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You and your colleague are dispatched for an urgent transfer from your community hospital to a larger regional hospital.

Initially, this was coded as a routine transfer but it has been upgraded because the patient has become more unstable.

Mr. Smith is a 67 year-old male who was admitted with pneumonia three days ago. Over the last three days his condition has worsened.

On arrival to the medical unit you find an obese man in bed. The head of the bed is elevated to 45 degrees. The patient is pale, wheezing, and diaphoretic and wearing a NRB. He is connected to a telemetry pack. An RT wearing a protective gown and mask is at the bedside checking the patient’s SpOs. He tells you it is 85%.

You see a sign posted on the door that says ‘droplet isolation’.

The vital signs sheet is on a clipboard by the door and things do not look promising:

HR 120 irregular

BP 75/45

SpO2 85%

Temp 37.6

The nurse is on the phone talking with the receiving hospital sorting out where at the regional hospital the patient is to be admitted.

Cheers

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Whats the droplet precaution for?

Suspect Active nastiness. Don't tell me you went in the room without precautions did you?

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Hello,

Sorry for the delay.

The nurse finished on the phone and gives you an update.

The patient was going to a medicine floor at the regional hospital but he is now going to be assessed in the ED.

He was admitted with community acquired pneumonia but he has been getting worse and his viral swab came back positive for influenza ‘A’. He is in renal failure with a Cr of 470 and a K of 6.2.

You put on gowns and face shields and enter the room. The patient is awake, alert but very tired. You can hear him wheezing from the door.

He has #18G IV x2.

His foley bag has maybe 20cc of urine in it.

He has a high-flow face mask on. The RT tried some Bi-Pap but the patient got too anxious to tolerate it.

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Hello,

They gave him Kayexulate an hour ago.

They have also started him on Tamiflu.

The EKG shows a rapid A.fib.

Cheers

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First, do not accept this transfer. You cannot transfer a pt from an inpatient bed to an ER. It must be an equal or higher level of care transfer so this pt needs the ICU, not the ER.

What can the pt tell you?

What is his past history?

Let's see the admission cxr and the current cxr.

Let's see the admission EKG and the current EKG.

What meds is he on?

Let's see all of his labs.

Let's see the culture reports.

Vitals, including Is and Os.

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Hello,

The patient is SOB but he tells you he has felt like 'hell' a few days before he came to the hospital. Now, he feels worse.

He is a heavy smoker and has a history of HTN, DPL, COPD, and a MI 2 years ago.

He is on Pip-Taz TID , ASA OD, Ventolin + Atrovent QID, Tamiflu PO BID, Prevacid PO and was given some Lasox last night for low urine output.

His K is 6.2, Cr 470, WBC 28, Hgb 95, Random Glucose 22, and Mg .6

He is positive for influenza 'A' and sputum is positive for something that Pip-Taz works on (I don't know micro very well).

VS are not so good. BP in he 70-80, HR 120 (Fib), and Spo2 85% or so.

Cheers

David

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What has been the trend of his BP?

When did he go into afib?

What has his urine output been over the last 24 hours?

Fluid intake (oral and IV) for the last 24 hours?

Current 12-lead ecg, initial, and a previous if there is one.

BUN?

BNP?

Was there ever a chest x-ray?

Current lung sounds?

JVD?

Peripheral edema?

PND?

Clinical signs of dehydration?

What treatements have been given since admission?

If the wheezing is due to bronchoconstiction start treating him with albuterol and atrovent; with his Mag being that low a Mag drip wouldn't be a bad idea, but that's going to wait until his BP is better.

Need to know more about the afib; if this is new onset afib with a known start time the low BP might (that's a large 'might') be due to the loss of his atrial kick, in which case cardioversion would be appropriate. But, that's a large drop, and there probably isn't a known onset, so this will wait, but may come into play later.

Start a fluid bolus; even if he is in renal failure (that's not certain yet) he'll be getting dialyzed, and at this point volume is needed. Once the first bolus is in and the airway secured check for fluid responsiveness; if he is then give more fluid. If he's not due to a sepsis induced cardiomyopathy or some other reason, start him on levophed...probably slowly give another bolus at that point as well.

Unless there is a marked improvement with the albuterol he must be intubated before leaving. Talk with the attending and if one is available, anesthesiologist. If they can do an awake intubation with light sedation and a topical anesthetic then great, if not, plan for a difficult intubation, have a video laryngoscope handy (if there is one), use a high-flow nasal cannula to help with the desatting, and start with just a lower dose of ketamine (0.5mg/kg-1mg/kg) without paralytics. If you have to paralyze you're doubly screwed as rocuronium is all that should be used. Have your backup airway ready and a scalpel...though that would be a nightmare. Keep him sedated with versed (or ketamine I suppose) and fentanyl.

Pneumonia/flu

sepsis

COPD exacerbation

acute renal failure

new onset afib

Biggest questions right now how long has he been in afib, and how he does with the above treatements.

edit: shit, missed the blood sugar. What's the ABG?


First, do not accept this transfer. You cannot transfer a pt from an inpatient bed to an ER. It must be an equal or higher level of care transfer so this pt needs the ICU, not the ER.

That's not entirely true; patient's can go through the ER if for some reason their condition changes during the transfer, and there are hospitals that, depending on the type of patient, will evaluate them in the ER and potentially keep them there for treatement before sending them to a specific unit.

I don't know specifically about a direct transfer from a standard medicial floor to an ER without a known destination in the new hospital, but I don't see how this would be innapropriate; not all hospitals and doctors are created equally, and what one thinks is a severe, critical patient may not be to another. To have them checked in the ER to see what type of care is needed makes sense.

But, if this is an EMTALA or JCAHO violation it wouldn't surprise me.

Edited by triemal04

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