乌鸦传媒

"We tried all night to reach her."

Yesterday, during a routine day of practice, there were multiple patients seen who ended up having critical lab values, results on their testing that led to a call in the middle of the night from the lab to our on-call doctor, with what could be potentially life-threatening findings on their blood tests.

In one case, a patient was on multiple medicines known to cause electrolyte abnormalities and, despite feeling fine when being seen in the office during the day, ended up having critically high readings on just those electrolytes, findings which could result in dangerous arrhythmias and even death.

The resident who had seen the patient said in the note that the patient felt fine, and there was nothing in his behavior that made anyone suspect that these findings would appear.

Another patient with long-standing poorly-controlled diabetes was seen for her routine quarterly visit for the ongoing management of her health conditions.

The resident stated that she too had felt fine, and he did a detailed probing because he knew that her sugars were known to be extremely high. A complete relevant review of systems had been unable to unearth any clues that would have suggested that her diabetes might be so profoundly out-of-control as to put her at immediate risk of serious complications.

When those labs came back with a glucose reading so high that the lab result was bolded and highlighted a deep blood-red maroon in the computer with multiple exclamation points, this result was dutifully noted by the lab, and the mechanisms to contact our practice went into play.

The documentation in the computer system shows that the on-call doctor was paged, that the on-call doctor called back, that the critical value was read to the on-call doctor by the laboratory technician, and then read back by the doctor as confirmation that it was received.

Then we went to work.

In our electronic health record, one of the fields is called "SnapShot" which brings together the patient's name, date of birth, address, close relatives and emergency contacts, pharmacy of choice, medication list, problem list, allergies, and other potentially useful information, all collected on one nice big page for easy reference.

Unfortunately, when the resident tried to reach the cell phone, home phone, work phone, and all of the multiple emergency contact numbers listed, nothing worked, nothing went through, no one was reachable.

At this point, the question becomes, what do we do, what's our duty, what's in the best interest of the patient, what do we have at our disposal to help make sure this patient is safe?

For one thing, the patient felt fine in the office many hours earlier when that lab was actually drawn. The resident said, how do I know that that patient didn't go home, take her insulin, and her glucose is now totally normal? How do I know that maybe she went home, didn't take her insulin, and now it's even worse?

There's the rub.

Nothing to do but act in the patient's best interest.

Point-of-care testing can help alleviate or minimize some of these problems. Getting a glucose reading right in the office on a diabetic who you suspect might be out of control, who may present with symptoms, can let you know at least a ballpark figure when their lab results are critically high, and let you start doing interventions right there in the office.

Another trick used to help prevent these overnight misadventures is, if you suspect that you're likely going to get an abnormality, to do a bit of advanced planning.

Talk to the patient about what you're worried you're going to find, and why you think they might get a call in the middle of the night. Make sure their contact information is accurate, and even ask them to make sure that their cell phone is fully charged.

Signing out these potential upcoming critical values to the on-call doctor, with an "if-then" plan, can make everyone's life easier, and lead to better outcomes for patients.

If the labs gets a value above X, then I suggest you tell the patient to do Y. If above A, then definitely B.

But should every patient who takes a medicine that is known to cause high potassium get an EKG done in the office whenever they get labs checked in case they have hyperkalemia and then we want to know if they have peaked T-waves on their EKG, once that potassium comes back at 6.8 in the middle of the night?

Not very practical.

Once, several years ago, a critical value got reported to our on-call doctor, and after long discussions with the attending who serves as their back up, they finally ended up calling paramedics and the police to go to the patient's house to try and see if someone was there, and then to try and enter the apartment if necessary.

There was no landlord, no neighbors had the keys, and ultimately, fearing for the worst, the police kicked down the door.

The apartment was empty, but while the police and paramedics were in the apartment, the patient and his daughter returned from a lovely dinner out they had been having together, surprised to find these events unfolding in his home.

The next morning, when we finally reached the patient after he had been taken to the emergency room and checked out and sent home, we expected him to be furious that we had broken the doorjamb of his apartment's front door.

Much to our surprise, he was only appreciative of our efforts to make sure he was safe. Because we'd acted in his best interest, he had nothing but praise for the team who'd made those efforts to take the best care of him overnight.

Often, for a variety of reasons, our patients are hesitant to list contact information, sometimes they worry about documentation, sometimes they don't want other family members to know about their health status, but the concept of an emergency contact is crucial to our being able to take care of people.

In this modern age, it's hard to imagine someone not being reachable. Most of our patients come to their office visits with their smartphones, oftentimes not even wanting to put them down while we're examining them, either continuing to do work or posting on social media about their doctors' visit as it is happening.

The electronic health record and its patient portal should be able to provide us a system that effectively and efficiently allows rapid communication and help to bridge that gap between us, the patient's results, and the patient getting to know those results.

I wish that critical lab value actually went right to the patient, some sort of a loud annoying alarm that went off on your phone that said your sugar came back at 850, not good, we're connecting you to your doctor, please stand by.

No matter what, I think we need to make sure that we're always able to reach our patients. We do a disservice if we collect lab tests that could result in the necessity of us contacting them urgently overnight, and we don't have any way to reach them.

If the patient doesn't want to be reached, I don't want to do a test that I need to reach them about.

So leave me your phone number, somewhere I can reach you, some way we can make sure you're all right, to continue to get you the best care.

Because critical values are often critical.

Comment