ED Discharge Instructions -- At what point should the pt come back?

[BeaverhausenRN]

Hi all, hoping to maybe gain some insight on this. It's a long one, but I didn't want to leave anything pertinent out!

Disclaimer: This was not MY patient. I was floated to help cover, and the fast track side of this facility's ED is small & collaborative (to an extent).

A pt came into the ED a couple of days ago stating she was having a "gastroparesis flare-up." This pt used to be a FF with pretty much all the same complaints, but she actually hasn't seen for this for quite a long time. She presented today with n/v, dizziness, and upper abd pain she rated at an 8/10, as well as feeling lightheaded and like her "heart was beating a little funny" at times. Pt stated the "flare-up" began ~1 week ago, but that things had gotten much worse ×3-4 days, including some bright red blood in her vomit. Her home meds include (but aren't limited to) the highest dosage of promethazine I've ever seen, carafate, RX K+ supplement & multivitamin (malabsorption/malnutrition is an issue here), a ppi, psych meds (an SSRI & a benzo) and valproic acid for seizures (her Dx list includes epilepsy & pnes; pt believes most are the latter) and anxiety/depression. She also takes oxycodone for the abdominal pain. All of her meds are self-administered via the j-port of her gastrojejunostomy tube, with the g-port used exclusively for venting. She had several episodes of emesis while she was with us, and it just seemed like gallons (my exaggeration, not hers) of stinky, thick, sticky, deep yellow gastric gunk. I will say the poor girl looked & sounded absolutely miserable.

However. Her labs were "OK" -mostly WNL, but did show some elevated eosinophils & ALP, low chloride & hgb, etc - and CT & CXR both clear. So the resident made the call to dc her. Resident said pt "had the option" to be admitted (what?) but would likely be receiving less medication (lower doses) in the hospital than she has at home, so pt decided to go ahead and be dc'd. When she asked at what point she should come back to be seen, the resident told her that if she couldn't keep anything down (check), felt lightheaded/dizzy (check, check), vomited blood (check), or just generally was feeling "really bad" (um, check), to come back in. The pt expressed confusion, as these were pretty much all the reasons she had come in the first place. So the resident told her that the whole bag of vomit should be filled with frank blood for it to be necessary to come back in. The pt just sort of looked at the resident, quietly collected her belongings, and left. 

Granted, I was not privvy to every detail myself and a few bits of this story I heard secondhand. And I know we can't just "fix" everything/everyone, but I just felt so bad for this poor girl. She used all of the tools her pcp/gi had recommended, to no avail, and her symptoms objectively seemed severe. I feel like this is one of those situations that's going to be weighing on me for awhile. I feel like more should have been done for her than giving her than a crushed pepsid & some mylanta to push via her j-tube. She had an IV put in for the IV contrast for the CT, and I do feel like she could've at the very least benefitted from some IVF while she was here, but the doc didn't order any. 

I don't know. I feel like she was sort of pushed out to deal with things herself, and I honestly don't know if she even would come back in -- or how bad she'd let it get before coming back, as she was unsure about those instructions when the doc gave them at d/c. I don't know. Any thoughts?

[JBMmom, MSN, NP]

It sounds like a very unfortunate experience for your patient and I wish I had a great answer. Unfortunately the diagnosis of gastroparesis and the treatment of flare ups is very challenging. It's often misdiagnosed and patients are sometimes accused of drug seeking behaviors. I have only seen three patients in my inpatient experience, and it was very difficult to tell what their pain really was. The doctor probably did give the right information about the dose of medications being lower than what she was receiving at home, and it might have been to her benefit that she wasn't admitted. Has she had a full gastric emptying work up? If so, and she's still have flare ups while being treated, she may benefit from a surgical consult, but that can be done outpatient.  While she left with some confusion related to when and if she should return, acute treatment in the hospital, if her labwork doesn't show any concerning instability, probably isn't even in her best interest. I believe this must be a very challenging conditions for the patients and providers.