Department of Medicine Morbidity and Mortality Conference ... · they prepare by locating the patient near to the nursing station, observe for fall risk. On occasion, patients are

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Department of Medicine

Morbidity and Mortality Conference

February 13, 2018

“54 year old female presents with shortness of breath

and encephalopathy”

Presenter:

Burton Shen, MDInternal Medicine-Pediatrics Resident, PGY2

Prepared by Seth Clark, MD/MPH

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Panel Discussants

Joann Jannitto, RNClinical Manager Jane Brown 4N

Barbara George, CPHRM, CPPSLifespan Risk Management Coordinator

Mary Jane Pizza, MSW, LICSW, LCDPSubstance Abuse Coordinator

Alexander Chirkov, MDMedical Examiner

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Disclosures

Our presenters have no financial interest in or

affiliation with any commercial supporter to

disclose.

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Presents via friend in severe respiratory distress, stabilized in critical care

bay with supplemental O2 and able to provide following history.

Chief Complaint: Shortness of breath

History of Present Illness:

• 54 YOF with AIDS on HAART (VL undetectable) , HCV,

polysubstance use, and asthma presents to ED with 2 days of worsening

shortness of breath. Reports 2 weeks of generalized fatigue and dry

cough with progressive SOB that began the day prior and acutely

worsened 1 hour prior to arrival while at rest. Denies DOE, fevers,

chills, sputum production, chest pain, recent travel, prolonged

immobility, or sick contacts.

Case Presentation

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Past Medical History:

•AIDS (CD4 count 616, VL

undetectable)

•HCV untreated (VL 7.4 million

IU/ml)

•Schizophrenia

•Anxiety

•Depression

•Substance use DO (crack cocaine)

•? Asthma

Past Surgical History: None

Allergies: None

Family History:

•CAD in father

History (Continued)

Medications:

•Atazanavir/Cobicistat – 300/150mg daily

•Emtricitabine / Tenofovir – 200/300mg daily

•Paliperidone palmitate – 156mg Qmonth

•Respiridone – 1mg daily

•Trazodone – 50mg HS

•Gabapentin – 100mg BID

•Trihexyphenidyl – 2mg BID

•Ventolin – 90mcg inhaler PRN

Social History:

•Current smoker, 40 pack year hx

•Denies active illicit drug use

•Remote hx IVDU, last reported 2004

•Hx crack cocaine use, last reported 2012

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Physical ExaminationVital Signs: T 98.9 HR 144 BP 92/42 RR 33 O2 sat: 99% venti mask

General Medical Exam: Distressed, using accessory muscles for breathing.

HEENT: Normocephalic and atraumatic. Oropharynx is clear and moist. Airway patent. Conjunctivae and EOM are normal.

Cardiovascular: Regular rhythm and normal heart sounds. Tachycardia present.

Pulmonary/Chest: Tachypnea noted. She is in respiratory distress. She has decreased breath sounds and mild expiratory wheezes throughout all lung fields. Speaking in 3-4 word sentence. Frequent dry cough.

Abdominal: Soft. There is no tenderness.

Musculoskeletal: She exhibits no edema or tenderness. No obvious signs of injury or deformity.

Neurological: Lethargic, requiring frequent stimuli. Moves all four extremities.

Skin: Skin is warm and dry.

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Laboratory Results

11.414.7

148 137 103

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1.25187

44.3 3.4

VBG 7.30/60 Utox + Cocaine

Lactate 2.2 - Opiates

- Benzodiazepines

Trop 0.018

BNP 64.2 RPP + Rhino/Enterovirus

Urine toxicology testing was otherwise negative at this time.

Dr. Garland, from the audience, had seen the patient intermittently

in his outpatient office but noted that she kept her appointments

inconsistently and had not been seen in the office for a long period

of time

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CXR

No acute cardiopulmonary process was observed on the admission chest x-ray

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CTPE

Official Reading: No pulmonary embolism. Patchy tree and bud airspace opacities

bilaterally, likely infectious or inflammatory in etiology

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Hospital Course

• Assessment: asthma exacerbation precipitated by URI

• Plan: admit for inpatient care of bronchospasm in light of respiratory distress

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Hospital Course (HD 1-2)

• Remained somnolent in ED on BiPAP, intermittently attempting to leave AMA

• Treated with repeated doses of duonebs, IV steroids, 2L NS, and ativan

• Weaned off of BiPAP at 0600, remained tachycardic, admitted to the floor

• Arrived to the floor at 0730 and noted to be minimally responsive to sternal rub with significant wheeze, placed on non-rebreather

• No response to narcan

• ABG: 7.32/53/169 on 4L NRB

• Transferred to MICU

There was no clear reason for this patient’s somnolence upon admission. The patient

was initially triaged to the Medical ICU due to her dyspnea.

The patient had initial treatment for presumed asthma flare with solumedrol 125mg x2

doses, as well as bronchodilators for presumed asthma exacerbation

The patient had received Ativan which could have worsened hypoventilation, though not

enough to explain encephalopathy.

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Hospital Course (HD 2)

• In MICU continued on IV steroids, albuterol nebs Q4H

• Family reports the patient occasionally smokes crack cocaine, unclear last use

• O2 weaned from BiPAP to 3.5L NC, family notes baseline mental status

• Remained in sinus tachycardia (HR 90-130)

• Treated as asthma exacerbation secondary to rhinovirus, tachycardia believed due to albuterol and anxiety

• Transferred back to medicine service

• Remains alert, asking to leave AMA, but redirectable

Ms. Jannitto (Clinical Manager on Jane Brown 4N) noted that when the floor nurses

receive word of a complex patient being transferred to their floor from the Ed or MICU,

they prepare by locating the patient near to the nursing station, observe for fall risk. On

occasion, patients are placed in the hallway for closer observation, particularly at night.

