

Sometimes we get complacent.  A very nice diabetic came to the hospital about 10 days back having been at our other campus not long ago.  He had a foot wound requiring two toe amputations here.  Glucose management at the other hospital seemed more difficult than it was here, with the continuation of insulin dosing proving too much, particularly the nightly basal dose which brought the dawn glucoses too low.  With some minor revisions the glucose control coasted along, his BP remained decent on medicine and his underlying cardiovascular disease mandated high dose atorvastatin which he continued uneventfully.  He always seemed pleasant, never seemed in any distress, a placid and pleasant fellow who never complained, at least not to me.

Ordinarily I take a look at my medicines on daily rounds.  The computer makes this easy by putting an asterisk next to the medicines I ordered.  There were antibiotics and there were analgesics ordered by other people to which I did not pay a lot of attention, his being in the hands of medical and surgical colleagues who do this professionally.

As he prepared for discharge I went over the list and noted a prn q 4h oxycontin order.  When I called up how much he actually took, it turns out that he has been requesting 4 doses a day on roughly a q4h while awake pattern every day for 5 consecutive days.  It seemed like a much larger amount of medicine than I would have anticipated for somebody who never looked uncomfortable at any of my visits.  Needless to say there are questions relating to his medical care and there are better ways to manage ongoing anticipated pain.  Was his pain control adequate or was there incomplete treatment of its source?  Does he really desire euphoria more than analgesia?  Does the prn nature of the order create a conflict between a patient in pain now and a surgical nurse who is otherwise occupied at the time with other patients whose needs are more immediate?

And who should be the one noticing this aberration?  I asked some of the nurses on the ward at the time if they note excessive prn use of opiates as the patients start demanding it of them repetitively.  Generally no, as no single nurse dispenses more than two in any shift and doesn't really come passively on the overall utilization.  I asked the pharmacist.  There really is no automatic mechanism to detect this.  Every day  there is a group meeting to discuss the progress and discharge planning for each patient.  Needless to say, this would not continue past discharge, but it whizzes by the daily sessions.  And then there is the surgical resident.  They look at wounds at the bedside.  Looking at medicines is a distraction from their surgical tasks.

So as we deal professionally with excess opiate utilization as a public health crisis, how much of that was our own creation, initial legitimate prescribing with a blind eye to use that seems excessive.  We have no mechanism to intercept that other than individual diligence in paying attention to medicine orders and administration.  Alas, good systems work better than astute people, and our system here seems absent.

Friday, July 6, 2018

Old Records

Got a semi-urgent consult, a man with a calcium of 11.9.  He was asymptomatic but what made it urgent was the desire to send him to a rehab facility the next day.  Not being otherwise engaged, I went up to see him, having read the current chart from my desk.  As I got to the charting room, some brand new interns, first week, were milling around, already discussing discharges with each other to the neglect of incomplete medical care.  One of them owned up to having been assigned this fellow who just had his hyperparathyroidism confirmed by the lab.  So the questions were obvious to me:  what was his previous calcium?  Did he have urolithiasis?  Did he ever fracture anything?  Why was he on Casoex?  They looked at the lab work, called me, took no relevant history, did not seek out records, and plotted his exit at the earliest possible time.  Not a good way to imprint the expectations of medical care on medical newbies.

I called the young'un over.  We opened the chart from the other campus of our medical center, about a five minute effort.  He had been hospitalized the previous year.  His calcium was consistently 10.6-11.0.  No testing was done, though he did have an abdominal CT which showed no renal stones at the time.  There was a lab result from six months ago, calcium 11.0 so it is clearly rising.  He had a medicine list.  hctz on it, though stopped here.  Also leupron on it so now it is clear why he also took Casodex.  Renal function normal, then and now. 

Haven't even entered this fellow's room and it was clear he had hyperparathyroidism with a rising calcium and he also had prostate carcinoma that was being treated medically.

Interviewing him did not add a whole lot.  He could tell me who was prescribing the prostate treatment.  He did not have stones, moans, groans, or psychic overtones.  He had also not been told of the calcium elevation before.  And his bp was pretty high, presumably some of it from stopping the hctz.

So he would benefit from a parathyroidectomy and from some revisions in his antihypertensives.

