Hypotensive dialysis transfer

[Brandon O]

Hi guys. Thought you might enjoy a somewhat less whacky scenario; this one happened to me a few weeks back and am interested in opinions, since I just got a chance to follow up on the dx yesterday. Since it was a while ago, some of the details are sparse or fictional, but you should get the drift.

You're dispatched for a routine transfer from St. Whatever Dialysis back to Misty Greens rehab. Ms. Elderly Renal is one of your frequent fliers, but this is your first time taking her.

On arrival at St. Whatever, staff direct you to the patient's seat and indicate to you that she was recording a run of hypotensive BPs during her run of dialysis. You see them charted on the monitor, like this -- 100/61, 120/78, 96/59, 121/75, 91/61, fluctuating during the course of her treatment, but basically low. They further indicate that Ms. Renal has been very stuporous, barely responsive and communicating little if at all, just puddled in her seat for the majority of her treatment. Neither of these are typical for her, according to staff; "it's not the Ms. Renal I know," you're told.

The patient presents as an elderly black female slumped in her chair, wrapped in blankets. Her eyes are more or less open but she's clearly obtunded, her verbal responses varying from nothing at all to brief, grunted, coherent words. She obeys simple commands.

You notice immediately that the right side of her face seems to be noticeably drooping; asking her to smile, it is more pronounced. She is barely able to lift her arms in front of her, so although her right arm seems to lift less well it is difficult to tell. She squeezes your fingers with fair strength and you can't decide whether it's your imagination that has her right side weaker. You have her repeat a sentence after you (which in appropriate tradition is something like "why the hell is it always raining in Boston?"), and she gets it right but slurs it.

Radial pulses are equal, but very nearly impalpable; you manage to count one at around 100. The last BP from the computer automatic cuff is 91/61, but you're unable to obtain one manually. Respirations are 18 or so. Her hands are perceivably cold, up through her forearms. Pulse oximetry and BG chem are unavailable to you.

The paperwork available to you is just a master copy of your company's dialysis run sheet, which has a PMH including various uninteresting tidbits. You look in particular for history of CVA or baseline hemiparesis, and also for diabetes; you see neither, but these documents have a habit of not being especially exhaustive.

Having expressed its concerns and scribbled some things in Ms. Renal's dialysis book, staff pats you on the back and sends you back to Misty Greens. You load her up and are sitting in the back of your truck. Now what?

I'm particularly interested in what you guys would do, not when viewed through zebra-calibrated retrospectoscopes, but if you actually took this routine transfer tomorrow. This is one of the two major decision-making points so I'll unfold the rest of the story for you later.

 

[Onceamedic]

Altered level of consciousness = transport to nearest appropriate facility which in this case is not the nursing home. This lady needs to go to the hospital, specifically a stroke center. Try and find out from the patient (as the documentation is incomplete) whether she has deficits from a prior CVA. Get a FAST score on her (or whatever you use to quantify stroke) and diesel bolus to the hospital.

 

[redcrossemt]

Altered level of consciousness = transport to nearest appropriate facility which in this case is not the nursing home. This lady needs to go to the hospital, specifically a stroke center. Try and find out from the patient (as the documentation is incomplete) whether she has deficits from a prior CVA. Get a FAST score on her (or whatever you use to quantify stroke) and diesel bolus to the hospital.

+1

From the story, it sounds like she normally doesn't have the deficits that are now apparent to you. If the patient is alert and oriented, talk to her and figure out if she has had these issues before, express your concerns, and talk her into transport to the nearest appropriate emergency receiving facility, preferably a stroke center.

 

[Seaglass]

Altered level of consciousness = transport to nearest appropriate facility which in this case is not the nursing home. This lady needs to go to the hospital, specifically a stroke center. Try and find out from the patient (as the documentation is incomplete) whether she has deficits from a prior CVA. Get a FAST score on her (or whatever you use to quantify stroke) and diesel bolus to the hospital.

+2. While she might usually be a routine transfer, she's now an emergency call. We're going to the stroke center.

If the patient is alert and oriented, talk to her and figure out if she has had these issues before, express your concerns, and talk her into transport to the nearest appropriate emergency receiving facility, preferably a stroke center.

Of course I'd try to obtain her consent, but the scenario reads like we may not need be needing it. In some cases, we can take altered patients even if they're correctly responding to the A&O questions. Would be my medic's call (as well as PD's, her physician's, medical control's, her legal guardian's, etc. as applicable), though, not mine.