Dr. Fagan, from the audience, noted that the patient demonstrated a high degree of

acuity, including abnormal vital signs and a lack of explanation for her altered mental

status or respiratory illness. Were this his patient, he would prioritize the patient to be

seen early on rounds and often thereafter while an aggressive investigation was carried

out..

Dr. Bayliss noted that the patient had a negative troponin, normal BNP and an ECG

showing only sinus tachycardia, prompting a search for an alternative explanation of her

tachycardia. Note that thyroid studies were normal.

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Hospital Course (HD 3)

• Stable overnight

• Remained in sinus tach to 130, on 3L NC

• 1700 – Patient signed out by primary team to crosscover as intermittently confused and does not have capacity to signoutagainst medical advice

• Also advised to hold benzodiazepines given encephalopathy

An audience member noted that the standard toxicology screen will not detect all drugs

of abuse , such as bath salts. Opiate withdrawal is also possible and there is often

fentanyl cut into cocaine.

Dr. Tammaro, from the audience, noted that her persistent and documented

encephalopathy would prompt him to consider other causes of altered mental status than

hypercarbia, including drug intoxication or withdrawal. Some of this work up had

already been done without identification of a cause.

Dr. Shen noted that the daytime team signed the patient out upon their departure to an

on-call intern who was also admitting patients. The patient’s resident would also sign the

patient over to a covering resident should the patient have active medical issues. While

this usually goes well, the handoff time is often very busy and followed by another

handoff later that evening to the overnight team.

Barbara George, from the Lifespan Risk Management office, noted that the patient’s

capacity for decision-making is best documented in the record.

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Hospital Course (HD 3)

• 1520 – Patient alone with visitor for roughly 30 min

• Nursing notes increasing agitation following visit

• 1800 – Agitation continues to escalate, patient removing O2 and tele leads. Desatting to 70s without O2, HR 140s.

• Cross cover paged, attempted to redirect, placed on venti mask

• 1815 – Patient placed in non-violent restraints after continuing to remove O2 and tele leads, notes “security may be needed”.

• 1845 – Nursing paged cross cover for persistent agitation and HR in 160s.

• Team reviewed CT with radiology and confirmed no PE

• HR and agitation transiently improved with verbal engagement and reassurance

Ms. Jannitto noted that this patient, due to her behaviors, was under constant

observation. A nursing assistant from the unit was in the room as a constant observer but

would likely have had difficulty holding a mask on the patient or preventing her from

removing telemetry leads.

Mr. Scott Hemingway from RIH Security explained that the need for extra supervision

is real, but that clinical staff on the med/surg floors at times expect security to provide

an ongoing presence beyond their staffing and ability. Security staff are best equipped to

provide safety oversight regarding visitors but cannot offer physical restraint efforts for

patients on a prolonged basis.

Despite the constant observation in the room, the patient continued to remove telemetry

leads and oxygen mask, resulting in transient episodes of hypoxia.

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Hospital Course (HD 3)

• 1920 – HR noted to be in 30s on tele, patient unresponsive, pulseless, code blue called

• PEA arrest ROSC with CPR + epi intubated (midazolam and morphine administered) PEA arrest, code called after 9 rounds CPR

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Alexander Chirkov, MD –

Medical Examiner

The patient had elevated levels of cocaine in her blood – although this could reflect

cocaine ingested before or after hospitalization. The ME examination suggested that this

might be pre-hospital ingestion of cocaine. Acute ingestion can be detected in urine for

up to 70 hours. The autopsy did not suggest acute lung injury from inhaled cocaine use.

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ME Report

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ME Report

• Benzoylecgonine – cocaine degradation product

• Halflife – 6-10 hrs

• Average blood concentration in patients admitted to ED for cocaine related medical complaints – 1280 ng/mL

• Average blood concentration in cocaine related fatalities –7900 ng/mL (700-31,000 ng/mL)

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Visitation Policy – Inpatient Adult

The working diagnosis for this patient was death from asthma exacerbation. The ME

exam raised issue of cocaine ingestion as potential cause or trigger of flare.

Dr. Garland noted that the patient had been seen in the clinic off and on for 15 year and

had sustained periods of sobriety from drug use.

Barbara George from Risk Management noted that HIPAA protects medical records for

50 years after death. The death certificate is a public document and so, even if a patient

expressed wishes that their condition not be shared with others, anyone in the public

could request this document after a patient expires. HIPAA also holds the clinicians

involved in the care of the patient to the privacy rules as long as the physician is aware

of the patient’s wishes.

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Body and Belonging Search Policy

If contraband or harmful substances are suspected, patients can be searched. Clinicians

and nurses should confer and reach a consensus on whether or not there is sufficient

cause to initiate a search. Such discussion should be documented in the record and be

based on team discussions.

There are three levels of search: Room -> Body -> Body Cavity. When a search is

initiated, the patient is informed in a respectful manner first and then, after the patient

and any companions are escorted from the room, the search is carried out., even despite

patient protest.

Note that a hospital policy on caring for patients who are prescribed medical marijuana

is being drafted.

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Body and Belonging Search Policy

Mr. Hemingway noted that hospitals with procedures for vetting and registering visitors

have decreased episodes of patient compromise by harmful ingestions in hospital.

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Thank you!

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Questions?

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