So, it being July (yes I know it's August but this happened a few days ago) we are dealing with overzealous new residents who want to work up everyone for everything and do everything exactly by the book. I'm wondering if I overreacted to this situation and how this sort of thing is handled elsewhere.
My pt was postpartum day 1. During labor the previous day she spiked ("spiked") one BP of 150/73 and then a few hours later she had a BP of 142/something normal. All her other BPs were perfectly within range. She had no headache, blurry vision, epigastric pain. And again, her BP was textbook perfect when I was taking care of her, like SBP 116.
An intern with less than one month's experience as an MD decided she needed to be worked up for PEC because of her two (I would argue one, really) elevated BPs the previous day. Putting aside the fact that they really should have made that call at the time of the elevated pressure (which was when she was in labor and, I dunno, maybe in pain or something) this seemed utterly ridiculous to me. Especially when this intern instructed me that the urine sample absolutely HAD to be from a straight cath rather than a clean catch.
We rarely do PEC workup from a straight cath, especially if the pt is already voiding on her own. It's invasive and introduces risk to the pt and is best avoided if possible. I understand that if the clean catch isn't really clean you get a contaminated sample and you don't know if any protein is from lochia or actually proteinuria. But it seems to me that can be a matter of assessing the pt's lochia (if she's bleeding heavily a straight cath is more reasonable than if she's hardly bleeding at all) and also counseling really well on the necessity of cleaning and doing the clean catch properly. If the sample comes back negative for protein, great, you've avoided an invasive procedure. If it comes back positive, well then based on the rest of the lab results (CBC/CMP) maybe you can decide from there whether or not to do a straight cath to confirm the protein is from the urine.
In any case, I had two major problems with these orders: one, that her BP was currently perfect and the workup seemed wholly unnecessary in the first place; and two, that the urine sample should have to be from a straight cath. I made my case as best as I could to the resident but was shot down.
(The results: slightly elevated protein/creatinine ratio and one slightly elevated LFT. Platelets normal, everything else normal. They decided to diagnose her with "preeclampsia without severe features", which also seemed ridiculous. What, were they going to mag a pt whose BP was perfect, who was asymptomatic, and whose labs were only ever so slightly out of range?) (The only order they ultimately changed was vitals Q4 instead of Qshift, which, ok, whatever.)
I feel like if this pt had delivered in February rather than July this would never have happened. We certainly don't work up everyone who has two instances of BP >140 and a straight cath has rarely been required in my experience. What are your thoughts?
Aug 2, '17
I agree this patient probably would not have been subjected to a work-up had a more experienced practitioner been involved in her care.
Do your residents round with an attending? Might that have been an opportunity to discuss options with the group, advocating for a "watch and see" approach?
Did you plead your case up the chain of command to your charge nurse/manager/attending?
I'm glad that she was well, but also believe that we have some responsibility to rein in costs, and it sounds like some unnecessary money was spent chasing a learning experience for a new resident.
Aug 2, '17
Not only the costs, but the unnecessary invasive procedure, painful, embarrassing, and risk for infection.
Aug 2, '17
When in doubt follow up with the attending.
Aug 3, '17
What kind of adult who's voiding on her own would even LET a nurse near her with a straight cath?
This reminds me of when I was last hospitalized, 7 years ago, in August for a water deprivation test. This test requires labs and urine samples q 1hr. An overzealous intern came in to explain the test to me. She asked me if I knew what it involved. I told her that I had done one on a 3 year old before. She said "oh, that must have been hard, what with the Foley and everything." I explained that we didn't use a Foley- we weighed his diapers to get the output and put cotton balls in them to catch the urine samples (all the q 1hr U/As are looking for is spec grav and osmolality). She said "well we're going to use one on you!" I calmly replied "no, you are not. You will provide me with a urine hat and I will void in it." Then she tried to order a Foley because I heard the nurses explaining the same thing to her- "we don't put Foleys in ambulatory 26 year olds who can walk to the toilet and void in a hat."
Aug 3, '17
The attending should have been overseeing this brand new MD.Not to mention her residents...where were they?? Yikes!
Aug 4, '17
If I can walk to the bathroom and pee on my own, anyone that comes near me with a catheter is gonna get strangled with it. We also have to chart the reason why we did a cath (perioperative procedure, end of life comfort or what have you). It's one of those drop down menus and "so Doogie Howser can show off his shiny new MD" isn't an option.
Aug 4, '17
This is definitely a situation where you go over the resident's head and call the attending.
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