Guide to the Incarcerated Patient

 Guidelines to help with the management of an incarcerated inpatient

Guidelines to help with the management of an incarcerated inpatient

Dr. Eddie Maldonado led us through a fascinating case on Monday that touched on multiple medicolegal and social themes that are encountered on the wards. We were also joined by two representatives from our wonderful OHSU social work team who assisted answering questions about complex issues.

Incarcerated patients, when admitted to our services, have certain considerations, rules, and legal protections that we should keep in mind. Remember, implicit and explicit biases by the entire care team must be carefully considered while administering treatment for this vulnerable populartion, and their incarcerated status can change (and often does!) during the course of a hospital stay.

Thank you, Eddie!

Flozin down that river of knowledge: a wild case of undifferentiated shock!

This afternoon Dr Cara Levin brought us on an exciting journey of a middle aged man with a significant cardiovascular history (prior CABG, DES, TAVR) who was transferred to OHSU for ongoing management of shock initially felt secondary to acute GIB and acute hypoxic respiratory failure, who, when presenting to our institution, demonstrated difficult to explain labs: significant mixed AG and non-AG metabolic acidosis with respiratory acidosis, profound neutrophil predominant leukocytosis (to the 50,000s), mildly elevated lactate and then stable Hg.

What was the cause of his shock if we now couldn’t blame it on hypovolemia from his GIB bleed? Could it be cardiogenic? Was he septic? Were his new vent settings causes obstruction?

We turned to the lab abnormalities we did observe in search of other clues for our unifying diagnosis, namely… his acid base status!

In true internal medicine form, we broke down those labs in a step-wise fashion. Find below a helpful diagram courtesy of Dr Joel Topf (@kidney_boy), as featured on the hit IM podcast, “The Curbsiders”.

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Through these steps we arrived at our multifactorial mixed AG and non-AG metabolic acidosis with respiratory acidosis and grew our differential through expoloring causes for a MAGA (metabolic anion gap acidosis) with the helpful mnemonic “Goldmark”.

goldmark 2.jpg
goldmark 2.jpg

In this case, it turns out that our patient had been on Empagliflozin, an SGLT-2 inhibitor agent used in management of type 2 diabetes. While the SLGT-2 inhibitors have shown great promise in terms of reducing important cardiovascular outcomes in patients at high risk fo CV events (like our patient!), they unfortunately have a known side effect of increased risk of euglycemic DKA.

Euglycemic DKA can present with an MAGA, leukomoid reaction, and elevated lactate, like this patient. More so, acidosis is a direct cause of hypotension and shock. Per one source " Cardiac contractility and cardiac output are reduced and arterial vasodilatation develops, which contributes to the development of hypotension". (source below) After appropriate treatment with insulin and glucose, this patient’s gap closed.

In full disclosure about this case, although his labs have improved, the etiology of his initial hypotension and shock picture is not yet clear. This is, however, often the case in medicine, and shock in particular, that a single, clear, elegant explanation doesn’t exist. And as such, we again thank Dr Levin for this honest and exciting case that allowed us to walk down the often confusing paths of shock and its attedant management in a real “choose your own adventure” fashion.

Citations: -https://img.ma-shops.com/hild/pic/image01646.jpg -https://ai2-s2-public.s3.amazonaws.com/figures/2017-08-08/4eb58c5284bc04a8a9c4325f003add3d36b4e18a/7-Table2-1.png -https://thecurbsiders.com/show-notes/88-acid-base-boy-bands-grandfather-clocks-joel-topf-md -https://www.medscape.org/viewarticle/718583_6

Adult Henoch-Schonlein Purpura

Dr. Kiefer presented a fascinating case of Henoch-Schonlein Purpura presenting in a patient with a complex medical history who received antibiotics and presented with new renal failure, unique “palpable purpura” rash, and hypotension. While more common in pediatric populations, HSP occurs in adults as well, and can be a result of drug reaction. While a trigger is only found in a minority of patients, in addition to medications, triggers for adult onset HSP can include infections.

