Wtf?

[Birdstrike]

I have seen so much bacterial meningitis in the past few months, including 2 cases in the past month, that I'm wondering how much I missed in the past 10 years:

Case 1: 3 month old this week with no fever no white count (low wbc) and only 6 wbc's on LP. Positive gram stain, + group B strep antigen screen and + culture.

Case 2: 2 1/2 month old without fever, sent in by peds for diarrhea and "looking dry" who had an infiltrate on cxr (whom I didn't tap but thank god I admitted and treated and got tapped later). Again, low, not high WBC

Case 3: 22 yr old female on 100mg methadone who I could hear screaming "I WANT SOMETHING FOR MY HEADACHE! I WANT SOMETHING FOR MY HEADACHE NOOOOOOOOW! before I even walked into the room who ended up having 34,000 WBC on LP (looked like skim milk). Again, no fever (went up to 106 later). Miraculously, lived and left the hospital with only minor short term memory loss (where'd I put my keys? kinda stuff). This one, on a day I saw 47 patients (I'm still hurting from that shift).

...and a 6 year old 10 days ago who had culture proven Meningococcemia (but not meningitis) who presented with fever and hip pain. Also miraculously, he did great.

"WTF?"

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[WilcoWorld]

WTF indeed. Especially the 1st case. 3 months, 6 WBC's? I can easily imagine someone arguing to discharge that patient.

 

[Birdstrike]

WTF indeed. Especially the 1st case. 3 months, 6 WBC's? I can easily imagine someone arguing to discharge that patient.

Saved by the gram stain (and confirmed by PCR and culture). Just insane.

 

[Apollyon]

"WFT?"

Someone needs some time off!

As to your question, though, I agree - I think back to patients I've "horribly mismanaged", and thought a few things: first is, "it's better to be lucky than good", but, the other is that you really haven't been missing things, as there would definitely be a pattern that Birdstrike was leaving kids dead left and right in his wake, and that hasn't happened. Alternatively, there's the less-likely possibility that many kids have survived bacterial meningitis under- or untreated without deficit.

 

[Birdstrike]

Someone needs some time off!

Considering the high acuity I've been seeing, the ridiculous amount of hours I've been working, the fact that I was slapped with a meritless lawsuit this week, combined with the fact that our ED is overwhelmed yet our COO is in the ED 4-5 times per day flipping out because he can't figure out why we can't "greet" every patient in under 15 minutes makes your above statement pretty much the most accurate statement I've ever seen on this forum, or anywhere on the internet, for that matter. I've got 9 days off coming up in a few weeks. Thank god.

 

[Stitch]

WTF indeed. Especially the 1st case. 3 months, 6 WBC's? I can easily imagine someone arguing to discharge that patient.

Yeah, I probably would have (except for the gram stain!).

Good catches Birdstrike! Were these kids vaccinated?

Oh and never trust a CBC in a kid. I tapped a 6 month old, and pus poured out (seriously). Serum WBC? 8. CSF WBC 1500. I take the low counts more seriously than the high or normal.

 

[Emergency!]

For educational purposes, what was it about the 3 mo old's story/exam that made you do an LP?

 

[thorg12]

i was just gonna ask the same question. Why did u tap the ones that were afebrile?

 

[Birdstrike]

Were they vaccinated? Yes

Reasons for tapping:

Case 1: was a premie, hr elevated in absence of fever, pale, wasn't eating per mom, also not as responsive per mom and did truly look lethargic with poor tone. Also, WBC low. Also, hit with a meritless lawsuit the day before. "Everyone" was getting tapped that day, LOL.

Case 2: admitted and treated for an infiltrate confirmed by rads. Was tapped later by peds when condition worsened. Fortunately, sepsis/pneumonia antibiotics started in ED and admitted, so an earlier tap wouldn't have changed treatment (turned out to be common bug)

Case 3: looked fine on arrival. Worsened dramatically in ED, fortunately before discharge on a very, very busy day.

As stated above, it's better to be lucky than good.

 

[WilcoWorld]

Nothing will push your (and my) practice towards the conservative side like a lawsuit. Fortunately, it wears off after a while, but the worse the suit, the longer it takes.

 

[yahoomail]

I have seen so much bacterial meningitis in the past few months, including 2 cases in the past month, that I'm wondering how much I missed in the past 10 years:

Case 1: 3 month old this week with no fever no white count (low wbc) and only 6 wbc's on LP. Positive gram stain, + group B strep antigen screen and + culture.

Case 2: 2 1/2 month old without fever, sent in by peds for diarrhea and "looking dry" who had an infiltrate on cxr (whom I didn't tap but thank god I admitted and treated and got tapped later). Again, low, not high WBC

Case 3: 22 yr old female on 100mg methadone who I could hear screaming "I WANT SOMETHING FOR MY HEADACHE! I WANT SOMETHING FOR MY HEADACHE NOOOOOOOOW! before I even walked into the room who ended up having 34,000 WBC on LP (looked like skim milk). Again, no fever (went up to 106 later). Miraculously, lived and left the hospital with only minor short term memory loss (where'd I put my keys? kinda stuff). This one, on a day I saw 47 patients (I'm still hurting from that shift).