And the new trainees need to redirect their focus away from discharge to more thorough care while the patient is their responsibility.

Wednesday, June 20, 2018

The Non-Consult

Sometimes it is the silliest of things that expose some of the systemic deficiencies of what we do.  One of the psychiatrists asked me to see a patient with a glucose of 295 taken by finger stick in the ER  The patient had no known diabetes.  He had been in the hospital the year before with a random lab glucose of 117 and otherwise normal lab work, so the progression from pre-diabetes to diabetes was plausible.  During his few days in the hospital, several bedside glucoses were obtained and were all normal.  A HbA1c measured 4.9%.  By all evidence he does not have diabetes but had a spurious ER fingerstick, which made for a very brief consult and the lowest billing code available.

What caught my attention, though, was that the entire evaluation was done by the psychiatrist.  Every psychiatric inpatient gets seen by a medical physician, typically the nurse practitioner or on weekends the resident, with review of the hospitalist.  Even though that 295 was the most recent glucose obtained in the ER the day before, there was no recognition of it by the Internal Medicine people, not to repeat it, not to do a HbA1c, not even a concern that he might be a newly identified diabetic.  But the psychiatrist either was attentive, or was the recipient of this lab value by verbal report from the ER and took it upon himself to check it out when it whizzed past the medical people who often function more as scribes to put a paper in the chart than as consultants to take advantage of a patient on the psych unit who frequently slips through the ordinary venues of scheduled outpatient care.

And we have erroneous lab data.  Did that fingerstick belong to somebody else who should have been treated?  Was it contaminated?  Should it prompt a lab draw from the ER?  No, it was just added to the chart, assumed to be true and passed along to somebody, though not necessarily the person best able to act on it.

And yes it is ok to give him Risperdal if it helps the psychosis.  No risk of severe hyperglycemia this time.

Wednesday, May 2, 2018

Copy & Paste

Patients in the hospital get seen by a lot of people.  There's the admitting resident, the hospitalist, any number of consultants each with their own niche. And on transfer out of the ICU a new crew takes over.  As the consultant I do not ordinarily encounter the person on the first day.  By then they can give me a history, which I take, but I also read the History of Present Illness.  Too often, the HPI's done on Day 1 by different providers look a little too identical, though each signed independently.  If journalists did that it would be plagiarism though when doctors do it the term is copy & paste or even more benevolently, gathering needed information from available records.  That's an OK thing to do, even an expected thing to do.  Calling it your own is not, particularly if you never really gathered any information directly from the capable patient but misrepresented what you have done personally.

But while it enhances payment and reduces work, does it harm patient care?  To some extent I think it might, particularly when I look at my histories taken from the patient, usually in happier circumstances, have details and insights not elicited by others but could have been.  Histories are often tapestries, contributions from different interviewers who stumble across something unexpected by relevant that differs from information the previous person obtained.  And sometimes it makes all the difference

Thursday, April 19, 2018

Reviewing Medicines

Obsessive-compulsive, probably not.  Attention to detail, probably.  Inquisitive, for sure.  Two interesting encounters this week, both very typical consults on uncontrolled diabetics.

First fellow came in with ketoacidosis following a lapse in insulin from a previous prescribing snafu that left him without basal insulin for two days.  He had been a type 1 diabetic for more than 50 years.  His history was an interesting one, being started on NPH and regular insulin in the 1960's as a preschooler, then having a number of revisions in his protocol as the fashions for using these types of insulins changed from decade to decade.  He had been on the same treatment since the 1990's, maintained by his primary doctor from visit to visit, never converted to the current analogs.  he had been seeing a nephrologist as his creatinine rose.  At his last encounter, the switch was made but he had marginal prescription coverage and never received it, resulting in the current hospitalization.  After treatment of the ketoacidosis, Levemir and Humalog were initiated and an endocrinology consult was requested.  He had an interesting glucose pattern for the previous three days:  normal or low in the morning but 400+ at lunchtime every day.  On looking at the medicine record, it seems he had not received the Humalog at breakfast for each of the last three days, since the nurse opted not to give it based on the morning glucose, which was never extremely low.  That's easy enough to figure out and correct for that patient, a lot harder to correct as a system-wide policy where the aggregate nurses think this is the right thing to do for that situation each time it arises, despite the predictably adverse outcome.

