Thank God She Didn't Have A Femur Fracture

Watching two doctors argue about who's right and who's wrong can take on so many different personalities. The patient's wet. Give him lasix. The patient's dry, give him fluid. Thus is the battle between sworn medical enemies. The great battles declared daily between the cardiologists and the nephrologists. Often times, it's quite funny to watch. On occasion, when doctors actually bump into each other on rounds, they may actually talk to each other. Shocking, isn't it. Doctors talking to each other. One says granny's wet. The other says granny is dry. And I sit there and laugh, silently in amusement. While each makes their compelling arguments on why they hold the ace of spades. I know the cardiologist thinks they are right. And I know the nephrologist knows they are right. So who's right? Often times we will have normal saline running at 150 cc/hour, while giving hefty doses of lasix.

Well granny. Are you wet? Or are you dry? It's the great battle. And often times, you just can't tell. Trial and error. There is no magic wand. There are clues. Leg edema, JVD, xray findings, lab findings, coughing, PND, ascites. But medical care isn't straight forward. I could go into a whole lecture about how you can be total volume overloaded while simultaneously being intravascular volume deplete. We have cardiac output. We have prerenal azotemia. We have hypoalbuminemia. They all play against each other. And tweaking out the management options can be very difficult for folks who walk that very fine line. The folks who tip over the edge into decompensated illness just by looking at a can of soup. And that's why both the cardiologist and the nephrologist can both be right at the same time, even though they have incongruent management. Yet, each is convinced that the other is oh so wrong.

Sometimes you get the really confident doctor who feels compelled to flex their muscles, over riding all other orders by doctors and claiming victory on the scales of knowledge. Underlining with exclamation in the chart. Declaring boldly that another docs orders are inappropriate for "my patient." I have been on the receiving end of ego battles through way of chart wars. I laugh it off as a personality disorder. Sometimes, you only see what you want to see. Which brings me to my main point.

How can two health care professionals look at the exact same patient data and come to two completely incongruent diagnosis? We accept patients from all over our state. As a regional referral center, we see everything that comes our way. On one occasion I was called with a really sick granny. Granny was found down at her home. Potentially a two day process of immobility. Granny was seen by a physician assistant in small town Grannyville. All the appropriate labs and xrays were ordered. Based on the PA's history and exam and interpretation of the xray and labs, I was called to admit sick grandma for "fluidity in the lungs". A working diagnosis of congestive heart failure was presented to me. Granny had some lower blood pressures in their ER. Granny had elevated CPK's of 800's, MB's of 20 and Trop I of insignificant amount. Granny had some belly pain and chest pain as well. Granny was on high doses of oxygen. I accepted the patient for transfer to our cardiac floor for "acute systolic heart failure"

It takes a while to transfer a patient. Paper work. Ambulance, more paper work. Phone calls, coordination. More phone calls. More paperwork. Eventually the patient arrives, several hours later. With labs, a disk of xrays and the ER records. I scan the documents then talk to the nurse. "She doesn't look so good", "I'm told. Walking into the room I see granny on full facial oxygen mask. I see blood pressures of systolic 80's. I see scared family members waiting for some answers. I look at the patient. She's breathing 30 times a minute. I see mottled skin. I see a very tender abdomen, everywhere.

I see septic shock. I tell the family, mom has signed DNR orders. I could see the hesitation in their eyes. "Should we reverse it?" they ask. I said, "Mom signed those for a reason". She would not want to go through the horror that we can do to little old ladies in the ICU. Mom doesn't not want to live as an invalid should she survive this major illness. She signed those papers for a reason. I would not let them reverse it. I explained very clearly that reversing it would be inappropriate and against mom's wishes. They cried. I then stated we need a central line. We need to go to the intensive care unit for pressor, fluid, CVP monitoring to titrate our therapy.

It became apparent to me, after evaluating granny for 5 minutes that we were not full of fluid. We were in fact so fluid deprived that all her organs were trying to shut down. At this point I consulted orthopaedic surgery to help me manage my septic shock. But they never called back. So I went ahead and placed a subclavian line, and started pounding in fluids as quick as I could. Her CVP came back 3, which to all the non medical folks, means your dry as a prune. Granny got a ton of fluids. Granny was also producting lactic acid due to lack of tissue perfusion. Granny had abdominal pain, potentially a result or the cause of her sepsis. Granny had pneumonia. And granny had acute renal failure. This is septic shock with multi organ failure.

The surviving sepsis campaign has very clear evidence based guidelines for surviving this deadly illness.

It's situations like this where it never ceases to amaze me how two people can look at the same data and one be so right and one be so wrong. This isn't a matter of walking the fine line of too wet or too dry. This is life and death. Whether it is MD vs PA, generalist vs specialist, dumbass vs smartass. This is life and death stuff. I'm just glad I happened to be there to help her. And I thank God she didn't have a femur fracture.