 

[Brandon O]

Nice analysis, guys.

The especially interesting part of this one, for me, is what both of you hit on. The entire crux of this run hinges upon the available history. If I knew for a fact that everything I was looking at was this patient's baseline, or within a reasonable range thereof, there would be no emergency and we'd toddle back to her facility with yawns all around. Conversely if I knew for sure that none of it was typical for her, or could be explained by any unexciting etiology, I'd be tearing out of there and calling a stroke alert. But since I didn't know anything for sure, it was a stinker.

Dialysis patients are regularly sick as hell, and if you hit the big red button every time one of them looks bad you're going to have a very tiring week. On the other hand... they're sick as hell, which means they're in a real position to deteriorate or undergo acute downturns while in your care, so you can't just play taxi driver.

I'll share the next page in a bit.

 

[medicdan]

+3. Ultimately you may get pushed around by the staff at the clinic, and encouraged that it's nothing, but ultimately it's your choice. It's likely I have seen this patient (or their rough equivalent) before, and played it different ways. At some point, you should trust the dialysis staff, they know the baseline better then anyone else. Patients like this come in looking terrible, and out tired but happy, or come in happy, out exhausted and mad at their tech.

Depending on your proximity to the hospital, and/or SNF, you may consider just going back to the SNF and talking to the RN. These patients are hospitalized often enough, so finding out the facility of choice is important, but so is talking to someone who really knows the baseline, as the RN and CNA most likely do.

If you are unsure, give the Field Supervisor-du-jour a call. What do your manual vitals say? What does your gut say? Is the patient stable enough to go back to the SNF? Go back to the basics (ABCs). What is (or could be) killing the patient first?

Hope this helps. Unfortunately, these cases are extremely ambigious, and personal judgement plays a big role. I guess it boils down to "How comfortable do YOU feel with this partient, and what is in their best interest?

 

[firecoins]

+4 Call medics and meet up with them.

 

[sbp7993]

+5 I would definitely transport this patient to the nearest hospital. The blood pressure is off, the slurring of the speech and the unequal lifting of the arms would cause me to suspect a stroke, she was cold, i mean the list goes on and on.

 

[rescue99]

Nice analysis, guys.

The especially interesting part of this one, for me, is what both of you hit on. The entire crux of this run hinges upon the available history. If I knew for a fact that everything I was looking at was this patient's baseline, or within a reasonable range thereof, there would be no emergency and we'd toddle back to her facility with yawns all around. Conversely if I knew for sure that none of it was typical for her, or could be explained by any unexciting etiology, I'd be tearing out of there and calling a stroke alert. But since I didn't know anything for sure, it was a stinker.

Dialysis patients are regularly sick as hell, and if you hit the big red button every time one of them looks bad you're going to have a very tiring week. On the other hand... they're sick as hell, which means they're in a real position to deteriorate or undergo acute downturns while in your care, so you can't just play taxi driver.

I'll share the next page in a bit.

Any labs on this patient?

 

[Brandon O]

Any labs on this patient?

Yeah, I banged out an ABG after I checked the pupils...

Nah, what you see is what you got. So far, anyway.

 

[redcrossemt]

Depending on your proximity to the hospital, and/or SNF, you may consider just going back to the SNF and talking to the RN. These patients are hospitalized often enough, so finding out the facility of choice is important, but so is talking to someone who really knows the baseline, as the RN and CNA most likely do.

Good thought! You could try calling the SNF and speaking to the patient's nurse or a CNA that knows the patient well.

If no one can give you a good baseline, or it's obvious that this is not baseline behavior, you need to transport to an emergency department.

 

[Onceamedic]

They further indicate that Ms. Renal has been very stuporous, barely responsive and communicating little if at all, just puddled in her seat for the majority of her treatment. Neither of these are typical for her, according to staff; "it's not the Ms. Renal I know," you're told.

Asked and answered. The altered LOC is reason enough to go the ED. Establishing a baseline for symptoms of CVA is a bonus.

 

[Brandon O]

Thanks guys. You see the issue, of course.

I was going to tell you more about what unfolded and tease this out a little longer as a scenario, but what the hell; I'll just share the actual events.

