WebM&M Cases & Commentaries
Inadvertent Use of More Potent Acid Leads to Burn
Howard I. Maibach, MD; January 2016
An attending physician recommended using acetic acid to evaluate a lesion on the perineum of a woman who had previously experienced a wart in the same area. The resident physician asked the medical assistant for acetic acid and unknowingly received trichloroacetic acid, which burned the patient's skin.
Harm From Alarm Fatigue
- SPOTLIGHT CASE
- CME/CEU
Michele M. Pelter, RN, PhD, and Barbara J. Drew, RN, PhD; December 2015
Following a non-ST segment elevation myocardial infarction, a man was admitted to the hospital and placed on a telemetry monitor. As the monitor was constantly sounding with "low voltage" and "asystole" alerts and the patient was well each time clinicians checked, they silenced the alarms. The patient was found dead 4 hours later.
Managing Ascites: Hazards of Fluid Removal
Kevin Moore, MBBS, PhD; December 2015
A man with cirrhosis and abdominal distension was found to have significant ascites. The emergency department providers performed a large volume paracentesis to relieve his symptoms, but, as the 10th liter of fluid was removed, the patient became acutely hypotensive.
Hyperglycemia and Switching to Subcutaneous Insulin
Tosha Wetterneck, MD, MS; December 2015
Hospitalized with nonketotic hyperglycemia, a man was placed on IV insulin and his blood sugars improved. That evening, the patient was transferred to the ICU with chest pain and his IV insulin order was changed to sliding scale subcutaneous insulin. However, over the next several hours, the patient again developed hyperglycemia.
The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy
- SPOTLIGHT CASE
- CME/CEU
Jacob Reider, MD; October 2015
After leaving Hospital X against medical advice, a man with paraplegia presented to the emergency department of Hospital Y with pain and fever. The patient was diagnosed with sepsis and admitted to Hospital Y for management. In the night, the nurse found the patient unresponsive and called a code blue. The patient was resuscitated and transferred to the ICU, where physicians determined that the arrest was due to acute rupturing of his red blood cells (hemolysis), presumably caused by a reaction to the antibiotic. Later that day, the patient's records arrived from three hospitals where he had been treated recently. One record noted that he had previously experienced a life-threatening allergic reaction to the antibiotic, which was new information for the providers at Hospital Y.
An Obstructed View
Jonathan Carter, MD; October 2015
A patient with severe abdominal pain was admitted to the medicine service for observation, pain control, and serial abdominal examinations. Surgical consultation was not requested at admission. Two days later, the patient's abdomen worsened. Consultation led to urgent surgery, which revealed a strangulating bowel obstruction and associated perforation.
Amphotericin Toxicity
Jerod Nagel, PharmD, and Eric Nguyen; October 2015
A woman who had recently had her left lung removed for aspergilloma presented to the outpatient clinic with pain, redness, and pus draining from her sternotomy site. She was admitted for surgical debridement and prescribed IV liposomal amphotericin B for aspergillus. Hours into the IV infusion, the patient developed nausea, vomiting, sweating, and shivering, and it was discovered that she had been given conventional amphotericin B at the dose intended for the liposomal formulation, representing a 5-fold overdose.
Abdominal Pain in Early Pregnancy
- SPOTLIGHT CASE
- CME/CEU
Charlie C. Kilpatrick, MD; September 2015
After several days of abdominal pain, nausea, and vomiting, a pregnant woman visited the emergency department and was swiftly discharged with antibiotics for a UTI. However, she returned the next day with unchanged abdominal pain and more nausea and vomiting. Apart from a focused ultrasound to document her pregnancy, no further testing was done. The patient again returned the following day with increased pain and now appeared more ill. An MRI revealed a ruptured appendix.
A Fumbled Handoff to Inpatient Rehab
LauraEllen Ashcraft, MSW, and Jeremy M. Kahn, MD, MS; September 2015
An 18-year-old who sustained a traumatic brain injury after a motor vehicle collision required a decompressive craniectomy, a prolonged stay in the adult trauma intensive care unit, and a second operation (cranioplasty) several weeks later. After the second procedure, the patient was transferred to a pediatric acute rehabilitation facility, had new onset seizures the next day, and was transferred to an acute pediatric hospital for evaluation. Findings indicated that another surgical procedure was needed, and he was then transferred back to the adult trauma facility where he had his surgeries.
Dual Therapy Debacle
Steven R. Kayser, PharmD; September 2015
Following a myocardial infarction, an elderly man underwent percutaneous coronary intervention and had two drug-eluting stents placed. He was given triple anticoagulation therapy for 6 months, with a plan to continue dual anticoagulation therapy for another 6 months. Although the primary care provider saw the patient periodically over the next few years, the medications were not reconciled and the patient remained on the dual therapy for 3 years.
Privacy or Safety?
- SPOTLIGHT CASE
- CME/CEU
John D. Halamka, MD, MS, and Deven McGraw, JD, MPH, LLM; July/August 2015
A hospitalized patient with advanced dementia was to undergo a brain MRI as part of a diagnostic workup for altered mental status. Hospital policy dictated that signout documentation include only patients' initials rather than more identifiable information such as full name or birth date. In this case, the patient requiring the brain MRI had the same initials as another patient on the same unit with severe cognitive impairment from a traumatic brain injury. The cross-covering resident mixed up the two patients and placed the MRI order in the wrong chart. Because the order for a "brain MRI to evaluate worsening cognitive function" could apply to either patient, neither the bedside nurse nor radiologist noticed the error.