...and a 6 year old 10 days ago who had culture proven Meningococcemia (but not meningitis) who presented with fever and hip pain. Also miraculously, he did great.

"WTF?"

gotta have a low threshold for tapping the patients who are extreme of age.
Neonate not "looking right" or that nursing home patient whose baseline is alert and oriented x 0 now presenting with "altered mental status" are literally time bombs waiting to explode if not worked up in detail including invasive testing. I always offer it to all these patients in the right clinical scenario, and if they refuse, I clearly document that.
Also patients with refractory headache who have a normal head CT get offered an LP from me. If they truly have a headache, they'd not care. If they are drug seeking, they refuse. I have had drug seekers just disappear from the ED once I walked in the room with a shining new LP needle in my hand !!

 

[gutonc]

gotta have a low threshold for tapping the patients who are extreme of age.
Neonate not "looking right" or that nursing home patient whose baseline is alert and oriented x 0 now presenting with "altered mental status" are literally time bombs waiting to explode if not worked up in detail including invasive testing.

I would argue that the nursing home patient with a baseline of A+Ox0 presenting with AMS would probably benefit from just letting it go at this point. Check a UA and call it a day.

 

[yahoomail]

I would argue that the nursing home patient with a baseline of A+Ox0 presenting with AMS would probably benefit from just letting it go at this point. Check a UA and call it a day.

For sure, but what about the family members who vehemently insist that "everything must be done" for their loved one who they last saw about 2 months ago !! And also there is some pressure from the attendings as well.

 

[Arcan57]

gotta have a low threshold for tapping the patients who are extreme of age.
Neonate not "looking right" or that nursing home patient whose baseline is alert and oriented x 0 now presenting with "altered mental status" are literally time bombs waiting to explode if not worked up in detail including invasive testing. I always offer it to all these patients in the right clinical scenario, and if they refuse, I clearly document that.
Also patients with refractory headache who have a normal head CT get offered an LP from me. If they truly have a headache, they'd not care. If they are drug seeking, they refuse. I have had drug seekers just disappear from the ED once I walked in the room with a shining new LP needle in my hand !!

I'm sure you've heard this point before, but getting the headache to go away has nothing to do with the cause of the headache. If you're only tapping people who's head still hurts after the CT and headache cocktail, then you're going to miss SAHs.

 

[yahoomail]

I'm sure you've heard this point before, but getting the headache to go away has nothing to do with the cause of the headache. If you're only tapping people who's head still hurts after the CT and headache cocktail, then you're going to miss SAHs.

U r right, in an opioid naive patient, morphine or dilaudid can pretty much fix any headache, and thats why doing an H&P BEFORE medicating the patient proves useful !! That initial assessment is what guides further intervention(s).
And interesting that u brought up the point of missing SAH. I think a negative head CT, depending on the age of the bleed, is about 95-97% accurate in diagnosing SAH. So if thats negative and the patient doesn't have a good story, them having any significant SAH is pretty minimal.

 

[tkim]

And interesting that u brought up the point of missing SAH. I think a negative head CT, depending on the age of the bleed, is about 95-97% accurate in diagnosing SAH. So if thats negative and the patient doesn't have a good story, them having any significant SAH is pretty minimal.

A 3-5% miss rate for SAH is huge. Like MI, our expected miss rate is zero.

 

[xaelia]

For sure, but what about the family members who vehemently insist that "everything must be done" for their loved one who they last saw about 2 months ago !! And also there is some pressure from the attendings as well.

Academic centers can be a bit different, in that doing more "for practice" on patients who will derive little benefit may have valid ethical justification in the sense that it benefits society as a whole to increase trainees skills. This balances out the otherwise inappropriate resource consumption and effort that may not be necessary in a relatively futile situation.

Patient and family autonomy goes a long way, but it should have limits.

 

[deleted109597]

And interesting that u brought up the point of missing SAH. I think a negative head CT, depending on the age of the bleed, is about 95-97% accurate in diagnosing SAH. So if thats negative and the patient doesn't have a good story, them having any significant SAH is pretty minimal.

Any blood in the brain I would consider significant. Remember, if they make it to your ED, they're likely to survive the first bleed no matter what you do. But if you let them go home without diagnosing it, they're more likely to die from the next one. As in nearly 70%.

And if you're letting CTAs take the place of you doing a little procedure, then you're overtreating people with asymptomatic aneurysms and possibly making them have highly morbid/mortal surgery that isn't necessary.

 

[xaelia]

Any blood in the brain I would consider significant.