What struck me more was the conversation with the referring resident who asked why I thought those spikes were occurring.  Having received the patient from the ICU, he never expanded the history beyond that needed to address the presenting crisis.  He also never sought an explanation of why the glucose would spike the way it did, even though it would be obvious from a review of what insulin the patient actually received.

The other consult was also very typical, a man with uncontrolled diabetes that came under reasonable control after resumption of insulin following an unintended interruption.  He had injured an amputation site which was revised.  However, five days later he was still requesting his prn iv opiates at just under the minimum allowed interval.  The residents were next to me in the computer room.  I asked them how his pain was doing, told OK, and then showed them the narcotic administration record.  Either he is having a lot of pain, or the sensation that he desires from the hydromorphone is more euphoria than analgesia.   Needless to say, he needs his pain revisited as he should not be needing that much IV narcotic.  Or if the pain were not going to resolve, there are many better ways to give this than q 4-6 IV dosing.  In either case, nobody read what is actually being given and therefore did not appreciate the need to reassess the pain management before they sent him home with that iv prn order still in place and no better long term alternative.

The essence of work rounds in my era, and in my office encounters today, has been to focus primarily on the medications.  What are people taking and how are they doing on what they are taking?  What is prescribed often differs considerably from what is actually being swallowed or injected.  At least the hospital medication records are accurate, the office ones border on fiction.

And there is also the question of being inquisitive.  If something looks extreme, as a glucose going from 70 to 400 on consecutive days would be, this cries out for an explanation.  Even if it had no bearing on what I am there to do, it's presence would attract my attention, as did the opiate schedule which was really not integral to the endocrinology consult.

One of the attending physicians of my residency, an outstanding rheumatologist, once pulled me aside and told me how he was taught to do consults and passed the advice to me.  Be thorough.  If you see something that needs to be fixed that seems to be neglected, mention it in the note even if not rheumatology.  It is that ingrained attention to detail that has kept the patient encounters professionally challenging, even as other elements of being a physician in the modern age have taken their toll.

Monday, April 16, 2018

Keeping People Independent

Diabetic blindness used to be much more common than it is now but fortunately with laser photocoagulation and vitrectomy, sight preservation has advanced greatly as more diabetics live longer and become more subject to this.  Still, visual loss is an unfortunate reality while their diabetes and need for testing and insulin continues.

Such a person came to my attention recently, nice fellow on oral agents whose family member had been testing his glucoses twice a day.  He developed a foot wound, came to the hospital rather hyperglycemic.  Hyperglycemia persisted after below knee amputation while the residents tinkered with his pills and eventually added basal insulin.  Cavalry called in, basal insulin increased, pills discontinued, and prandial insulin introduced.  Quick, easy, straightforward,  Glucoses corrected in a day and remained controlled the remainder of his stay, with a slight insulin dose reduction toward the end.

In New Age Hospital Medicine, once corrected people just kind of go on auto pilot with no refinements to medical care but all sorts of efforts to move people to their post hospital destination. And so it was here. Ready to go, all fixed.  And then came the phone call from the intern, what do we do about his insulin if he cannot see?

Forgive me, but the medical center pays through the nose for a very expensive discharge planning process that includes a meeting on every floor every day from the day of admission attending by a who's who of hospital functionaries experienced at sending people home.  This isn't really very hard, and why was it not addressed by these people of professional title earlier?  So I asked the intern, who lives at home with the patient?  He didn't know.  How was he getting his finger sticks done all these years?  He could not tell me if the patient had an auditory machine or if somebody at home did it for him.  I knew, because I asked him as  part of the initial consult.  Basically there is somebody else home most of the time.  And he had one leg less than when he arrived, not that the infected leg was of much use for walking prehospitalization.  So keeping him independent would require more than providing him insulin.

Basically, they had two choices, either pre-fill syringes one week at a time and keep the two types of insulin separately in the refrigerator in different shape containers that he could identify by feel and inject himself, or send him home with pens that either somebody else could give him or since the doses are low, he could probably just count clicks on the dial with each injection.  Amid the grandiosity of a hasty exit from the hospital, sometimes the simplest of things cause the impediments.