Although I was very uneasy about it all, we decided to transport back to Ms. Renal's rehab. When it came down to it, without any knowledge of her medical history and current situation except spotty paperwork, I wasn't comfortable wheeling off to the ED with no story in hand except "er... she seems wrong, gov'nor." As I suggested before, what I really wanted to know was her history of stroke and diabetes. The patient herself was far too obtunded to be a useful historian.

The one piece of this I didn't mention is that the dialysis tech was swearing she had been in this condition since she came in. That was well over three hours ago, since she completed her full session. In other words, if we're going to talk about stroke, fibrinolytics ain't going to happen anyway; the deadline isn't exactly looming, it's already past.

The facility wasn't next door, but it wasn't a long transport -- call it 10 minutes -- and I monitored her like a hawk the entire time. I remained unable to obtain a BP, and as we bumped down the road I found myself unable to palpate a radial or brachial pulse any longer. I managed to get one apically, no major changes.

We show up at Misty Greens Rehab, wheel her past the desk, and tell the loitering nurses about the hypotension. They say they'll have a look. I ask them about the hemiparesis. One of them glares at me -- "I KNOW you didn't bring her here with her face drooping." They say she's not diabetic, no history of stroke. They also claim that she was doing fine when she went out for dialysis this morning. I'm ready to haul her out of there but they have me take her to her room.

I stay with her, grimly. After a bit an LPN floats through with a vitals trolley and puts an automatic BP cuff on Ms. Renal. It's backwards and doesn't record. An RN shows up, chases off the LPN, and puts it on properly. We get a pressure of 71/49.

Eyes wide, she wanders off. The staff drag their feet and call the facility MD, who decides that, well, shucks, I guess she'll go to the hospital. They then proceed to putter around, getting together referral paperwork with painstaking slowness.

I'm perched at Ms. Renal's side, reevaluating her continuously. At this point I've got her on O2 by cannula, 4 liters (IIRC); I don't know what's going on but oxygenation seems like a nice thing to have. Her hands are still cold, now up through her arms and shoulders. I fluctuate between thinking she has an obvious strength deficit between her two hands/arms and thinking I'm imagining it; her lower extremities seem fine, anyway.

I'm continually on the brink of just grabbing her and hauling her off. The facility staff seem to be teasing me, making sure to include in the paperwork every detail of her current care, including the fact -- admittedly interesting -- that she hasn't been eating the past couple days.

They finally get everything together (at which point I've already got her back on the stretcher, packaged to go and waiting by the door), and we take off, in classic wait-and-hurry-up fashion. I point my partner at the requested hospital, which is a stroke center and pretty much everything else you could ask for. Flipping through the paperwork I note that she's on thinners (aspirin, coumadin); at this point my cleverest guess is a hemorrhagic stroke, but that makes almost no sense.

At triage, we hook her up to the usual wires and I get a pressure I can't remember -- low -- and a sat of something like 49. Undoubtedly incorrect due to poor perfusion. She's admitted directly to one of the trauma rooms and the team starts to fuss over her; I give a somewhat-chaotic report as best I can and leave them to it, attempting to bring some sort of narrative thread to the paperwork in the hallway. I hear them unsuccessfully attempting IVs and watch a portable X-ray get wheeled in.

Some time later, I head back in to get a signature for my PCR. The nurse handling things signs me off, telling me we did great by noticing something was wrong and bringing her in. Their current thoughts are that dialysis simply took too much fluid out of her, which clashes with the claim of their tech that she had been in her current condition from the moment she came in the door -- but never mind.

***

This was all a few weeks back. A couple of days ago, I took a run transferring Ms. Renal from a local ED back to Misty Greens. I was excited to get the chance to poke through her chart and see what came of our little episode, as well as see the lady herself.

She was far more together than I remembered, conversational and alert, although her speech was indeed slurred. Ironically, this time she'd been in the ER because one of our crews had taken her from dialysis and again noted her as hypotensive. The outcome was that the renal consult had decided her current pressure (something like 97/69) was her baseline now and it wasn't going to get much better. She's soldiering on; tough old lady.

In any case, I got hold of her chart, and discovered that following my own run three weeks prior, she'd been diagnosed with... drum roll please...

1. Urosepsis
2. Hypoglycemia

Yes, folks, the woman was diabetic. In retrospect, this probably should have been obvious no matter what I was told; she's a friggin' dialysis patient, after all. So she hadn't been eating and was low. Why neither the dialysis center nor Misty Greens had figured this out is beyond me, but then, most things are.

