Difficult Situation Survey for Patho Class

1. What is the most difficult case that you can remember dealing with?

Some years ago when I was working on a med/surg unit we admitted a lady in her late 30's (young by most accounts!) with a DVT (Deep Vein Thrombosis) in one of her lower extremities. If I remember correctly, her doc first thought this was a side effect of her being on birth control pills. She ended up being a diagnostic puzzle. This was not a side effect of the birth control pills. What was difficult about her case was that her diagnosis was changing and her treatments changed. She was in danger of having a stroke or going into renal failure at any time.

2. What was wrong with the patient? What are the S&S?

First, the DVT. All the signs and symptoms: redness, swelling and tenderness and warmth to touch in the involved leg . Then, after treatment, it came back and treatment started all over again. It came back. Then, DIC (Disseminated Intravascular Coagulation) was diagnosed. Then, they started looking for the underlying cause of the DIC and they found cancer in her pancreas. She started getting petechiae all over her body indicating small hemorrhages. As I recall, when they finally found her cancer it was very occult and had not presented any symptoms up to that point. By the time they found it, it had metastasized to her liver. Her prognosis was poor. In the space of a month she went from being a strong, fairly healthy and active 30-something woman to being at death's door. It was a very sad situation and the patient herself was devastated emotionally.

3. What specific action was taken? How were you involved in the diagnosis and/or treatment of this patient?

For her DVT she was treated with continuous Heparin drip IV infusions followed by titration on oral Coumadin, twice, I believe. When the DIC was diagnosed she was also placed on a Heparin drip. PTTs were constantly being drawn. We had to work around her very carefully because the slightest pressure on her skin resulted in a bruise. She also got some infusions of blood clotting factors which none of us had ever given before. She bled from her IV sites. When they were investigating the underlying cause of the DIC she had a battery of lab tests and x-rays since the underlying causes of DIC are usually an infection or cancer. Needless to say, this whole thing was an emotional roller coaster for her and she took a lot of one-on-one by the staff to just be with her and listen and be emotionally supportive with her.

Would you do anything differently if faced with this type of patient in the future? If so, what would you do differently and why?

Nothing to do differently except follow the doctors orders and document the patients signs and symptoms and her responses to the treatment being given.

This happened about 20+ years ago. I remember it because each day that I came in to work there was some new development in her case and it was always shocking. She was discharged home eventually when they got the DIC under control, but she was readmitted about 3 weeks later and died at that time from the cancer. It was very sad because you don't normally see people that young dying of these kinds of things. I was a fairly newly licensed RN at the time, so this was kind of shocking for me to experience.