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House Call Clinical Pearls - PowerPoint


									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
   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
8) INRs in a 2nd floor patient with no
7)  Aikido and the chronically angry
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
#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
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

   Ms. W.
   Surgeon #2 “Lap Choley”
   Preop: Stabilize VS, Bun/Cr, EKG,
    Echo, simplify meds, goals with family,
    geriatric anesthesia, delirium
   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

   Good news- Medicaid waiver -> 16
    hour aide approved

   Better news- Excellent aide (Quinta)

   Bad news- Depressed, irritable,
    constipated patient

   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
#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

   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
   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
   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

   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!”

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

   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
   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

   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

   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
   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
   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
   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

   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

   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

   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
   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

   Oversee aides to ensure they meet her needs

   Cost of NH care for 3 years = $225,000

   Cost of Waiver/ HC care = $135,000

   Value of elder staying in her home and

   Value of GREAT Social worker = Priceless
#1- How to get blood from
resistant, anxious dementia
   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!”

   Give candy before and after Blood

   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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