 representative image courtesy of  Brown EM res blog

representative image courtesy of Brown EM res blog

We used this as an opportunity to review our most commonly discussed vasculidities. Please note that this below chart is not meant to be exhaustive! It may however be useful for board prep or when thinking of a differential when a vascular inflammatory process is considered.

 schema courtesy of your friendly ohsu im chief resident

schema courtesy of your friendly ohsu im chief resident

Noon Report: Hyponatremia Review

Hyponatremia Pearls

On Wednesday we had an instructive noon report by Dr. Horton wherein an admitted patient was found to have new heart failure with a sodium concentration of 112 meq/L.

We worked through the diagnostic plan for someone with newly found profound hyponatremia, and thanks to the Curbsiders’ handy algorithm, residents were able to quickly identify their treatment plan.

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Dr. Horton PICO question evaluated whether hyponatremia had any prognostic value as a marker for mortality when diagnosed among hospitalized patients. He discussed a study by Abraham et al., in Journal of the American College of Cardiology wherein each decrease in serum sodium by 3 mEq below 140 was associated with an increased risk of mortality, and furthermore could be incorporated into a risk-prediction nomogram to calculate a patient’s risk of in-hospital mortality.

Check out the entire podcast episode here: https://thecurbsiders.com/medical-education/48-hyponatremia-deconstructed

More information about hyponatremia as a predictor of mortality available here: Abraham WT, Fonarow GC, Albert NM, et al. Predictors of In-Hospital Mortality in Patients Hospitalized for Heart Failure. Journal of the American College of Cardiology. 2008;52(5):347-356. doi:10.1016/j.jacc.2008.04.028.

Noon Report: Palliative Care in the ICU

Dr. Anna Stecher presented a novel take on noon report today as she led us through 3 separate clinical stories she has encountered that involve complex goals of care and end of life conversations.

With these stories as a starting point, participants reflected on past difficult conversations they have had, with a focus on complex “Family Conferences” which can be particularly stressful for a primary team resident to lead with multiple subspecialists, strong emotions, and family dynamics.

We discussed the “Vital Talks” Framework for such conversations, which is a helpful (but not all-encompassing) guideline for approaching these moments.

The framework can be described as follows:

1. Pre-meet

  • Meet with other members of the team (subspecialists, nurses, etc.) and share key points of agreement, update on clinical status and potential family dynamics
  • Decide on whom is leading the meeting

2. Introduce

  • Ensure private location
  • Clearly delineate purpose of meeting (“get to understand patient’s wishes better”, or “hear concerns, provide an update, and plan together”, as opposed to “decide on a code status”).

3. Assess

  • Elicit the family’s understanding and perspective of situation as it stands

4. Update

  • Provide broken-down pieces of information (not as a monologue or lecture)
  • Ensure ample time understanding and questions
  • Summarize succinctly

5. Empathize

  • Wait and acknowledge emotion. OK to provide time to process/allow for silence if appropriate

6. Prioritize

  • Elicit patient’s values: have family provide information about the patient as a person sans illness- what were their priorities, what would the patient want?
  • Stress that family’s role is not to make a decision on behalf of the patient, simply to act as a translator for what the patient would want or learn about what options are most consistent with the patient’s values

7. Align

  • Demonstrate how a potential plan of action or several options might align with the stated values of the patient
  • Consider making a recommendation based on what you know of the patient’s values and medical situation if necessary
  • Give all family members opportunity to express different views without taking sides

Dr. Stecher presented some data about palliative care consultations for terminally ill patients in the ICU. While data is somewhat sparse, introduction of early palliative care may possibly reduce mortality rates and likely shorten length of stay within this patient subset.

jama icu.PNG

There is also some literature describing the most commonly cited barriers to goals of care discussions for hospitalized patients and their families, including factors such as perceived difficulty by family members to accept a loved one’s poor prognosis, and difficulty understanding limitations/ complications of life sustaining therapies. The most evidence-based interventions to address these and other concerns include: printed info, structured communication by the ICU team, and ethics and/or palliative care consultation.

