I overheard a social worker describing a patient discharge plan to the floor care manager.
"He came in last night with an INR of 20. He got some potassium...".
For those not in the medical field, the abbreviation for potassium is K. The abbreviation for vitamin K is vitamin K. Vitamin K is used as a reversing agent for coumadin, an anticoagulant that causes a person's INR to go up, making it more difficult for them to clot. This patient got vitamin K, not potassium, which would have done nothing but increased his potassium level.
After we laughed, I got to thinking. I wonder if the Marijuana Mafia (MM) has looked into this dangerous association between K and K. How could two drugs have the same name, yet be so different. I wonder how many deaths have been attributed to the administration of subQ potassium. If given in large doses, intravenous vitamin K can kill you as well. I wonder if we should sue the American Chemist Society for allowing vitamin K to be confused with potassium on the perdioc table of elements. All those needless deaths.
I have a solution. Maybe we should give potassium the letter P instead of K. Oh wait, P is claimed by phosphorus. Perhaps we can change phosphorus to Ph. Maybe that's too difficult.
Perhaps we should start writing "NS with 20 meq of 19". You just wait. That day will come. But wait. The 19 looks too much like 10, and the 20 can look like 29 and the meq can look like micro. And the NS can be confused with nasal stank.
I'm sure once the MM get wind of this major patient safety issue, we will be commandeered to write
"Normal Saline With Twenty milliequivalents of Nineteen" Dated 12/31/08 at 15:07:22, signed ( signature stamps not acceptable)
Thank you MM for saving this patient's life so they didn't get dehydrated in the hospital and experience an adverse event, I mean, a never event. I don't know what that patient would have done without your safety initiative. Perhaps, they would have drank some water.
But like every rule, consequences arise. Years of intense data mining by the Medicare National Bank's computer hub, the ones that don't talk to each other, determined that in the time it took me to write that order, date it and sign it with my scribble (without a signature stamp)
Two of my patients died of acute hypercapnic and hypoxemic respiratory failure complicated by acute renal failure on CKD Stage IV, acute systolic heart failure and uncontrolled diabetes mellitus type II.
But not to worry. Since I documented three complicating conditions, Happy's Hospital got paid an extra $5,000, my actual mortality was less than my expected mortality and I will look like the best doctor on earth. Even though your granny died waiting for me to write fluid orders on a healthy 23 year old with a one day history of cellulitis that the ED asked me to admit so the patient didn't go home, get septic, die, and sue them for all they got. That $5,000 hospital stay that could have been managed by a $20 course of pill antibiotics.
Now, go out and exercise, stop smoking, eat right and hope to God you don't get sick enough to get admitted to the hospital. Chances are your doctor has his/her ass planted in front of a computer screen, signing off charts and avoiding the coffee police for fear of persecution.
Welcome to American Health Care In A Nutshell. (at least hospital medicine)
7 Outbursts:
It would be really really really cool if this post was fiction.
Ohio Onc.
I feel asleep when the score was 17 to 15. Dang. Care to give me a play by play on how it ended?
Remember that INR is a logrhythmic scale and NOT a linear scale. This scale is not directly correlated with bleeding risk (the bleeding risk tends to increase linearly while the INR increases logrhythmically). Therefore an INR of 20 is NOT twice as likely as an INR of 10 to produce significant bleeding - the bleeding risk of the two is actually not much different. Also, INR is only used on patient who are taking Coumadin - it is not standarized for other products. So if there is a sugestion of another ingestion the correct measure is the PT. BTY I can't beleive the Buckeyes are up by 3 on Texas in the tird quarter!
How about Special K -animal tranquilizer or breakfast cereal... You make the call.
Anon. It wasn't meant to be a slam on the social worker. It was a funny slip of the tongue.
But regardless, I see patients with an INR of 20 all the time. They don't automatically bleed.
I don't consider an INR of 6 to be panicky.
An INR of 2 with active bleeding is panicky.
An INR of 20 with no bleeding is really not a big deal.
The vit K and FFP can reverse fairly quickly.
Do you work with coumadin frequently?
Happy, that's why you are licensed to practice medicine, and the social worker is not. Also, don't believe anything that she may have said, except maybe that the patient came in to the hospital.
An INR of 20! Sounds like a case of ingestion of brodifacoum rat poison or similar superwarfarin, rather than a case of too high an INR from a prescribed Coumadin regimen. If 20 is correct, that patient should be dead. An INR of 6.0 is a panic value. If the INR were truly 20, then the patient, if not dead, would have had major GI bleeding and would have required more than just vitamin K1 (e.g. FFP). If a superwarfarin were involved, there would be an extended hospital stay (~5 days) to prevent recurring admissions.
Happy. See http://www.stanfordlab.com/pages/panicvalues.htm for Stanford Hospital's panic value of INR >= 5.0. The textbook panic values for INR are anywhere from 5-6, or PT time >50.
I agree with you that an INR of 2.0 with active bleeding is panicky especially in certain locations (e.g. intracranial bleed), but I disagree that an INR of 20 w/o active bleeding is not. The high INR patient is potentially VERY unstable analagous to avalanche conditions when a snow slab forms on a powder base. The higher the INR, the more unstable. Hairtrigger events such as small bumps, or sometimes nothing at all can lead to catastrophic bleeding. Again, the catestrophic level depends where the bleeding is. I do agree that K1 and FFP will reverse the anticoagulation very quickly and will avert tragedy if no bleeding has yet occurred, but that is a BIG if with a true (assuming the lab didn't allow the blood to coagulate) INR of 20.
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