Au revoir Dick
The patient had intussusception. The patient has a loop of bowel inside another bowel. It looks like pneumatosis (air in the bowel wall), but it’s not. If you look carefully, the outline of air is separate from the bowel wall (not in the bowel wall). The patient went to the OR and had an unremarkable recovery. Most adult intussusceptions require an operation; some resolve on their own. Don’t call radiology to reduce it with an air edema. Intussusception is a rare disease in adults, so it’s usually diagnosed on CT, not an xray.
Dick is unique in many ways. As we all know, Monday nights tend to be crazy shifts. Yet, Dick never misses anything. If Dick says the guy is for real, that’s good by me. As we know too well, sign-outs are a dicey affair at times. When you get to know your sign-outs, you learn when you need to double-check things and when you don’t.
As typical for patients with real problems, this opioid-dependent patient did not scream for pain meds. He barely asked for meds at all. Dick will be missed.
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sepsis answer
If you asked “how did the patient look?”, you win.
Despite good “numbers”, we admitted the patient to the ICU after covering her with abx.
“Why does the patient look so bad and her numbers look so good?” asked the Kume (sic). The teaching point here is that vital signs, blood tests (e.g. lactate), and imaging are not substitutes for the clinical impression. The patient looked ill. Critical Care may hem and haw over the phone, but they put up little resistance to an ICU admission once they see the patient.
A great weakness of lactate in sepsis is that a normal lactate does not mean that your patient will not decompensate and die, so it’s not a reliable prognostic indicator. In addition, lactate ≠ sepsis; lactate ≠ hypoperfusion. Because of the recent emphasis on lactate and sepsis, doctors incorrectly associate the two. There are many causes of lactate acidosis. Just because someone makes lactate, it doesn’t mean they have an infection. They may have a different critical illness that you are missing because you’re chasing an infection.
The patient went to the ICU and crashed in about 12 hours. She had E Coli septic shock, was intubated, on pressors for a few days in the ICU, but eventually made it out of the hospital.