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A Tale of Two Thrombi


 

It was the best of care. It was the worst of care. It was acts of wisdom; it was acts of foolishness. It was an epoch of evidence; it was an epoch of anecdotes. The patients were full code; they were DNR. It was the summer of safety and the winter of sentinel events. In short it was a hospital so like all others.

It was a slow day when Charles Darnay hit the admission office of Tellson General Hospital. Lucie sat at the terminal, glad for the distraction. She entered his information: DOB 04/21/29/Dr. Defarge/RTKA/Iodine Allergy/Regular Diet/Semi-Private/Regular Diet. Lucie was unsuccessfully trying to place a red seven on a black nine when the phone rang with a direct admit: Darren Charles/Dr. Mannette/DVT/NKDA/ Private/Diabetic Diet.

Darren Charles was not happy to be hospitalized. The CEO of an international fast food chain, he had been flying back from a business trip to London when his leg started to ache. He went to the emergency department where a right femoral vein thrombosis was observed on ultrasound. With a serum glucose of 380, he was incarcerated. The mattress was hard, the pillows starchy, and the cable selection poor. He knew this wasn’t a hotel, but he expected better service. He was tired of finger sticks, blood draws, and IVs already.

PA Carton looked at the radiologist, whose sneer changed to surprise as he looked at the massive saddle embolism. He turned to her and said, “This is a far, far larger clot then I have ever seen before.”

Inside Charles Darnay’s right knee joint, cartilage rubbed against cartilage. It was a wheelchair or surgery. He was adopted and a bachelor and the thought of a long lonely rehab left him cold. Dr. Defarge made it sound like it would be a breeze.

Syd Carton was the first physician’s assistant to work at Tellson General. She loved her job and had become very efficient over the last three years. She had started as an orthopedic PA, but switched to Dr. Mannette’s general medicine service to get a wider variety of cases. She took Mr. Darnay’s history. DVT post-airplane flight, with diabetes poorly controlled and dietary noncompliance. His glycohemoglobin was 12. He was high maintenance; she could live without taking care of VIPs.

Jerry Cruncher, the orthopedic intern on Dr. Defarge’s service, was fried. He’d been up all night on the graveyard shift, and it was now 1 p.m. His wife would not tolerate him coming home late again. She was likely to become a whistle blower and sink the whole residency program if he went over his allotted hours again. He loved orthopedics, but working for the infamous Dr. Defarge was a challenge. She was a great surgeon and sewed beautifully, but was mythically unpleasant. The slightest medical problem with a patient and she would bellow, “Off of my service.” It had better happen that way or it would be Intern Cruncher’s head. At any rate he was almost done—just an order or two to write and he’d be in his nice warm bed, with his nice warm wife.

PA Carton received a stat page. Mr. Charles’ oxygen saturation had dropped acutely, and he was complaining of shortness of breath. A fragment of thrombus had broken off from the expanding mass of platelets and protein in his leg and had gone for a wild ride through his circulatory system. A larger strand of thrombus fluttered precariously in the current of his femoral venous flow. Why did the VIPs always have complications?

PA Carton checked Mr. Charles’ PTT, therapeutic. His INR was coming up nicely with warfarin, but it sounded like he’d flipped a clot. She checked his vital signs: He was moderately tachycardic, but not hypotensive. His O2 sat was 84, and only came up to 91 with 4 liters nasal cannula oxygen. She ordered an EKG, troponin levels, and a CT angio. His renal function was normal, but he was on metformin. She held that drug, and called the radiologist. It took a bit of persuasion, but they would do the procedure that day.

Mr. Darnay’s right leg begun to swell. He had missed his physical therapy because it was Saturday and the pain medications made him lazy. His right popliteal vein began to fill with clot, and slowly spread proximally. Mr. Darnay’s nurse, Janice Lorry, would never have gone in his room if she hadn’t had a hankering for a Snicker’s bar, which she took from the bowl he kept to encourage visitors. She was surprised to see him looking uncomfortable; he asked for more pain medication. Something seemed wrong. She checked his oxygen saturation, 88 on room air; it had been 94 earlier that shift. She paged the intern on call.

The radiology resident sat in his office. It was a Saturday, and now he had to call in his technician and hang around to read the CT image. He had tried to put PA Carton off, but she was persistent and played the VIP card. When it was negative he was going to give her an earful.

Intern Cruncher was smiling. He was ready to check out; his wife was waiting. Connubial bliss and deep REM was all he could think of. He reached for the phone as his pager went off. It was that nurse on 14 West that drove him crazy. She said Dr. Defarge’s patient was hypoxic. He looked at his watch. He told her to encourage the use of the incentive spirometer; that it was probably post-operative atelectasis. He rolled his pager over, checked out, and went home.

Transportation was notified that they were ready for Mr. Charles in radiology. Kurt Rorcher from transportation had another patient to bring to the whirlpool, and they were short staffed on the weekend. When he finished with this first patient he would head up to 14 West, although he might have to stop by admissions and check out Lucie on the way.

Jarvis Lorry glanced over the terminal where he was polishing up a complex discharge summary. He’d been a hospitalist for two years now and enjoyed the flexibility of hours—and especially being around his wife, Nurse Lorry. However he recognized the look on her face; she was angry about something. He toyed with idea of sneaking down the back stairs, but then she spotted him. She wanted him to take a look at a patient for her. He knew better then to say no.

It was one of Dr. Defarge’s orthopedic patients, Mr. Darnay. He was hypoxic with a swollen leg. In Dr. Lorry’s mind every ortho patient with hypoxia had a PE until proven otherwise. He called radiology immediately. As expected on the weekend the reception was cool, but the tech was already there. He noted the patient’s iodine allergy and ordered a dose of Solu-Medrol.

The transportation aide went to the nurses’ station. They were ready for Mr. Darnay to get a CT angio. Nurse Lorry was amazed at how quickly it happened; her husband could sure get some action going. She helped load Mr. Darnay onto the stretcher. As soon as the transportation aide Torcher got down there they told him there was another patient to get on 14 West. Too busy for a Sunday. He might have to call in sick tomorrow if this kept up.

As Darren Charles made his way down to radiology on the second stretcher, Charles Darnay was getting contrast for his CAT scan. When Mr. Charles arrived he was given a dose of Solu-Medrol, which had been meant for Mr. Darnay. It would not be long until his glucose started to skyrocket.

Dr. Lorry ran down to radiology when he heard the code called. He never missed a chance to use his ACLS skills. He was happy to see PA Carton already running the code. It was Dr. Lorry’s patient, Mr. Darnay, in anaphylactic shock. The radiologist was fuming. Why hadn’t Mr. Darnay been premedicated? Dr. Lorry knew he had written that order.

When the dust cleared, Darnay was stabilized, and in fact, he did not have a pulmonary embolism. It looked like post-operative atelectasis after all. He did have a deep venous thrombosis in his leg.

PA Carton stood by the radiologist as he read the film on her VIP patient, Darren Charles. It would be later that night when his glucose inexplicably hit 500. The radiologist glared at her. What was with these people constantly ordering CT angios on a weekend? Did they know the cost and manpower involved?

PA Carton looked at the radiologist, whose sneer changed to surprise as he looked at the massive saddle embolism. He turned to her and said, “This is a far, far larger clot then I have ever seen before.”

It was the best of care; it was the worst of care. It was acts of wisdom; it was acts of foolishness. It was an epoch of evidence; it was an epoch of anecdotes. The patients were full code; they were DNR. It was the summer of safety and the winter of sentinel events. In short it was a hospital so like all others. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

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