As for the sepsis, the odds of my nailing that one were minimal. She was admitted to the ICU and spent some time there with vancomycin and the rest.

In any case, if there's a lesson here, it's probably not a diagnostic one, since the diagnoses here were gnarly and not even super relevant in the end. But it's interesting to look at how the information both available and missing played a major role in how things played out, particularly with the fragile nature of a patient like this. In the textbook, someone like Ms. Renal would be an outright emergency... but in the textbook we aren't making dialysis transfers, and in the end of the day I have to give the benefit of the doubt to the personnel and facilities who see this person everyday and who have greater training and resources than I do. Nevertheless, it's a tricky situation, because although I'm taking the patient between two locations, BOTH of which should know more than me, NEITHER of them really feel like it's their problem... so it's easy to fall through the cracks.

Hope this was interesting for some. Happy to answer any questions, although I may not remember many of the details.

 

[MrBrown]

Take her to the hospital

 

[Aidey]

Just an FYI, hemodialysis can make a pt hypoglycemic also. She may have left the facility acting fine, with a borderline sugar, and after they started her treatment it dropped low enough she was obtunded.

What is strange is that with so many (50%+ roughly) of dialysis patients being diabetics the facility should have at least one glucometer on hand.

 

[redcrossemt]

Also, the body's metabolism shoots up (at least for a while) in any sort of sepsis... Nutritional support is important, and hypoglycemia is often seen.

 

[medicdan]

Brandon--

Thanks for the great writeup. Unfortunately, cases like this happen more often then any of us would like to admit. It argues for much more training for "Just EMTs" on the care and assessment of dialysis patients (arguably the sickest barely-stable patients we ever see). it argues for giving you field tools such as glucometry, and empowerment for the clinic or SNF to listen when you say, "something looks wrong", or the ability to call a supervisor and say "something's wrong".
Where can you go from here? What will you do differently, if given the same patient again?

 

[Akulahawk]

That was a pretty good write up! As presented in your write up, I wouldn't have taken her back to the SNF, I'd have gone to the ER with her. The fact that the dialysis staff was saying that she's "not normal" perks my ears up. The droopy face, slurred speech, altered level of consciousness and so on, puts CVA on the high index of suspicion list. Dialysis or not, she's not supposed to be cold. Cold and hypotensive (even if relative for her) can put sepsis on that list too.

Trust your gut. Sometimes the "oh CRAP" reaction is the correct one.

 

[bunkie]

Yes, folks, the woman was diabetic. In retrospect, this probably should have been obvious no matter what I was told; she's a friggin' dialysis patient, after all.

Not all dialysis pt's are diabetic. Something to keep in mind.

 

[Brandon O]

Thanks guys.

Truth be told, although I can see the possibility of doing certain things differently, I'm not certain that I would do them, even in retrospect. This call ran on assessment, not treatment; for the latter the only thing I can imagine is maybe throwing her on oxygen sooner, perhaps by NRB. If the assessment had been there, I suppose I could have given glucose, but frankly I wouldn't have trusted her airway.

The biggest piece that was missing was the diabetic one. In one way or another I should have been able to confirm she was diabetic, or at least suspect it so strongly as to make no odds; with that knowledge, I could have probably demanded that either facility take a BG chem. Again, would my treatment have changed? Maybe, maybe not -- but the way I look at it, the goal should always be the best possible understanding of what's going on. At least that way you don't feel as dumb.

The main decisions here were decisions of transport. So the REAL choice I could have made differently would have been to grab her and burn diesel, either shortly after our arrival at dialysis, or shortly after arriving at the SNF. And I can easily see someone making those choices. But here again, I don't necessarily think I went the wrong way, given the information available. In a way I was able to dodge the issue, because the only really critical scenario on the table was the possibility of CVA, and as I mentioned, given the onset of symptoms 3+ hours before, the time for tPA had come and gone regardless. So with close monitoring I did not feel like we were at the level of danger where we couldn't take the time to keep the regular caregivers (you know, the folks who know her background, provide a higher level of care, and oh yeah, pay our bills) in the loop.

But like I said, it could have gone either way, and I wouldn't call anyone wrong for doing it differently.

Akula: is low body temp a particular flag for sepsis? I'd just have put that down as one more sign of shock. As a matter of fact, isn't septic shock considered distributive -- i.e. if anything shouldn't I expect to see HOT skin due to vasodilation?