Blood in the brain from traumatic SAH can be pretty meh. Those people really don't need to be admitted all the time.

And if you're letting CTAs take the place of you doing a little procedure, then you're overtreating people with asymptomatic aneurysms and possibly making them have highly morbid/mortal surgery that isn't necessary.

Thank you Dr. Hoffman. We can all download EMA ourselves anytime we like.

 

[Hamhock]

Blood in the brain from traumatic SAH can be pretty meh. Those people really don't need to be admitted all the time.
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Have you sent home a traumatic SAH from the ED?

HH

 

[xaelia]

Depends; I have been on the trauma service that offers the patient discharge home from the ED after tiny traumatic SAH.

 

[lucky_deadman]

And if you're letting CTAs take the place of you doing a little procedure, then you're overtreating people with asymptomatic aneurysms and possibly making them have highly morbid/mortal surgery that isn't necessary.

What's the first thing that happens when you diagnose a patient with a SAH via LP? The Neurosurgeon has you get a CTA of the brain and/or MRI/MRA of brain and the patient is admitted to the medicine service.

Basically getting the CTA early saves trying to blindly harpoon Shamu. If there is an aneurysm on CTA it needs close monitoring and likely coiling early before it bleeds. Rarely will a patient live their whole life with an aneurysm and it not cause them problems.

What happens when you get a negative LP just because the aneurysm hasn't ruptured yet? Does this make you less likely to get sued for not having diagnosed it?

 

[danielmd06]

Have you sent home a traumatic SAH from the ED?

HH

Yes, they can be sent home. It just depends. I was involved in a small handful (less than 5) cases like this in residency.

Basically, the neurosurgery resident would insist that the patients didn't need to be admitted for trace amounts of subarachnoid blood, and the EM attendings would consult neurology "just to be sure" there hadn't been a seizure or some such and that we agreed with NSG.

 

[danielmd06]

What's the first thing that happens when you diagnose a patient with a SAH via LP? The Neurosurgeon has you get a CTA of the brain and/or MRI/MRA of brain and the patient is admitted to the medicine service.

Basically getting the CTA early saves trying to blindly harpoon Shamu. If there is an aneurysm on CTA it needs close monitoring and likely coiling early before it bleeds. Rarely will a patient live their whole life with an aneurysm and it not cause them problems.

What happens when you get a negative LP just because the aneurysm hasn't ruptured yet? Does this make you less likely to get sued for not having diagnosed it?

Right, but when you get the CTA for the NSG in this case, you've already diagnosed SAH via LP. It's a different situation than stumbling upon an unruptured aneurysm that is too small for intervention.

Most specialists would expect the LP first, and then the CTA.

Finding an incidental unruptured aneurysm (of less than 10-12.5 mm...larger than this and they would get surgery/interventional procedure) isn't a huge legal issue. They usually follow-up annually in clinic with neurosurgeons and get once-yearly imaging studies.

 

[deleted109597]

What's the first thing that happens when you diagnose a patient with a SAH via LP? The Neurosurgeon has you get a CTA of the brain and/or MRI/MRA of brain and the patient is admitted to the medicine service.

Yes, but the angiogram isn't to confirm diagnosis, it's to determine where it is and how to repair it. Not all of them can be coiled.
Also, medicine never admits these at our shop.

Basically getting the CTA early saves trying to blindly harpoon Shamu. If there is an aneurysm on CTA it needs close monitoring and likely coiling early before it bleeds. Rarely will a patient live their whole life with an aneurysm and it not cause them problems.

Not true. Depending on source, 2-5% of the population walks around with asymptomatic brain aneurysms all the time. The presence of one doesn't mean it is bleeding, just like the presence of the AAA doesn't mean it's causing the abdominal pain.

What happens when you get a negative LP just because the aneurysm hasn't ruptured yet? Does this make you less likely to get sued for not having diagnosed it?

Doesn't make you any less likely, because suits don't require merit to be filed. Absolutely it makes you less likely to lose the case. Remember, the aneurysm isn't the emergent condition, just like incidental AAA. The ruptured one is.

Have you sent home a traumatic SAH from the ED?

HH

Yeah, but only after consulting someone else.

 

[WilcoWorld]

I agree with the argument that some aneurysms are asymptomatic & that for this reason LP remains the gold standard for diagnosing non-traumatic SAH.

As for the traumatic brain injury patients (a very different disease process): At my shop, if the bleed is small, the patient has a normal neuro exam, and they meet several other inclusion criteria (age, coagulation status, can be discharged to a safe environment, etc) we observe for 12 hours, repeat the head CT and, if there is no decline in clinical status or progression of the bleed, we discharge the patient from the ED Obs Unit. This is all done in consultation with Neurosurgery.

I'll admit that it took me awhile to become comfortable with this plan, and that it wouldn't work for your average community ED, but we save a lot of ICU admissions without having worse outcomes. I think that's a good thing.