Link to full study here

Tips to not feeling incapacitated by capacity assessments

Thank you, Dr Nelson, for an unconventional case today that allowed us to pursue a discussion regarding patient capacity and the role of our foundational ethical principles during these difficult cases.

Specifically, Dr Nelson present a patient with schizophrenia who presented with acutely worsening shortness of breath secondary to massive malignant pleural effusion from known extensive stage SCLC. Having previously undergone 2 rounds of chemotherapy and suffering significant side effects, the patient decided to forgo further treatment and expressed her wish to discharge home with comfort measures.

The questions were raised:

  • Does this patient have capacity to make this decision?
  • How does her underlying schizophrenia affect her capacity?
  • What do you do when the patient’s wishes don’t align with your own or those of the patient’s family members?

To help answer these questions and equip you with some tools for future similar encounters, here are some helpful resources:

The medical ethics alphabet: autonomy, beneficence, confidentiality, do no harm/non-maleficence, equality. When in doubt, go back to basics and honor these principles. With these are your guide posts, you will be thoughtful in your approach to the patient and dilemma at hand. (picture below)

Have confidence with capacity: This is not only something we can and should assess, it is something that the primary team is best suited to do. As the primary team, we know the patient best and thus in the best position to understand and advocated for what is truly right for the patient. This NEJM article discusses the topic nicely and offers this helpful review of how to approach capacity assessments. (picture below)

Be conscious of unconscious bias: Below are some of the key points that Dr Nelson nicely discussed in her review of this topics:

o    Impairment in capacity is not a hallmark of schizophrenia; in fact, the majority of patients with schizophrenia do have capacity (estimates range from 10-52%)
o    Physicians are more likely to identify a patient as lacking capacity if the patient is making a choice other than what the physician sees as appropriate, regardless of the demonstration of the 4 domains of capacity
o    We tend to overestimate the capacity of our non-psychiatric patients
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Necrotizing Face-iitis!

Today Dr. Sulpizio presented a thrilling case of a young poorly-controlled diabetic male who presented with acute onset of rapidly progressive facial swelling refractory to steroids, found ultimately to have the dreaded necrotizing fasciitis! Though a surgical diagnosis, it is crucial that we as internists not miss this! The table below is from an excellent summary from NEJM – Necrotizing Soft-Tissue Infections from Dec 2017. It details common pitfalls in diagnosis, such as being falsely reassured by imaging that shows edema only without frank gas or abscess (our major pitfall today!).

nec fasc snip 3.PNG

Take Home Points:

  • Early recognition is VITAL.
  • There are two types of necrotizing soft tissue infections.
    1. Type I (polymicrobial) – Enterobacteriaceae, bacteroides, clostridium, GAS
    2. Type II (monomicrobial) – GAS, Staph aureus
  • Do NOT rely on the LRINEC score (performs poorly in external validation studies).
  • Surgical intervention is the only definitive diagnostic and therapeutic approach.
  • Include IV clindamycin with empiric antibiotic coverage to counter toxin production.
 Shout out to MedComic for this hilarious graphic!

Shout out to MedComic for this hilarious graphic!

The Big Man speaks on Liddle-Man’s!

Today Dr Grovenburg (the “big man”) presented a show stopping case of impressive hypokalemia (K 1.6) in an older woman who was also recently found to be hypertensive and demonstrated a significant metabolic alkalosis.

What a great presentation for the classic triad often seen in mineralocorticoid excess of: 1) Hypokalemia 2) Hypertension and 3) Metabolic Alkalosis.

MCE.jpg

The causes of mineralocorticoid excess are further broken down, as seen in the table below.

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In the case of our patient, who was found to have LOW renin and LOW aldosterone, the jury is still out if her diagnosis is Apparent Mineralocorticoid Excess or Liddle’s Syndrome. Worth note, licorice can also do this, but not your average twizzlers… the real kind. Below is a nice compare and contrast of these two conditions (well three conditions—there is a shout out to licorice).

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