Breathe Easy: Safe Tracheostomy Management
Matthew S. Russell, MD, and Marika D. Russell, MD; July/August 2015
Admitted to the hospital with sepsis and pneumonia, an elderly man developed acute respiratory distress syndrome requiring mechanical ventilation. On hospital day 12, clinicians placed a tracheostomy, and a few days later the patient developed acute hypoxia and ultimately went into cardiac arrest when his tracheostomy tube became dislodged.
Baffled by Botulinum Toxin
Krishnan Padmakumari Sivaraman Nair, DM; July/August 2015
A 5-year-old boy with transverse myelitis presented to the rehabilitation medicine clinic for scheduled quarterly botulinum toxin injections to his legs for spasticity. Halfway through the course of injections, the patient's mother noted her son was tolerating the procedure "much better than 3 weeks earlier"—the patient had been getting extra injections without the physicians' knowledge. Physicians discussed the risks of too-frequent injections with the family. Fortunately, the patient had no adverse effects from the additional injections.
Anchoring Bias With Critical Implications
- SPOTLIGHT CASE
- CME/CEU
Edward Etchells, MD, MSc; June 2015
After multiple visits to both his primary care provider and urgent care for chronic burning left foot pain attributed to peripheral neuropathy, a man presented to the emergency department with worsening symptoms. His left lower leg was dusky and extremely tender, with non-palpable pulses. CT angiography revealed complete blockage of the left superficial femoral artery due to atherosclerotic peripheral arterial disease. The patient required emergent vascular bypass surgery on his left leg, and ultimately, an above-the-knee amputation.
Inflicting Confusion
Frank I. Scott, MD, MSCE, and Gary R. Lichtenstein, MD; June 2015
Admitted to the hospital with a small bowel obstruction and ileitis consistent with an exacerbation of Crohn disease, a man was given empiric antibiotic therapy and infliximab prior to consultation with gastroenterology. Gastroenterology recommended sending stool studies and initiating infliximab only after those studies were negative for infection. The stool studies were sent, but the primary team did not discontinue the infliximab. The patient was found to have Clostridium difficile infection.
Unseen Perils of Urinary Catheters
Diane K. Newman, DNP, MSN; Robyn Strauss, MSN; Liza Abraham, CRNP; and Bridget Major-Joynes, MSN, RN; June 2015
A hospitalized older man with a complicated medical history had not voided in several hours. The patient voided just prior to catheter insertion, which produced no urine, and the nurse assumed that meant the patient's bladder was empty. Two hours later the patient complained of discomfort and a blood clot was found in his tubing. Continuous bladder irrigation was ordered, but the pain became worse. Urgent consultation by urology revealed that the urinary catheter was not in the bladder.
Errors in Sepsis Management
- SPOTLIGHT CASE
- CME/CEU
David Shimabukuro, MD; May 2015
An older woman with a history of pulmonary hypertension, chronic obstructive pulmonary disease, and coronary artery disease was admitted to the hospital with pneumonia. She received levofloxacin (administered approximately 3 hours after presentation). Twenty-four hours after admission, her blood cultures grew methicillin-resistant Staphylococcus aureus, and vancomycin was added to her antibiotic regimen. The patient developed respiratory failure requiring mechanical ventilation as well as septic shock requiring vasopressors.
Transitions in Adolescent Medicine
Megumi J. Okumura, MD, MAS, and Roberta G. Williams, MD; May 2015
A 21-year-old woman with a history of Marfan syndrome complicated by aortic root dilation presented to the emergency department with abdominal pain and was found to be pregnant. It was her second pregnancy; she had a therapeutic abortion 4 years earlier due to the risk of aortic rupture during pregnancy. At that time, the patient had been advised to have her aortic root surgically repaired in the near future. However, after the patient turned 18, she did not receive regular follow-up care or pre-conception or contraception counseling despite the risk to her health should she become pregnant.
Departure From Central Line Ritual
Dustin W. Ballard, MD, MBE; David R. Vinson, MD; and Dustin G. Mark, MD; May 2015
A man with a history of poorly controlled diabetes and pancreatic insufficiency was found unresponsive. Paramedics transported him to the emergency department, where a resident placed a right internal jugular line for access but was unable to confirm placement. The resident pulled the line, opened a second line insertion kit, started over, and confirmed placement with ultrasound. The patient went into cardiac arrest, and a chest radiograph noted a retained guidewire in the pulmonary artery.
Dissecting the Presentation
- SPOTLIGHT CASE
Shirley Beng Suat Ooi, MBBS (S'pore); April 2015
A woman admitted to the hospital with a presumed transient ischemic attack and possible gastrointestinal bleeding was found unconscious and in cardiac arrest on hospital day 2. Despite maximal resuscitation efforts, the patient died. Autopsy revealed that the cause of death was an acute aortic dissection.
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