Routine transfer goes wrong

[mobey]

So I just got home from a routine transfer, that was less than routine.

I'll lay it out for you, but I do not have a strip, so you will have to take my word for it.

Called for a long distance transfer (2.5hrs) for investigation of infected foot. Headed to a foot clinic in the basement of a major hospital. Possible amputation, this is a consult.

75 y/o male, in decent physical shape for age and history.

Pt has huge history including: CVA x3 last one Feb 2009 which was hemmoragic requiring surgical intervention. During surgery pt suffered cardiac arrest and was revived with deficits to speech and swallowing.

Over the last 4 yrs pt has had aortic valve replacement, triple bypass, Pacemaker post bradycardia episode, multiple MI's. Hx also includes hypothyroidism, rheumatic fever (Mitral valve calcifications) IDDM, recent fungal infection of respiratory tract. recent parkinson dx

Pt has hard time with speech d/t CVA so hx obtained from wife/nurse notes.

Meds that you would expect: Lipitor, Antifungal, Lasix, Synthroid, Morphine PO, antiparkinsonian.

BP 108/64 stayed there for entire transfer

ECG (3 lead only) Wide complex tach at 130

BGL 11.3

Temp 35.8

SpO2 94% RA

Physical fairly normal.

Bilateral basilar crackles noted, but not alarming to me given the hx. No SOB, no acc muscle use.

Toe looks necrotic, foot red, swelling noted.

Let me be clear here: This is a transfer out of a hospital to another for a consult of a necrotic toe! This is NOT an emerg call, This is my complacency speaking.

So I drop the guy off for his appt and go for lunch.

I soon recieve a call asking me to report upstairs to the ER as my patient has had an "event"

I go to recus room to find my pt Uncx with a NRB on, and looking half dead. Grey, diaphoretic, laboured breathing.

500ml NaCl administered, and pulmonary edema now becoming an issue. They were contemplating dopamine when I left.

Apperantly he developed chest pain shortly after we left, and was brought upstairs. chest pain has resolved, Vitals as follows.

BP 78/40

HR 110 wide complex tach. 12 lead = LBBB

BGL 4

Temp 36

pt responsive to loud verbal, but confused, not answering questions.

So: Shoulda done a 12 lead.... yaya... I am my biggest critic here.

Maybe low flow o2

But really.... I feel i missed something big here. The guy was tachy when I got him, and perhaps I should have tuned into it a little better. To be honest... I was thinking "He is a fragile heart patient, who knows what his normal is. Since i just got him from a hospital bed, it should be safe to assume the tachycardia is not new"

My DD includes AMI, SIRS, CHF exacurbation. could go on forever, but those are the top 3

Thoughts?

To be honest I am beating myself up a little

Edited January 26, 2011 by mobey

[HERBIE1]

Sounds like this guy was a ticking time bomb and any one of a number of events could have occurred. Initial thoughts- septicemia- secondary to infectious process in foot? PE? Threw a clot?

He was tachycardic initially- due to infectious process? You also noted a pulse ox of 94%- room air or on supplemental o2? Did they do a 12 lead prior to the transfer? Did he have a white count?

Was he on any IV meds during the transfer?

I would bet that there was nothing you could have done differently, Moby. Let's say he suddenly occluded a coronary artery- your 12 lead may have been completely benign up to that point. Bad things happen to seemingly healthy people, but based on this guy's PMH, anything is possible.

I understand your desire to make sure you didn't miss anything, but I suspect this was beyond your control.

[medicgirl05]

This scenario just sucks...but it sounds like you did what you could for your patient.

In hindsight I would say a 12 lead may have been helpful, but on a routine transfer I can't say I would have done one. In fact I can probably say I would not have, with the info you provided. With his history it would be difficult to know if a "new" event was occuring anyway.

Don't beat yourself up about this. In my opinion there isn't much you could have done differently.

[P_Instructor]

Quit beating yourself up. These things can always happen even with patients that have no prior histories. He sounds like the perverbial train wreck that finally de-railed. About the only thing(s) you could have obtained was a more complete history of how the patient has been during his initial hospitalization and if there were any complications that could be expected........but that report could have taken hours and you usually never can get that from the floor nurse. Bad way to think of this, but he was maintaining in your presence.......he only changed after someone else took over and want to pass the blame. You can only do what you can do.

[Just Plain Ruff]

Do not beat yourself up.

I would not have done a 12 lead either. I would have given him a comfortable ride to the receiving facility.

Like everyone else has said - don't beat yourself up.

[Richard B the EMT]

By the sounds of it, the patient must have been hanging by a thread, and it broke, unavoidably, on your watch. Won't specify, but been there, done that.

[DwayneEMTP]

What kind of pacemaker did he have?

I do believe that I would have done a 12 lead on this guy as I don't like that wide complex tachycardia. Also I believe, (because I always the the completely right and thorough thing, its my gift.) that I would have given a few liters of O2 not only because bringing his SATS up couldn't hurt, but to see if it would cause any change in his rate.

Had the ER put him on Os when you returned to find his rate at 110?

It sounds as if this guy has had about a gazillion clot issues in the recent past. In the time you had availabe, I mean 2.5 hrs is all day, I'm curious why you chose not to do an EKG or O2?

Dwayne

[mobey]

He had a demand pacemaker. No spikes on the ECG.

The reason I did not apply O2 is simply because he was not "sick"... let me quantify.

He was at the sending hospital for a simple diabetic foot problem. He was being transfered for a consult of that toe.

As per his history, he has had no chest pains, no weakness, no SOB, no new swelling. I just hate answering to hospitals after I return thier stable patients from appointments that I applied 02 because the machine told me too. It makes my assessment skills look like shit when i treat a patient solely on the Sp02, and to be honest it makes no sense to me to apply a treatment when there is no symptom.

As far as I was concerned, an Sp02 of 94% was likely his normal. Note he was not tachypnic nor complaing of SOB. I am quite sure I am not the only one who transfers elderly patients with low 02 sats, or even low BP's that are normal for them. This guy was borderline, I always like a resting Sp02 of 95 or higher.

As I said before, my decision not to do a 12 lead was wrong.

The reason I did not was based on lazyness and complacency. The 2 reasons I did not do one was 1) hairy chest I did not want to shave and cause undue discomfort - then explain why I did to the sending facility when I returned. 2) With a wide QRS and an extensive cardiac history I assumed I would see a BBB, and possibly axis deviation, however any ST segment changes would be nondiagnostic.

Not solid reasons I agree.

I am sorry I did not include earlier, there were p waves corresponding with the QRS's! I did NOT suspect V-Tach.

When I think back about the rate wish I woulda put on 02, and tried some fluid.

[Just Plain Ruff]

What would the medical necessity be for the 12 lead in this instance?

I know that I don't care about insurance but more than likely the insurance company would kick this bill back and say "what was the medical necessity of said 12 lead?"

I never do anything based on insurance but I'm curious as to this being a routine transfer was it medically necessary?

more and more that I think about it I probably would have done one but it would have been down on my decision and treatment tree.

[DartmouthDave]

Hello,

I think that this patient's medical history caught up with him.

Maybe he was a little septic (Temp of 35) but who knows.

The only 'eyebrow' raise is for ED thinking about Dopamine with those second set of VS. Of course, hard to say what they were thinking.

Cheers