Hi, I am an ICU nurse in my local hospital, but I had to post my husbands visit to our ER here. I want you to please post on what you think the ER doc did, or should have done. Then I will tell you the outcome. This will be fun!
Ok, my husband is 2 years post liver transplant. He has Hep C, and was transplanted only due to a primary liver tumor, he has never decompensated. He is 56 and on treatment for Hep C with PegIntron and Ribavirin. Main problem during his transplant is strictures in the bililary ducts which required q3 month ERCP's for about 1 1/2 years to put in stents. The first time he had those done, he was in the hospital for pancreatitis. Fast forward about 11 ERCPs, and the last one he had put him back in the hospital with horrible pain, but not pancreatitis. So, a few weeks ago, he went back to have the stents removed. His hgb at the time was 9.1. Gastro not worried about this number. Ok, thats the history as short as I can tell it. He went to the big transplant hospital for all this. He did come home with oral cipro for three days. He never really felt well after this.
So, four days after stent removal, he develops a fever, chills, vomiting and diarrhea. I take him to our local ER, where the nurse got all his labs, started fluids and did all he could do. An hour and a half later the doc comes in. I told him the transplant doc wants a CT scan, and that he could call the gastro doctor there. He assured me that after all the tests come back, he would do just that. My husband was so sick, that I actually called the step down unit and told them he may be coming there. My hubby recieved dilaudid, zofran, and fluids, he was feeling good. Ok, labs came back at a hgb of 7.8 and a sodium of 127. His temp was 101.9 rectually. CT normal, heme neg stool, and only a trace of blood in his urine. ER doc calls gastro transplant doc, what do they decide?
I wish Transkat would have been the doctor! Ok, a couple of you were right. After consulting the Gastro doctor,(not the attending), the ER doc felt since there was no obvious signs of bleeding, that the blood test was flawed. So, he comes into the room and says, "Good news Bob, you are ok to go home." My husband is high on dilaudid, and is very happy. I however said, "WHAT! YOU ARE SENDING HIM HOME WITH A BLOOD COUNT THAT LOW?" Thats when he, in all his wisdom, explainded that something was probably wrong with the blood test. He said the gastro doc was more concerned about the sodium. I ask him why, since he was vomiting for two days? Anyhow, he left the room, and voiced my concerns to the nurse. She told me she was going to bring the doc back in. My husband, feeling like a new man, states"no, thats all right, if he says I'm ok, then I'm ok, I feel good." I informed him that it wouldn't last. Well, about 3am, guess what, he starts running a fever and vomiting again. I was going to call off work that morning, but he insisted he would be alright. No sooner then I got to work, his liver transplant nurse calls me and tells me to get Bob to the hospital, he is septic and needs admitted! OMG! By the time I got someone to cover me, got home, got Bob to the hospital, hours have passed. The same ER doc comes in fast, (do to my angry tone at the front desk), and asks me why I didn't get Bob there sooner! I looked right at him and said, "WHY DIDN'T YOU KEEP HIM?!!" Well, I didn't see him again. Bobs hgb was now 7, and sodium even lower. They found him a room fast, gave him 4 units of prbc to get his count up to at least a 10. Started him on Cipro, which was a waste because he has ECOLI in his blood. He came home with a PICC line and Iv antibiotics, and is ok now. Guess what me, the ICU nurse did? I won't keep you guessing, I wrote that doctor up! After the investigation, the Head Doc in the ER called me and said, "you husband was sent home on the ASSUMPTION he wanted to go home! I told him that is a stupid reason for an ER doc to send someone home. He agreed, the investigation continues..... Oh yeah, I called the Gastro doc, talked to his nurse, and she read his exact notes from that night, and the hgb of 7.8 was never mentioned.
My husband asked me what I want to come of this. I stated, "If that ER doc stops and looks harder at one transplant patient, or any patient, thats what I want." One last thing, the low blood count was due to the Ribavirin, not bleeding. He has stopped the Ribavirin, blood count is stable.
hugs to you!!!! it sounds like you are the best advocate your husband can have! i had a similar experience with my father, but unfortunately by the time the er doc admitted him - it was to late.
keep your chin up! never ever ever let the doctors bully you into being quiet! go with your gut and just keep going!
I asked a PAC that the ER doc sent in the room how they admit people. I told her I work in the ICU where we question the type of patients they send to us all the time such as stable belly aches ect. If I was recieving a liver transplant patient in the ICU with a low blood count, I would say, "Wow, this guy needs to be here." She didn't have a good explanation for me. One thing that didn't happen that should of, ER doc should have called Bob's attending on family practice, they admit everybody!
There has been alot of story's about this doctor, I'm thinking its time for him to retire. He used no critical thinking at all. Scary....
Good question, and even with the low sodium, why wouldn't you recheck before sending home?
I've been the nurse in this situation and can explain though I don't agree with the reasoning.
The nurse gave fluids, thus diluting the blood and making the Hgb falsely low. The doc can also look back at old blood tests and argue that the number is not that far off from the patient's norm. The patient was vomiting and losing sodium, now has stopped vomiting, and received say a couple litres of NS, the sodium will stabilize. Fever from dehydration, which they have fixed. Patient could stay another 6 hours and get all those tests redone, "But I'm pretty sure we've fixed the problem" sez doc, "and really, wouldn't he be more comfortable going home and coming back if he dosen't feel better?"
Patient comes back sicker in a few hours, and the doc says all is fine because they have followed the "appropriate" dc instructions, and now he'll treat for an illness "obviously more serious than it initially appeared." Most families buy this logic, because they figure the doc knows what he is doing. The doc is looking for rapid dispo numbers and a few hours sleep. However, the nurses see all these patients again the next day, or they respond to other hospitals looking for records, and know that most of the optimistic prognoses do not pan out.
