THIS is an emergency, not that finger pain...

The day started out pretty ok. The ED was busy as always but as I scanned through the list of charts to pick up a new patient for the day, it was exciting to see that everyone had pretty normal vitals (as opposed to the daily hypotensive, tachycardic charts I always see in the stack - that have NOT been seen for hours).

I thought to myself, today is going to be a good day. It was not. Most frustrating case of the day...

I went to go see a non acute patient when I noticed a man lying in a stretcher near triage. He did not look well (Kussmaul's breathing, extremely cachectic, and lethargic GCS 9). I asked the nurse and she stated they were making his chart and someone would tend to him shortly. About 20 minutes later I passed by that patient and he STILL was lying there with no one tending to him. I asked for his chart and saw this....

Bad..very bad...

Extremely cachectic

What?!! I asked the nurse why he hadn't been emergently brought back. The answer? They have no good way of assigning unknown patients charts and can not bring back patients until they have a chart. That is ridiculous. In the US, they would immediately assign him an alias name and correct it later. This is so his care would not be delayed.

After I explained he needs to be brought back immediately, the situation was complicated by there are no rooms for him to be brought back in. I started some peripheral IVs on him as he was in the hall to start fluids. As you can see he is very cachectic and had very sclerosed veins. He was agitated and pulled out all of his IVs x3 :(

When he finally was able to get a patient room, glucose reading read HIGH. I'm not sure about their glucometers but the ones in the states indicates this is more than 600-700 (normal is generally less than 120). I wanted to start a central line on the patient for access as well as to rapidly fluid resuscitate him. Unfortunately, there are no central lines in the ED. Also, none in the ICU that day that we could borrow.

My patient had finally got a room and it happened to be a trauma room. The nurse then informs me we need to move my obtunded, dehydrated, dying patient and move him to a unmonitored hall for a minor finger laceration?! I explained to the nurse, THIS is an emergency, not that finger pain... frustration ensued.

We finally use soft restraints (torn cloth) to prevent him from pulling out the pathetic (very tiny) 20 gauge IVs  I could finally get in him. Urine dipstick  and venous blood gas shows... (when we finally are able to get those studies)

++++ glucosuria
+++ ketones in the urine
Pt is in diabetic ketoacidosis.  All the physicians do their own dipstick urinalysis.

Very bad venous blood gas

It took nearly 3 hours to get him on an insulin drip. It took 4 hours for 3L to run because of poor access.

At home, DKA is handled so effortlessly. Things run very smoothly. Because of that I think sometimes people forget that DKA is a potentially life threatening illness. For those who are non medical, DKA results from a shortage in insulin. The body responds by burning fatty acids that eventually produces acidic ketone bodies. Notice my patient's pH is very acidic 6.96 (this is a logarithmic scale, so any fluctuation in the normal values is very bad) with a bicarb of 5.8 (normal is 24). Patients are often very dehydrated and can withstand >5L intravenously. I never have to actively seek out a pump for insulin. I never have to explain why an obtunded hypotensive patient needs to be seen first. If he didn't have good access, we just immediately place a central line in him and that issue is resolved in 20 minutes.

Overall, the patient did well. He responded after 4-5 hours and got more alert. I hear he is doing well on the ICU/wards.

This is how I feel today.

Other issues:

A foley/ indwelling catheter (or even a red rubber for straight catheterizations) was not immediately available for us to test urine for ketones. We had to "borrow" one from another part of the hospital. Labs are often delayed and so obtaining urine informs us that he is in DKA.

NOTE: If the hospital is low on a supply/ medication that the physician thinks is indicated. They will write a prescription for family members to go buy it at a pharmacy (not in the hospital).  This patient was homeless and had no family. This is really interesting to me considering a.) this prolongs care if it is an emergent issue b.) Can you imagine this in the US? How about the chronic pain patients? Would they be willing to pay for their medications up front like this?

Why yes,  that IS my name! Dr. Hellena Terran

CWM hospital, nice landscaping