Thursday, January 8, 2009

Fast Track Disasters

So, I thought I might post a series on fast track disasters. These are patients that presented with relatively mild complaints, and/or were overlooked by triage, and were put back into fast track, but ended up being pretty sick.

First case:

35 year old caucasian male with a complaint of "cellulitis". H/O Multiple Myeloma on immunosuppression. Patient states that his left elbow is quite reddened and swollen. Now, apparently triage was being manned by monkeys, as no one noticed his pressure of 90/45. OR his pulse rate of 126. Closer examination revealed full elbow ROM with only slight pain at the extremes of flexion. supination and pronation full without pain. Posterior elbow has a definitive infected Olecranon Bursitis, but looking closer, the rash encompasses his ENTIRE RUE. From the axilla down to his wrist, worse posteriorly, but present even circumferentially. I'm starting to get a little nervous now, but feeling at least a little better, after a BP recheck shows 100/50
I immediately order Zosyn, and a 1 liter bolus, look at our critical bed situation.....D*mn, only ONE bed left over there. Time to talk with my attending, I briefly discuss the case with her, and she is, as a new EM doc, a little scared as well. We talk to the charge nurse, and ask that another nurse come over for one to one care with q 5 minute vital checks, and while this is being arranged I am calling the Hem/Onc fellow. We chat briefly, and are both in agreement that he needs ICU care. I call the ICU, and speak with the fellow, and subsequently the attending there. They agree to accept the patient, with Hem/Onc being the primary service. We arrange for an Ortho consult when the patient reaches the floor. He was out of Fast Track within 45 minutes after arrival. Immunosuppressed Multiple Myeloma patient in early septic shock was how I coded that.

I thought briefly about taking the last critical bed, but the fact that his BP was climbing slightly, and that he was still mentating, and functioning okay, made me re-assured that with close one to one nursing care, and a rapid transfer to ICU care would be okay in FT. I simply didn't want to take the last critical bed from a level one MI (STEMI) or a level 1-2 trauma.

Anyway, that is just one of several postings to come about fast track disasters.


Anonymous said...

Awful young to have multiple myeloma...bad luck. One question though in your statement
"Multiple Myeloma on immunosuppression". Are you saying the patient was post allo-transplant on chronic immunosuppression or do you mean he is day X of cycle Y with chemotherapy drug combination Z and hence is at risk of a neutropenia (of course in addition to his presumed sepsis)?

physasst said...

day x of y cycle of chemotherapeutics.

Greater risk of neutropenia, If I remember correctly the patient was under consideration for BMT.

Anonymous said...

I had an intoxicated pt that triage put in fast-track. He had fallen and hit his head, definately needed a lac repair. Confused, stinky...but was this his normal baseline?

Fast-track is for patients needing 1 or less resources. This guy really needed a CT of the head, labwork, and suture repair (at least 3 resources, which disqualifies him for fast-track). Confusion automatically bumps you up as an acuity level 2, which is inappropriate for fast-track.

Anyways, head CT showed a subarachnoid bleed. He was definately one of those in & out patients; dont you agree?!

physasst said...

Don't get me started. I've had so many discussions with the various institutional committees, that my head hurts even thinking about it.