New to the ED, patient coded

[momentous]

Hi guys, first post here. I've known about your forum during my pre-pa years but didnt really go about making an account around 2-3 years ago. Now I just wanted to let things out see what other people who's been in the business for years think about this.

 

So essentially, I am a new grad, luckily landed a spot in the ED which helps new grads and have been in the system for close to 4 months now. The supervising PA trained me with the senior PAs for around 6 weeks rotating between fast track and main, roughly 50/50. During my training period, I got to learn the system, did more advanced procedures that I never got to do as a student, including LPs, intubations. However, they do have an EM residency so most of the high end resuscitation is given to the senior resident. Which is fine since I'm still learning from bottoms up, and thankful enough I got to do some advanced procedures already. There is a lot of hand holding, the attendings know I'm new and verify everything I say and see the pt after me, so we work collaboratively and closely together on every pt until they feel more comfortable with my work. I have received great compliments from them and senior pas so far, but I know I'm not functioning at a level that would warrant independence/solo run of patients yet so I don't let the compliments touch me. And so far I have loved the work and always knew I wanted to do EM (even attempted the EDPA residencies in my local area but didnt get in unfortunately).

 

As a student, I was exposed and helped run codes, do CPR, offered whatever services I could as a student. Or just witness it being run. Rotated through a level 1 trauma EM, so codes were running like clockwork and I've seen and experienced death. It does not phase me. Most often these pts came in already in the middle of acls.

 

So yesterday night in the main ED, I had an 85yo M BIBEMS with multiple comorbidities, hx of CVA with residual R sided weakness, hx of CAD/MI (unstented, untreated), ESRD (AVF recently placed and awaiting first HD), CHF @40% with chronic venous stasis changes/dermatitis and decibitus ulcerations on the leg secondary to R sided weakness, aortic stenosis, afib on coumadin 2mg daily last INR a month ago was "within therapeutic range" per pt. Presented with intermittent epistaxis x 3d which may be secondary to nose picking. Worse today, resolved while coming into the ED. Denied any CP, sob, diaphoresis, trauma to head, abdominal pain, visual disturbances, headache, dizziness, fever/chills. Due to his age, comorbidities, coumadin use, i did as much head to toe exam as I could since pt was bed bound. L nare had crusted blood, but no active bleeding noted. Looked inside the nose, and it seemed like the bleeding was from the anterior aspect with fresh blood noted near the inferior septum. Oropharynx was clear, there was no blood noted down the throat. Otherwise he had a known systolic murmur on the heart, irregularly irregular rhythm, but normal rate. Lungs CTAB, and abdomen was nontender. Neuro exam was mostly nonfocal, AxOx3, CNs was grossly intact, RUE/RLE was noticeably weaker which is pt's baseline from the CVA, sensory function intact throughout, EOMs intact, PERRLA.

 

To try and cut a long story short, after seeing pt I put in orders for labs and coags and was informed the bleeding started again from the L nare. I put pressure, sat pt up at 60 degrees to avoid aspiration. Bleeding stopped again but due to it's intermittent nature more intervention was going to be necessary. I presented to the attending, he went to say hi agreed with findings, recommended afrin sprayed into some gauze and pack it into the nose bilaterally. Did that with the attending and waited for 20-30m to see if bleeding stopped. In the meantime, the nurse was on break and we were pretty slammed with other pts so the labs were drawn a bit late. When the nurse came back she noted pt's documented temp (we use temporal temp) was 96F, and it was triggering a warning on our EMR (happens all the time). So she recommended a rectal temp (did not run it by me/attending) in which the tech did, laid the pt down on R lateral decibitus and got a rectal temp which was normal. During this rectal temp, I went back to see if the nose is still bleeding s/p afrin packing. ER tech turned pt back on his back and that was when he was unresponsive. Checked carotid/femoral pulse, no pulse, ER tech immediately began CPR, I called the code called for help moving pt to our resuscitation room, called attending who was feets away and we immediately began acls, attending was in charge, i helped cycle CPRs, the senior resident covering resuscitation was already on board ready to intubate and another senior resident was getting I/O prepped (pt had a 20G line only). Central line was placed, pressors started, code ran for 30m but pt didnt come back.

 

Mid code, labs finally came back, the abnormalities were hgb 7.5 not far from pt's baseline, K of 5.6, nothing that was immediately life threatening. And lo and behold I didnt order the coags..... I thought I did, I documented in my note I was going to, but I mustve missed it when going through orders. Overall I was just so stunned and shocked this pt coded. Like after the adrenaline rush died down I sort of felt completely off, like did I miss some subtle hint that I could've picked up earlier and avoided all this. It didnt help I kept getting callbacks for other emergent imaging findings requiring urgent surgical intervention during the code so I had to step away after 10m and stood there on the side lines, but we were well staffed and there was enough people helping out. I gave the best history I could, presenting pt's comorbid conditions etc.

