This is not just another Clinical Case that I am sharing with you all today. This case is going to form the basis of the Broome Docs team presentation at the ACEM Winter Symposium here in Broome on the 15th June 2013.
So this is your chance to get involved – and share your opinions with the audience at ACEM in a few weeks. So have a read of this case and contemplate the decision points I have selected. Let me know how you would manage this case and if you have any new (or old) evidence to support our decisions. One of the beauties of Social Media in Medical Education is that we can “crowdsource” expertise, opinion and know-how. So here we go – let us know how you would proceed. Here is the case…
Emily is a 42 yo. woman from Billiluna (Mindi Bungu) in the East Kimberley not far from Wolfe Creek crater. She has been living in Broome for a few months. She was sent in by the clinic for a Surgical review of her diabetic foot ulcers a while back – but has been ‘living rough’ in town ever since. Currently residing in a 2 bedroom unit with 10 other adults and their children.
Emily has been seen in ED a few times recently with minor injuries resulting from assaults. Her foot ulcers have never really healed and she has intermittently been seen in the dressing clinic for ongoing dressings. Emily doesn’t wear (or own) shoes.
In terms of PMHx, there are a lot of unknowns. We know that Emily has been diabetic for at least 10 years and has had significant hypertension and proteinuria for at least 5 years. She was seen by the visiting Ophthalmology team in Billiluna last year – they diagnosed moderate non-prolifertive retinopathy. There is not much more information – she has moved around a lot with her family so there is no “complete” medical record.
Emily’s current medications according to the Billiluna clinic’s fax – usually supplied a Webster pack with the following meds. Last dispensed 3 months ago.
metformin 2000 mg slow-release daily, ramipril 10 mg daily, amlodipine 10 mg daily, irbesartan 150 mg daily, aspirin 100 mg. She has an Implanon device in situ.
OK that is all the background you have when the Ambos roll in the door with Emily on the trolley. One of her housemates called them as Emily was complaining of being “short winded” with some fevers.
On arrival her obs are:- pulse 120 sinus tachy, BP 100/50, RR is 25/min SpO2 95% on 6 l via HM, her temp is 39.1 (102 F for the Americans), a finger prick BSL = 24mmol/l ( 432 mg/dL in the USof A)
Emily is shivering and looks uncomfortable. She is sitting forward and coughing intermittently. She is alert, looks anxious / scared. There is an unpleasant smell emanating from the dressing on her left foot.
Q1: OK here is my first point for contemplation. What further history do you want to know in the next 10 minutes?
As you are getting in a few lines and taking a history the nurse has run a VBG on the ED POC machine. Here are the numbers:
pH = 7.15
PO2 = 31
BE = -7
HCO3 = 15
Lactate = 5.1
Q2: Contemplation point #2: What is the significance of a lactate = 5.1 mmol in this context?
OK, she’s sick. Looks infected and has a high lactate. Her BP is lowish – but recall this is a woman who is prescribed 3 different antihypertensives to control her BP.
Lets start a bit of fluid resuscitation – I think we can all agree she is going to need it! We have a few big IVCs and a radial art. line in place. There are only 2 questions really – but they are not without their controversies.
Q3a: Which fluid will you use initially for your resuscitation?
3b: How much will you give empirically?
3c: How will you decide that you have given enough?
We need to localise the source of her sepsis. Her foot looks nasty, purulent exudate and you suspect a collection adjacent to that ulcer. Now – where else could it be coming from?
Physical examination reveals: bilateral chest crackles, an aortic flow murmur (very tachy though), no obvious skin sores elsewhere, urinalysis shows 4+ protein but no leuks or nitrites. She denies any headache currently.
Q4: Which empirical investigations or studies will you order to find the potential sources of infection? What time frame do you want to achieve this within?
Now I would like to fast forward this case about 12 hours. Emily has been resuscitated, worked up and admitted to the HDU [Staffed by a single RN and variably experienced Docs. Despite a trial of peripheral IV phenylepherine her BP and urine output have been lagging overnight, so the night MO inserted a CVC into her (R)IJ and commenced inotropes.
Q5: What is your first line agent for sepsis? Tougher question – why?
After a smidge of X [insert your answer to Q5] her numbers look a bit better, but….
The CXR from this morning reveals a right lower lobe pneumonia and it looks like there is a bit of patchy changes around the left heart border as well – they were not there last PM
She is getting more short of breathe, her sats are cruising in the low 90s on a high flow face mask. RR and work of breathing certainly worse overnight. She remains alert but looks tired. The arterial gases have showed a slow drift into deepening acidosis – both lactic / metabolic, but now with a creeping pCO2 – up to 46 mmHg. She is going to need some help. Her family are a bedside – so you decide to have a chat about the plan for the coming hours.
She is looking like she might need an ICU at some point. And if you are in Broome – this means a flight and a long one – 2000 km to our “local ICU”. Being a patient-friendly Doc, you mention this to her. You think she should be transferred as it is possible that she will get worse. You start to explain how this would mean being placed on a ventilator and an induced coma for days – possibly weeks…..
Emily stops you right there! She refuses to be transferred out of Broome. Full stop. When you ask why? She has recently lost a number of family members to illness – and they all left Broome on the plane and never came back. For Emily this is an unacceptable outcome. Dying “out of the Kimberley” out of her country is unacceptable. She wants to stay, she wants you to do all you can to keep her here.
Right. Tough one. The Nurse Manager is calling you into her office – there are 2 x “Trop negative Chest pains” awaiting admission to HDU and the surgeons are mid-way through a hemicolectomy on an 80 year old chap. She cannot possibly staff the HDU when all this arrives. Her position is: “Send her out ASAP” We are out of resources.
As you leave the Manager’s office you start wondering…. Emily is doing OK from a haemodynamic POV – she is requiring only the tiniest dose of inotrope. Her oxygenation and ventilation are the main issues right now. Sure – intubation would help that – but she has expressed a strong desire to avoid that option. And we know that intubation carries its own set of risks down stream. You know that there is NO way the retrieval team would take her ‘unintubated’ – just too risky. So what about a trial of NIV?
Q6: Would you trial a period of non-invasive ventilation in this case? If so, what end-points are you looking to achieve ? Or how do you decide if it is failing?
OK, lets fast-forward again 3 hours. Emily has tolerated the NIV well. Her respiratory rate has fallen and her gases are improving a bit – she is not hypoxic and her CO2 has come down to normal range. Just as you are suggesting a break from the mask the phone rings….
The RFDS are inbound with another sick patient who will likely need HDU level care. The Nurse Manager is not looking pleased! The RFDS say they have enough hours to scoop Emily to Perth if you think she needs… BUT…. she cannot go without a tube and all the works. But you have to decide in the next 30 minutes.
So here we are… decision time. Emily is looking better, sure she might get worse, but right now she is “Broome-worthy”. There are a heap of “non-Emily” reasons to transfer her. So how do you balance these?
Q7: Final decision – does she stay or does she go?
Your call (remember you are in Broome), you are going to have deal with the consequences and once this bird has flown, it won’t be coming back anytime soon!