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Top Ten Clinical Pearls Eric De Jonge, M.D. Washington Hospital Center April 29, 2009 “The Secret of Being a Bore is to Tell Everything” -- Voltaire, 18th Century MHCP Team MDs- George Taler, Stephanie Bruce, Namirah Jamshed, Eric De Jonge NPs- Jan Goldberg, Michelle Sullivan, Robyn Feely, Nancy Sassa SWs- Jenna Crawley, Monica Thomas, Sari Parnes Support Staff- Wanda Holeman, Sandy Mills, Patrice Thompson, Maria Copeland, Top 10 Clinical Pearls 10) Finding a Safe Path to Surgery 9) Healing pressure sores after hip fx repair 8) INRs in a 2nd floor patient with no veins 7) Aikido and the chronically angry patient 6) Mystery of a very swollen woman Top 10 Clinical Pearls 5) Daily aspiration and an anxious CG 4) When not to use BiPAP 3) Doing no harm at the hospital 2) How to avoid the NH 1) Getting blood from a pugilistic patient #10- Finding a safe path to surgery Ms. W.- 89 yo with 3 days of severe abd. pain, fever, RUQ tenderness, WBC of 19K, and ++U/S for acute cholecystitis H/O left CVA, old CAD, mild dementia, TAH, Expressive aphasia TIAs, decent function (can walk one flight) Surgeon #1: “Not a candidate for Anesthesia” (too old and sick) “Perc. Drain for 6 weeks” Family: “She picks and pulls at things” (like Perc. Drains) Geriatrics / Surgeon #2: Willing to try definitive surgical Rx #10- New 2007 JACC Guidelines Fleisher et al. J Am Coll Cardiol 2007; 50:1707-32 Key roles of RFs, Function, Type of OR – RFs- CAD, Compensated CHF, DM, Renal insuff., CNS vascular disease – Function- > 4 mets – Type of OR (low, medium, high) – Pre-op stress/ cath ONLY indicated for unstable/ active cardiac disease #10 Ms. W. Surgeon #2 “Lap Choley” Preop: Stabilize VS, Bun/Cr, EKG, Echo, simplify meds, goals with family, geriatric anesthesia, delirium prevention, To OR within 24 hours, home in 72 #9- Healing pressure sores after Hip Fx repair Ms. C- 88 yo with R-Hip Fx repair, severe combative dementia, bedbound at home Refusing PT/ OT/ OOB, eating poorly Dying son, ETOHic dtr., POA/ dtr. with dying husband New Stage 2s on sacrum/ right heel #9 Good news- Medicaid waiver -> 16 hour aide approved Better news- Excellent aide (Quinta) Bad news- Depressed, irritable, constipated patient #9 Rx for Wounds – Teach aide on pressure relief – Zoloft 25 mg with some mood response – Miralax powder daily and better appetite – Moist occlusive dressings/ elevation – OOB to chair / persistent PT – One month- Wounds 50% smaller and granulating #8- INRs in 2nd-floor patient with no veins Mr. A.- 85 yo man with labile INRs (1.0 to 9.0), LGI bleed from “tumor”, DVT/PE with IVC filter, worsening BLE phlebitis/ recurrent LE clots Severe CVA- 1989, Need consistent INR but no veins and cannot leave 2nd floor Decline colonoscopy, focus on staying home #8 Good news- Medicare pays for fingerstick Coagucheck at home Better news- Excellent son/ CG Machine and training in place INR 1.8 to 2.5 for 3 months, no bleeding Weekly reports sent direct to office #7- Aikido and the chronically angry patient Ms. C- 76 yo woman, with illiteracy, HTN, anemia, irritable mood, and angry about “being kept waiting”. Dislikes NPs Borderline personality traits- chronically dissatisfied, labile mood #7 Strategy (from senior NP) – Goals: De-escalate situation, feel less crazy – Sit NEXT to them, not in front of them – Ask what they want you to do (within reason) – Set clear limits, do not argue – Frequent visits – Aikido- Japanese martial art of blending and harmonizing with your adversary to neutralize an attack or conflict. #6- Mystery of a very swollen woman Ms. G- 76 yo woman with morbid obesity, basement-bound for 2 years, now with 4+ edema from feet to navel Non-healing stage 2 buttocks ulcer, aide less able to turn her No respiratory Sxs, 02 sat 95% on RA CBC, Bun/Cr, and Albumin normal #6 Grandson (age 22) cooks for her Very disheveled first floor/ kitchen Cabinet Biopsy – 8 ounce Del Monte Carrots/Beans – 460 mg of sodium – > 10 g of daily salt – Rx-- Lasix and Fresh vegetables #5- Daily Aspiration and an Anxious CG Ms. F- 