 

Like I said, I've gone through codes and death of pts without being phased. But this one got to me. Maybe bc it's my first where I'm the primary provider, but also it was just such a shocker on my end bc it was an epistaxis and boom pt dies. After talking with family I felt much better, talked it over with the attending if he had any thoughts on things we may have picked up to avoid this, and he didnt know, attributed death to MI. Maybe aspiration from the rectal temp/laying pt down. I told him about the coags I accidentally didnt order and he said it wouldn't have made a difference after the code, and not to add it on. I documented as best as I could of what happened, how I called the code, informed attending asap, immediate transfer to resus area where senior residents/attending assumed care of pt.

 

Anyways, I was pretty shaken up from this. And I felt pretty incompetent I couldnt do much more to help, however I know that I will gain more confidence and comfortability with time and experience.

I do fear of malpractice, esp so new to the field of medicine and considering the circumstances of how pt was here for a nosebleed and died. Unfortunately I know that our line of work is riddled with malpractice and it can come even if you did everything right. The only thing I didnt do properly was the coags, otherwise documentation I think I hit all the key aspects. I wanted to review my notes again, but it seems to have been locked bc pt is now deceased.

 

So, do you guys see anything that I may have missed or could've done better in my situation. So I can learn and avoid any future similar scenarios.

[rev ronin]

The patient was already dead... he just realized it on your shift.

[FfIghter23]

Naw, you won't be sued. 85 y/o with comorbids mentioned was a ticking time bomb. If he was 45 y/o, different story.

[Guest ERCat]

Sorry you're dealing with this. I am a new grad as well and am terrified of running into this situation. I am a newb but for what it's worth I agree with the above posts. If this dude was a 40 year old it would be a different story - not that you did anything wrong at all, I just mean that lawyers would be all over that and find SOMETHING to nail you. But the dude was old and had so many chronic health problems. Seems he just happened to die on your watch. I understand the anxiety though, and keep reminding yourself this stuff happens to even the best of providers. Stuff happens no matter how great of a job we do. Also there will be times when we DON'T do a great job because we are human and we make mistakes. Either way this is what malpractice is for.

 

PT/INR - who's to say you weren't GOING to order it? Even so would having it come back us therapeutic 20 minutes before this guy was gonna die change anything other than alert you that he wasn't properly anti coagulated?

[bike mike]

Ischemic cardiomyopathy and AS (severe?) is a bad combo and when these patients tip over very difficult to bring them back. Likely not much more you could do. 

[Boatswain2PA]

The human race has a 100% mortality rate.  

 

[EMEDPA]

The human race has a 100% mortality rate.  

 

 

and the most common rhythm is asystole....although 1/2 of all people who have ever lived are still alive right now, so your chances are pretty good, right? :)

[winterallsummer]

Nothing you could have done differently. He was dying no matter what, Rectal temp and coags or not. Not getting Rectal temp or getting coags wouldn't have made any difference. In our business death is all part of the job. Very, very few codes have good long term outcomes ever and some evidence exists that only CPR and maybe epi even help.

 

You did fine. Best case scenario this guy should've came in with DNR paperwork and died without chest compressions. But consider running codes on these old morbid pts practice for the few times you will have to code the dying young.

 

As far as cause of death it doesn't sound like aspiration. Probably the stress of the nose bleed taxes his already struggling heart into asystole. Frankly these elderly with so many health issues almost never do well. Such is life.

[momentous]

Thanks for the replies guys/gals.

 

I'm definitely not letting this stress me beyond that night. Right now I just wished I could've done more in the situation. I really want to learn more advanced procedures to help out and eventually run my own code, but most of the acute resus is given to the senior residents. Unless it's a stable pt, but again bottoms up. Will learn and experience the basics first before moving on higher and pushing new comfort limits.

 

During the code he was initially in vfib-asystole-back to vfib-back to asystole before calling it. Epi adminstered 3x before pressors were started via central line. Still no pulse and on echo the heart was complete stand still.

[Boatswain2PA]

.....Best case scenario this guy should've came in with DNR paperwork and died without chest compressions. But consider running codes on these old morbid pts practice for the few times you will have to code the dying young.....

THIS.  I use every ancient person code as a practice for my team.  The bad thing about this is, sometimes, we get a pulse back and then go "crap....that wasn't supposed to happen."  But then I use that, again, as practice for my team.  Hang the norepi, ice packs, ventilator management, versed...

 

During the code he was initially in vfib-asystole-back to vfib-back to asystole before calling it. Epi adminstered 3x before pressors were started via central line. Still no pulse and on echo the heart was complete stand still.

Why were pressors started via central line if there was no pulse?  Something I am missing here??

