You're Not Dehydrated.

LakeEmerald · Aug 22, 2015

Our MD's often order IV fluids before the labs are even drawn or complete. I think it covers the patient just in case they are dehydrated, and helps speed along their ED stay since their fluids will hopefully be at least half-way or all the way in by the time the labs result. Then hopefully, they can take their nondehydrated selves home!

It also seems to make a lot of people feel better to get fluids even if they aren't dehydrated. Maybe there's a medical reason or perhaps psychological that "something was done?"

What gets me a little is when a nurse or tech misses a patient's vein and they tell the patient, "it's because you're dehydrated" when they show no signs of it. Or the patient says, "Oh, it's because I'm dehydrated" and the staff agrees. No, sometimes, we just miss!

Anna Flaxis, BSN, RN · Aug 22, 2015

We frequently initiate line, labs, and a liter before the provider has even seen the patient, depending on the presentation/chief complaint. Often, the patient doesn't need all that, though.

I think you're right, it can be a matter of the person feeling like "something has been done"- and that as I've stated in other threads, sometimes there is really no therapeutic value in disavowing someone of their perceptions. In this particular instance, both me and the physician explained to the person that they were not dehydrated and offered evidence to that effect, and yet the person persisted with the idea that some IV fluids would really make them feel better. I think the physician chose the path of least resistance.

Which brings me to another topic- the person who just knows something is wrong and is searching for a diagnosis. In this instance, it was someone who had a list of rare conditions written down on a scrap of paper, who told me "I'm working on getting diagnosed with this" about several different conditions. They had a neurologist, a cardiologist, a general practitioner, and an appointment with a geneticist. This person was otherwise young, healthy, nontoxic in appearance, and by all indications (lab work, VS, physical exam) not acutely or even chronically ill. And of course, they had a staunch advocate who demanded in triage that the person be taken back immediately and allowed to lie down.

I am certain there are people who feel something is wrong and they are correct. Sadly, I've seen cancer diagnoses in the ER due to this sort of thing- and the ER is just a horrible place to receive such news. But, I feel that some folks who are just so driven to get a diagnosis are vulnerable to those charlatans and quacks out there who will take advantage of their desperation and tell them what they want to hear, then take their money and provide unproven, potentially harmful at worst and completely ineffective at best, treatments.

When faced with this situation, sometimes my approach is to ask the person questions, like "What is involved in diagnosing X condition?". Sometimes, I learn something, and other times, like this one, the person sort of jumps from subject to subject in a random, drawn out, disconnected, almost incoherent way and I end up having to interrupt and excuse myself from the room because I run out of time to be present and have other things I need to do.

People are just so interesting.

Altra, BSN, RN · Aug 22, 2015

In this instance, it was someone who had a list of rare conditions written down on a scrap of paper, who told me "I'm working on getting diagnosed with this" about several different conditions.

Good grief. I'm not sure I've ever heard someone state it so clearly (and without any trace of irony, I'm sure) ... though we can all name frequent flyers who devote a great deal of time to just that.

Yes ... to everything said in this thread.

Anna Flaxis, BSN, RN · Aug 23, 2015

No irony whatsoever. The person was completely earnest.

Guest219794 · Aug 23, 2015

"I'm so dehydrated!".
Your H&H are normal.
Your BUN & Creatinine are normal.
Your urine specific gravity is on the low end of normal.
Your urine is pale yellow and clear.
Your mucous membranes are moist.
Your skin is pink, warm, dry, with good turgor.
Your capillary refill is brisk.
Your vital signs are completely WNL.
You are neither vomiting nor have diarrhea, and have a good appetite.
You are not dehydrated.
"But I'm thirsty and my hands are dry."
I'll get you some water to drink and some lotion for your hands.
And yet, MD still orders NS 1L fluid bolus IV.
How often do you see this in your ER? Discuss.

All the time. And the reason they think they are dehydrated is because we tell them they are- that's what it means when a doc orders IVF. The doc confirms their misconception. And, they do, in fact, feel better after laying in an ER bed getting IVF and pointless labs- they will feel even better if we give them some therapeutic radiation.

Docs are not judged by outcomes, particularly with healthy patients. They are judged by customer satisfaction.

amoLucia · Aug 23, 2015

To OP - firstly, I do like your name. :yes:

Secondly, is your pt Psych, or is he grasping for a free 'Get Out of Lifetime Job/Work' card??? Like a DX that will assure some permanent disability excuse (whichever one can be diagnosed first) so as to collect SSDI or other financial aid? Just asking ...

I didn't do ER. But I knew someone who worked on trying to be diagnosed but the DXs just weren't there. Didn't have any career goals. Didn't like working. Loved to pity-party. Kept coming up with obscure S&S that didn't match anything and couldn't be validated.

Your pt just brought back the old memory.

blackribbon · Aug 24, 2015

Sometimes though, the problem doesn't show up on the labs in the ER. My husband always felt better after getting a bag of IV fluids when he was fighting cancer. He hated being in the hospital but he would stay an extra 2 hours if someone would hang a bag on him. I know one of his doctors would say, "I don't see that you need it but it can't hurt" and would order it for him. This was not a case of he felt better because they were "doing something" because he hated all the "doing somethings". I suspect that it was related to where one or more of his tumor sat in his body. I know that some of the nurses rolled their eye while hooking him up but I can testify, I took home a healthier man the days he got that extra liter of saline.

I have also had enough patients hit the floor with problems that didn't show up until they had been on the floor for about a day. Some people just seem to be in better tune with their body's needs.

However, there are also those patients who just want to be "professional patients" and almost think they are equivalent of a nurse based on the number of times they have been admitted.

Anna Flaxis, BSN, RN · Aug 24, 2015

To OP - firstly, I do like your name.
Secondly, is your pt Psych, or is he grasping for a free 'Get Out of Lifetime Job/Work' card??? Like a DX that will assure some permanent disability excuse (whichever one can be diagnosed first) so as to collect SSDI or other financial aid? Just asking ...

Thank you.

I have no idea. As a said, the person seemed completely earnest in their belief that they had several different rare diagnoses. Perhaps they do. I don't know. I just know that there was absolutely nothing out of whack in their workup, and they didn't meet the diagnostic criteria for the complaint they came in with.

weirdscience · Aug 24, 2015

I drink tons of water--TONS--and I never felt so much improvement so quickly as when I got two liters NS in the ER. Of course, I had pyelonephritis, but still. The cooling sensation + hydration = instant relief. (And no, it wasn't the pain meds--asked for no narcotics, got Toradol.)

Anna Flaxis, BSN, RN · Aug 24, 2015

Toradol is great. Effective pain relief without the CNS effects. We give it for stones a lot. I wish we used it more.

TheNGTKingRN · Aug 24, 2015

I love giving Toradol. 30MG SIVP Q6 with a max of 4 or 6 doses I believe before we have to consider benefit vs risk. But what do I know...!