73 yo with trach/ laryngectomy, PEG, and frequent aspirations (tachypnea, higher HR, low fevers) Bedbound, chronic fecal impactions due to non-adherence by CG Anxious CG/ nephew- 3-5 calls per week 0400 call-- “I think she aspirated!” #5 What do you do? A) Have CG report home vitals B) Agree to REALLY give bowel Rx C) Hold TFs for 12 hours D) Tincture of Time E) F/U Call or visit after sunrise #5 Use ER only when major change in home VS or change in mentation 10-12 such calls from CG 1 acute care admission for “PNA” that cleared within 24 hours #4- When not to use BiPAP Mr. C- 67 yo with Multiple System Atrophy and chronic respiratory failure, cachexia, Stage 4 sacral ulcer, PEG, DNR/DNI Cared for doting wife at home. PEG falls out Saturday AM Unsuccessful reinsertion by M.D. at home To ER for replacement #4 ER lacks G-tubes, GI lab closed Admit to floor for observation ABG- 7.35 / CO2- 70/ O2- 132 BiPAP placed for night House Call M.D. removes biPAP in AM PEG replaced by GI #4 That night, BiPAP replaced by night float for high CO2 Next Day- AXR- STAT “Massive gastic bubble into left thorax, worse RLL PNA” PEG pops out of Abdomen PEG replaced by GI to “low, intermittent suction”, AXR normalizes Wife and M.D. agree to not use BiPAP #4 Worsening Resp. failure, lethargy, due to MSA and aspiration PNA Wife declines hospice, Morphine Peaceful death in hospital Lesson- BiPAP has detrimental role in neurologically devastated person with no gag, who is in final weeks of life, regardless of “C02 level” #3- Do No Harm at the hospital Mr. Z- 82 yo with dyspnea / fever/ lethargy at home. Has Severe COPD, CAD, new BKA, DM, Smoking, PTSD from 1950s Wed. at 4:00 pm Clear wishes for DNR/ DNI, POA in Wisc. Trusts only House Call clinicians, refuses care from all others 5 potential hospitals for 911 #3 Dangers – Unrelieved sxs / ? death at home – Agonizing course on unwanted vent, under care of strangers at other hospital – Enmity between patient and hospital staff – Prolonged hospital course with predictable sequelae #3 Pearl Urgent NP visit at 5:00 pm Dx- Acute PNA, needs O2 and IV Abx Note, code status on wireless EHR Send via private ambo to our ER Call to ER Attending EHR viewable by ER/ hospital staff #3 Admit to Geriatrics service on IMC Aggressive supportive care, transient BiPAP (No ETT, minimal blood draws) Improved sxs, refer to home hospice for endstage resp./vascular dz Great education for residents Home in 3-4 days with NP visit on Day 1 #2- How to evade the NH Ms. M.- 72 yo with CVAs (1976 and 2002), HTN, severe hemiparesis, seizures, and chairbound No in-town family caregivers Lives in “independent” senior apt. Husband / CG dies in 2006 Apt. management advocate she move #2 Services over past 3 years – Frequent medical visits (20 / year) – MA waiver SW case mgt., adjust aide hours up to 16 to meet needs (hygiene of self and apt.), Lifeline when alone at night – Intervene with apt. manager to accept her presence, allow aides access to building – Engage lawyer for POA of HC/ Finances #2 Engage remote family to monitor bills and handle financial affairs Her wishes- “Keep Parthenia alive and talking as long as you can” Coordinate specialty visits with transport and reminders Oversee aides to ensure they meet her needs #2 Cost of NH care for 3 years = $225,000 Cost of Waiver/ HC care = $135,000 Value of elder staying in her home and community? Value of GREAT Social worker = Priceless #1- How to get blood from resistant, anxious dementia patient Mr. R.-- 78 yo with severe dementia, MDS with worsening anemia, bedbound on 3rd floor walk-up Physically wrestles NP/ MD when they approach with needles “You get away from me!” #1 Give candy before and after Blood Draw Successful about 75% of the time Lessons/ Summary 90% of HC care is not “Evidence-Based”, and the rest may not be either Most success comes from listening to patients and families, and trusting NP, nursing, and SW staff Huge opportunity to educate specialty and community partners on how to protect and preserve frail elders
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