[km88]

Unfortunately, sometimes there is nothing you can do to change the outcome. This is probably the hardest thing about emergency medicine. I've been in EM for 2 years and have had 2 cases that I've lost a lot of sleep over and still think about often. In my patients' cases and yours, it doesn't sound like the outcome could have been changed. I dread the day when this isn't the case and I can find some reason to hold myself accountable. 

[Disciple3]

Can't save them all

[sk732]

My first week in the ED I work in now, I had an older dude bounce back with a horrible pneumonia...we got him sorted out, his family were hanging out with him.  He asked me if he was going to die - told him yes, all of us will, but I didn't foresee it happening today.  5 minutes later, he coughed up a shyte load of bright red blood and died about a minute later.

 

Number one, crystal balls are foggy.  Number two, feces occurs...and fairly often.  Sounds like you were doing everything you should have.  The diagnosis here really amounts to TRO - Time's Running Out - and his number was up.  Once the number is up, it can't be pulled back.  I think what's bugging you the most is that they were your patient and they were sorta walking and talking - that makes it a little harder to deal with as you've already made a connection with them.

 

Take it easy and try not to dwell on it.

 

SK

[ventana]

afib

crf awaiting HD

HGB of <8 (baseline) 

with nose bleed and the list of others DDx

 

Well he probably just the big old MI or CVA right there in the dept and died - was not aspiration because you said he was awake and alert - if you start to choke on something you fight for your life

 

 

They were lucky to be in the ER as they got immediate world class care!

 

Simply put their time was up...... and rather you got the INR ordered makes ZERO difference!

 

sounds like you are starting to realize the gravity of our job!  We have it tough and need to do the best we can (and you did!)

 

sorry you have to live it, but welcome to the ranks!!

[EMEDPA]

it happens, a simple etoh withdrawal sz pt of mine coded recently after being medically cleared, observed, and discharged(was still in dept). bit his tongue, airway full of blood, resp arrest followed by vtach. difficult intubation, etc. he lived, but very messy and embarrassing all around. don't know if it was preventable unless we had given him etoh in dept before d/c. doc in dept at time said he wouldn't have done anything differently.

[Evolute]

Its tough when a patient comes into your ED alive and leaves dead. Its normal to second guess yourself, just don't beat your self up over it......refer back to rev ronin's post above.

[Evolute]

and the most common rhythm is asystole....although 1/2 of all people who have ever lived are still alive right now, so your chances are pretty good, right? :)

 

Not to mention the most stable rhythm.

[FfIghter23]

The four patients most likely to have a bad outcome in the ED are:

1) the very young

2) the very old

3) the very drunk

4) the very crazy

 

Best advice I ever got and I still go over those charts twice before deciding next step.

[EMEDPA]

The four patients most likely to have a bad outcome in the ED are:

1) the very young

2) the very old

3) the very drunk

4) the very crazy

 

Best advice I ever got and I still go over those charts twice before deciding next step.

and a pt can be in more than one category....gotta love the elderly/crazy/drunk meth user....who I actually see fairly often....

[primadonna22274]

Most common cause of death in ESRD is cardiac arrest. In an 85 yo frail gentleman with the other comorbidities you listed (or, as we say in the south, a typical patient), it was just a matter of time. I seriously doubt a Hb of 7.5 with epistaxis was the culprit. Most likely a fatal dysrhythmia triggered by positional change and lack of sympathetic tone...he couldn't compensate, he brady'd down (quickly) and arrested. He was old, he was frail, he had a good long life and you did nothing wrong. Keep learning and do the best you can for the patient in front of you.

 

Sent from my SAMSUNG-SM-N910A using Tapatalk

[Guest JMPA]

The afrin killed him

[GetMeOuttaThisMess]

Try an elderly patient sometime who is in the bed right next to the open providers work station answering your hx. questions (non-cardiac c/o) with a crash cart coincidentally sitting right beside the head of the bed and when you look up from the foot of the bed because they've stopped answering your question you notice that they've arrested. Still didn't matter. Who knows in this case if it was an MI, intracranial bleed, DIC, or whatever; death is death and it's hard to reverse over the long haul. We're the only profession expected to be 100% correct 100% of the time with a 100% failure rate.

[polarbebe]

The afrin killed him

I doubt if you had done anything differently the that outcome would be any different. That said, it's great to talk about cases and see if anything can be learned from them (as mentioned previously)

 

Some thoughts:

Afrin in addition to a person with aortic stenosis (should be severe) could lead to high afterload leading to flash pulmonary edema,.. but this presentation would be more gradual and pt would have noticeable complaints and hypoxia. Or stroked from the afrin.

 

It is possible he was supratherapeutic with the Coumadin (nosebleed only from nose picking? or from high INR?) . Although you stated one month ago it was within "normal range". We know it can vary widely with multiple interactions. A posterior circulation head bleed could cause sudden death.