Like I said, I don't agree with the doc, but that's the logic I've seen used in the past. We once sent a 35yo home during an acute STEMI because his troponins hadn't started to rise, the elevations "weren't too bad, I bet that's normal for him" and the patient looked too calm and comfortable to be having a big MI. Thank god the pt came back when he got worse.
I'm so glad to hear your husband is better now. You both have been through alot! I'm sure the ER doc will take a harder look at the next transplant patient before sending him/her home.
Good question, and even with the low sodium, why wouldn't you recheck before sending home?
Absolutely! I had a pt. with a bleeding ovarian cyst, and her hgb went from something like 12.5 to 11.6 in a couple of hours, and we redrew to see if she was dropping at all ... and we ended up admitting her. If I'd thought the test was flawed, I would have absolutely advocated to have it repeated. That is nuts.
Had a similar incident a couple of weeks ago, but it was the primary doc who wouldn't admit ... 80-something y/o pt from our long-term care facility, GI bleed, hgb was 9.6, hct wasn't too bad, and she was symptomatic -- weaker than usual, sats around 89% on room air. We did her workup, and her primary care doc was supposed to come see her in the ED. We waited FOUR HOURS for him to show up, and he finally called and said he wouldn't be showing up or even admitting her, he'd just write an order for O2 by NC for her at the long term care facility, and see her there. I was so mad -- she shouldn't have been sent back! I documented the heck out of all those things, and kept a close eye on her vitals -- her BP was good, at least. So two days later, she comes back with a hgb of 7, hct of 25, and hypotensive!! Arrghhh. I was SO MAD. Poor woman. She was such a lovely patient, too. She should have been admitted the first time, and our ED doc agreed, but her primary ... well. Enough said.
In any care, Dorie ... glad your husband is better! Jeez ... when given the choice, don't most patients WANT to go home instead of being admitted? Heh. I had a nice, older Austrian guy who came in because he'd had chest pressure and palpitations the night before with an MI/stent history, and his CK and myoglobin were fine, but his troponin was "high critical" -- something like 0.52. He signed out AMA! "I'm getting on a plane to Vienna tonight, I'll see my doctor in the morning." I kept expecting to see something on the news about someone croaking mid-air on SwissAir or Lufthansa or whatever. His poor wife was just sobbing with fear, and he was like, "Come on, give me the keys, I'm driving." (!!!) Often we keep the ones who don't need to stay, and the ones who need to stay don't want to, and go home!
OP, sorry for your troubles but I am wondering why you took your husband home if you thought it wrong to do so. I'm sure you've berated yourself plenty for that but I can't help but wonder. Yes, I've let myself be BS'd a few times, too, so don't feel too badly.
The only reason I took my husband home was because when the doctor told him he was good to go, then he wanted to go. I told hime the good feeling from the dilaudid, fluid and zofran wouldn't last, and he found out I was right. He was lucky I didn't put a pillow over his head that morning when he stated, "I can't believe they let me go home with that low blood count, I'm so sick!":banghead:
After writing this doctor up, I was contacted by the head of the ER. He came to the conclusion that my husband was discharged on the ASSUMPTION that he wanted to go home! I told him that was a stupid reason for an ER doctor to discharge someone. He never gave my husband the choice to stay or not. So, what is my ICU filled with right now? Sepsis patients! And a lot less sick then my husband was! Go figure
dorie43rn
142 Posts
I wish Transkat would have been the doctor! Ok, a couple of you were right. After consulting the Gastro doctor,(not the attending), the ER doc felt since there was no obvious signs of bleeding, that the blood test was flawed. So, he comes into the room and says, "Good news Bob, you are ok to go home." My husband is high on dilaudid, and is very happy. I however said, "WHAT! YOU ARE SENDING HIM HOME WITH A BLOOD COUNT THAT LOW?" Thats when he, in all his wisdom, explainded that something was probably wrong with the blood test. He said the gastro doc was more concerned about the sodium. I ask him why, since he was vomiting for two days? Anyhow, he left the room, and voiced my concerns to the nurse. She told me she was going to bring the doc back in. My husband, feeling like a new man, states"no, thats all right, if he says I'm ok, then I'm ok, I feel good." I informed him that it wouldn't last. Well, about 3am, guess what, he starts running a fever and vomiting again. I was going to call off work that morning, but he insisted he would be alright. No sooner then I got to work, his liver transplant nurse calls me and tells me to get Bob to the hospital, he is septic and needs admitted! OMG! By the time I got someone to cover me, got home, got Bob to the hospital, hours have passed. The same ER doc comes in fast, (do to my angry tone at the front desk), and asks me why I didn't get Bob there sooner! I looked right at him and said, "WHY DIDN'T YOU KEEP HIM?!!" Well, I didn't see him again. Bobs hgb was now 7, and sodium even lower. They found him a room fast, gave him 4 units of prbc to get his count up to at least a 10. Started him on Cipro, which was a waste because he has ECOLI in his blood. He came home with a PICC line and Iv antibiotics, and is ok now. Guess what me, the ICU nurse did? I won't keep you guessing, I wrote that doctor up! After the investigation, the Head Doc in the ER called me and said, "you husband was sent home on the ASSUMPTION he wanted to go home! I told him that is a stupid reason for an ER doc to send someone home. He agreed, the investigation continues..... Oh yeah, I called the Gastro doc, talked to his nurse, and she read his exact notes from that night, and the hgb of 7.8 was never mentioned.
My husband asked me what I want to come of this. I stated, "If that ER doc stops and looks harder at one transplant patient, or any patient, thats what I want." One last thing, the low blood count was due to the Ribavirin, not bleeding. He has stopped the Ribavirin, blood count is stable.