Case Presentation Chief Complaint: Chest Pain Brief HPI: 56 y/o with HTN, DM, transgendered genotypic male on estradiol 13:51: Patient evaluated by triage RN in ED. Endorsed chest tightness x3 days and new onset SOB. Tachycardia noted. 13:59: Patient placed in ED bed, ECG obtained. 14:00: POC troponin 0.27 (range 0 – 0.39) 14:00-14:29: Seen by Resident MD – note entered. HPI "56 y/o…on estradiol...complaint of CP. Began on Friday…substernal pressure + stabbing pain. Radiation down L arm…DOE report with CP. CP improves with rest and restarts when he does begins moving again.” 14:11: Labs Post: WBC 18.0 (H); Cre 1.9 (H); CKMB 3.9 (0.5-3.6); Lactate 5.0 (H) 14:26: 324mg ASA given; patient placed on 2L O2
Physical Exam/Vitals (adapted from note): Vitals: Pulse: 122 (07/06/2014 13:57) Resp: 20 (07/06/2014 13:57) B/P: 98/66 (07/06/2014 13:57) Pain: 0 (07/01/2014 08:11) Pulse Ox: Measurement DT POx (L/MIN)(%) 07/06/2014 13:57 92 General Appearance: NAD Chest: Lung Auscultation: Cardiovascular: Rhythm: Regular Auscultation: No gallop Inspection: Normal No murmur Trace edema. A/P (adapted from note): “CHEST PAIN: Suspect unstable angina…” Plan to trend enzymes, give ASA, BB, and Statin; admit to Medicine vs. Cardiology with telemetry
14:30: Atorvastatin 80mg given 14:44: ED Attending note entered. Endorses agreement with resident plan. 14:46: Medicine Certification for Admission placed 14:52: 12.5mg PO Metoprolol given 15:30: proBNP reported 8303 15:55: Patient reports CP gone. Repeat Vitals Pulse: 106* (BRACHIAL) (07/06/14@15:55) Resp.: 18 (07/06/14@15:55) Pulse Ox: 97% (07/06/14@15:55) B/P: 102/75 (BRACHIAL) (07/06/14@15:55) 15:30 – 16:40: Admitting Team is notified of patient. Patient examined in ED and accepting team work-up begins.
*Based on admitting resident note and de-briefing, there is documented concern about patient. This is escalated to admitting team’s attending. Per Admitting Resident’s H&P Plan: Hypoxic dyspnea: DDx includes PE, RHF with effusion, PNA. Most likely PE given estradiol predisposition to clotting, S1Q3T3 pattern on EKG, tachycardia, hypotension. AKI currently preventing CT:PE. BNP of 8000 concerning for right heart strain may be present and there is a chance patient would benefit from thrombolytics. - MICU consulted re: possible PE, appreciate recs - possible cardiogenic shock, thus treating with PE protocol heparin gtt (loaded with 10,000units and inital rate of 20ml/hr - PTT at 1:30am) - Unable to perform CT:PE at this time due to AKI (Cr. 1.9). Per MICU, if Cr repeat is <1.5 benefit would outweigh risk and would recommend CT:PE. - D-dimer pending, likely will be elevated, dopplers LE's pending. - CXR with small plerual effusion, no other acute pulm process noted.
16:57: AOD/Bed Rep confirms with admitting team Re: Admission 17:08: Cardiology Service is consulted. Admitting team indicates concern for PE and possible early “heart failure”, request STAT TTE. 17:23: Medical ICU Consulted 17:50: CPRS - Patient “direct” admit to 4B-OBS Unclear exactly what time patient arrived to floor 18:38: Delayed orders entered: Delayed Unitl: Admit to Internal Medicine – Heparin 10,000 Units Bolus IV Once
Approx 18:45: MICU Resident begins evaluation 19:18: Delayed Orders Manually Released 20:12: Heparin Bolus Ordered verified by Pharmacy 20:29: Heparin Bolus Administered – only 5000 Units given Approx 20:30: MICU final recs given, encourage STAT TTE, convey “no current need for ICU admission” Approx 21:30: Cardiology fellow reports TTE demonstrates large thrombus, RV dysfucntion
21:36: Heparin gtt started Approx 22:00: Patient transferred to MICU Per MICU Resident Admission H&P: -Admitted to ICU for monitoring given suspected large clot burden and RV strain as seen on TTE. -Spoke with oncall IR resident (Dr. Maldonado) about possibility of intervention to the seen RA thrombus - he stated that catheter directed thrombolysis would be a possibility if we were sure about a clot in the PA but even this would have to be done under angiography (would utilize contrast) and given the present AKI it would not be advised. Code Status: DNR/DNI 03:50 : RN Note “0350: Patient complained of shortness of breath and difficulty breathing, while assisting him, he became unresponsive. Dr. Vachhani notified and immediately arrived at bedside. 0420: Patient expired.”
Systems Issues Identified 18:38: Delayed orders entered: Delayed Unitl: Admit to Internal Medicine – Heparin 10,000 Units Bolus IV Once 19:18: Delayed Orders Manually Released 20:12: Heparin Bolus Ordered verified by Pharmacy 20:29: Heparin Bolus Administered – only 5000 Units given
Pharmacy cannot verify/view any order when entered as DELAYED, including STAT orders 1 HR delay from orders being released until verified from by pharmacy RN cannot see order until verified by pharmacy Order Entry Issue: VA carries vials of 5000 Units of Heparin. Order entered as 10,000 UNITS IV ONCE. Order appears as follows: 4B OBSERVATION 4B124-13 07/06/14 20:31 HEPARIN 5000 UNITS/ML SINGLE DOSE VIAL [10000 UNITS ONCE IV Inj Site: IV/LOCK] MJT 07/06/14 20:31 Given 7/6/14 19:18> HEPARIN NA 5000 UNT/ML UNIT DOSE VL,1ML 1.00 1.00 100 unit Comments: