Telemedicine in the ER

This is a link to a video I did about telemedicine in the ER.

http://www.youtube.com/watch?v=rTgLhPgXjR4&feature=share

Just because the Troponin is elevated doesn't mean it is a MI!

January 9, 2013

Most of us associate an elevated Troponin with a cardiac event. What do you do when you find no cardiac cause for the elevation? "Ralph" says: "send'em home their heart is ok." I am sure that none of you will do that, but where do we look, what do we look for? I have listed a few things that will cause elevation of the troponin without specific cardiac damage.
How did I figure this out? Well if you haven't seen by now that Brother Murphy hangs out with Ralph and I on a fairly regular basis, ya need to clean your glasses. If it is weird, uncommon, or "doesn't occur in this population", trust me, the patient will seek me out.
I had a patient present with a Troponin of 3.89 with NO EKG changes, NO chest pain, NO shortness of breath, NO CAD, and NO familial cardiac risk factors. His CKMB was at the upper limit of normal, and his CK index was normal.

After doing some research I discovered that sepsis, septic shock, systemic inflammatory response syndrome (SIRS),  hypotension, and hypovolemia, renal failure, inflammatory disease, burns > 25 % BSA, exertion, and post transplant were a few of the many reasons that could cause a "non cardiac event"  elevation in one's troponin.

I will let you research the patho behind these causes if you feel the need, but the point of this lesson is:
Sometimes we, as providers, forget that every patient does not "read the book". We ALWAYS have to treat the patient, not the monitor, or the lab results. If something isn't making sense, we probably need to look at it from a different direction.

In my patient, I ultimately found he had a chronic (undiagnosed) GI bleed. If I had "knee jerked" and given aspirin for an elevated troponin (thank you Dr Bandura, who told me "if the index is normal, look for something else"), I would have potentially made the patient worse.

Have a GREAT day!

Is your patient sick enough to admit?

1/6/2013

Is your patient sick enough to admit?

     For those of us that admit our own patients, we are always in a battle between case managers, utilization review, and our desire to provide the best care possible for our patients. Do you admit to observation, or do you do a full admission? Exactly how can we tell if our patient should be an “observation” status or a “full admission”?

     I am going to give you some “magic numbers for admission” from utilization review. This is by no means an all inclusive list, but it should give you some insight into how you patient should be admitted. These criteria are basically, “How sick is your patient?”

 1) Generally speaking, the condition should have an onset in the last 24 hours

 2) VITAL SIGNS

                Temp < 91 or > 106 (105 if patient is over 65)

Pulse- generally < 60 with symptoms or ? 3 second pause or >120 with arrhythmia +/- hemodynamic instability

Resp - >35 or impending intubation

SBP < 90 (only if decreased from baseline) or postural drop of > 30 or hypertensive emergency (sx or end organ damage)

SaO2 < 89%

 3) LABS

                WBC      > 16,000 (12,000 if suspect sepsis) or

< 4,000(if you suspect sepsis) or

Bands > 10%

                                Hgb < 6.0  Hct < 18%

                                Hgb < 8.3 Hct < 25% = age > 65

                                Plts < 60,000

                                Na < 120 or > 160 (with mental status changes)

                                K < 2.5 or > 6.0 with neuromuscular or ECG changes

                                BUN > 45

                                Cr > 3.0

                                Ca < 5.0 or > 15

                                Mg < 1.0 or > 3.0

                                Phos < 1.0

                                Acetaminophen > 300 + AST > 1000

                                Carboxyhemoglobin > 40%  or > 30% with mental status changes

WHAT ARE YOU DOING FOR YOUR PATIENT THAT CAN”T BE DONE AT HOME?

                Vital signs q 4 hours ( NOT q shift / while awake)

                Neuro checks q 4 hours

                IV fluids > 75 mL/hr

 IV meds _ antibiotics, proton pump inhibitor, insulin, steroids, pain meds (3X24 hours), diuretics (2X24 hours), anti-emetics (<3/24 hours)

Nebulizer Tx q 2 hours

O2 > 40%

Blood transfusion (>3 or 4 units/24 hours)

Chest tube TO SUCTION

GI suction

Hope this helps give you an idea as to whether it is an OBS or FULL admit. Unfortunately, as you can see even the guidelines "aren't sure".

The Flu is in Alaska!

1/2/2013

The flu is on the war path!

     Sorry for the sporadic posting, but I put these together in my apartment and then upload them when I have time at the hospital where my Wi-Fi access is. Now with that out of the way…..

     The flu has made it to Alaska! Interestingly enough, there is also a similar viral illness going around. It is only lasting for about 24 hours and all the “victims” are Flu A&B negative. Those that are Flu positive are predominately type A. So far we have only had two Type B positives.

     Another interesting note is that the Flu vaccine has only been available here since the middle of December, so several of the patients with flu “had their flu shot”. Interestingly enough, those that had their flu shot and now have the flu, had their immunization less than 2 weeks before getting the flu. Their body did not have enough time to protect itself from the virus.

     I have done some non scientific investigation into the evaluation and treatment of flu patients here. I got to wondering, actually Ralph was wondering, if we were getting flu swabs on appropriate patients. In other words, are we swabbing enough, too much, or just the right amount of patients? If we are not swabbing enough, we are missing cases. If we are swabbing everyone, we are artificially inflating the cost of health care. If we are swabbing “appropriately” we may miss one here and there, but we will be catching the majority of cases. At least, that is how Ralph and I think.

     So, I went to the lab and tallied up the total number of flu swabs done, the number of A positives, and the number of B positives. Using scientifically primitive math skills, I determined that 65% of the swabs we have done were positive. It would seem to me and Ralph that this indicates we are reasonably appropriate with our swabbing.

     Now some of you are in epidemiology and have real scientific evidence based data about the appropriate percentage of positives to negatives I am sure. I would appreciate your input on this so all of us can evaluate our practices and adjust accordingly. Please let us know what the “evidence based practice” goals should be.