From Missed Hemodialysis to Multiple Arrhythmias

From Missed Hemodialysis to Multiple Arrhythmias

Case Presentation

A 78-year-old male, known case of Chronic Kidney Disease on maintenance hemodialysis, presented to the Emergency Department with dizziness and lethargy complaints about 2 days. He had missed his last hemodialysis session due to personal reasons. We could not elicit any further history details as was significantly dyspneic (no bystanders with him at the time of presentation). Hence, the patient was received in Bay 1 for immediate resuscitative measures. The patient was afebrile, conscious, and well oriented, but unable to communicate because of severe dyspnea.

Vitals

HR – 142 beats/min
BP – not recordable
RR – 36 breaths/min
SpO2 – poor tracing, intermittently showed 98% on room air (15 LO2 via Non Rebreathing Mask was initiated nevertheless)

ECG

ECG on presentation
Monomorphic ventricular tachycardia

He was immediately connected to a defibrillator in anticipation of possible synchronized cardioversion. Simultaneously, the cause of the possible rhythm was being evaluated for and a thorough examination was carried out. On examination, his lung fields were clear. His left arm AV Fistula had a feeble thrill on palpation.

In suspicion of hyperkalemia as the cause of VT, patient was immediately started on potassium reduction measures while the point of care ABG report was awaited. He was treated with salbutamol nebulization 10mg, sodium bicarbonate 50 ml IV and 10% calcium gluconate 10ml IV. In view of hemodynamic instability, he was also started on intravenous noradrenaline infusion.

ABG Findings

pH – 7.010, pCO2 – 20.8 mmHg, pO2 – 125 mmHg, HCO3 – 7 mmol/L, Na – 126 mmol/L, K – 9.6 mmol/L

As hyperkalemia was confirmed, the patient was also given 200 ml of 25% dextrose with 12 units of Rapid-acting insulin IV. With the above measures, the patient’s cardiac rhythm came to a sine wave pattern. 

He was later taken up for emergency hemodialysis (HD) – Sustained Low Efficacy Dialysis (SLED) in the ICU, using a low potassium dialysate. Since his AV fistula was non-functioning, HD was done after placement of a femoral dialysis catheter. 2 hours into HD, the patient’s cardiac monitor showed a normal sinus rhythm. His hemodynamic status significantly improved. Noradrenaline infusion was gradually tapered and stopped by the end of the HD session, and repeat blood gas analysis and serum electrolytes showed improvement of all parameters. 

after hemodialysis

The patient was discharged 2 days later, after another session of hemodialysis (through AV fistula) and a detailed cardiology evaluation (ECHO – LVH, normal EF).

For the Inquisitive Minds

  1. The patient underwent a detailed POCUS evaluation, both in the ER and ICU. What findings do you expect to find on the RUSH examination for this patient?
  2. His previous ECHO report (done 1 month ago) mentioned left ventricular hypertrophy and normal ejection fraction. So what would be the reason behind the POCUS findings? Is it reversible?
  3. Why was the AV fistula non-functioning at the time of presentation? When would it have started to function again?
  4. Despite not having hypoxia, this patient was given supplemental oxygen. Did he really require it, and if so, what was the rationale?
  5. What was the necessity for carrying out SLED for this patient?
  6. Why was this patient not immediately cardioverted in the ER?
  7. If this patient had gone into cardiac arrest, what drugs would you have given for management of hyperkalemia?
  8. How differently would you have managed this patient?

Please give your answers and comments into "leave a reply" area below.

Cite this article as: Gayatri Lekshmi Madhavan, India, "From Missed Hemodialysis to Multiple Arrhythmias," in International Emergency Medicine Education Project, November 2, 2020, https://iem-student.org/2020/11/02/missed-hemodialysis/, date accessed: January 15, 2021
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Why Me? The Story of My Burnout – Part 1

why me - the story of my burnout

This story starts like almost every other: I fell in love.

The thing is, I LOVE heart attacks!

I know this is a weird statement, maybe even a little ​overstated. I know that people can get uncomfortable when I say this. When I said it for the first time, full of enthusiasm and with sparkling eyes, my ex-fiance looked at me in a concerned and puzzled way: ‘Can you say that?​’ – He asked, wondering if it was appropriate for a doctor to say that they actually enjoyed the experience of people being so unwell.

Clearly, as a doctor, I have nothing against people. Quite the contrary, I unceasingly fight for them to survive and thrive. Yet the paradox is real, despite my battle to save my patients, I am so in love with heart attacks!

Why? Perhaps I love the puzzle behind it. When the patient arrives, I see the position of the body, the hand on the chest, fingers tightly pressed against the skin, the skin color, the sweating… I consider the nuances of pain types, the comorbidities, the risk factors… All are informing my judgment and decisions even before I get to look at the ECG.

I love knowing the diagnosis as it reveals itself. I love that I can treat it. And when it works, I’m the queen of my craft. The scores of survival game change. 1 for me, 1 for my patient, and 0 for the heart attack!

So that’s why you would see me so happy when a patient arrives in my ED. I love this feeling. I love this adrenaline rush that is emergency medicine and me! I love leading a code, guiding actions, organizing my team to the point of ROSC. I love that roaring energy that runs through the whole team as we effortlessly move to the next stage of resuscitation.

This is why I love Emergency Medicine.

Emergency Medicine is new In Brazil. The general assumption is that ED is where junior physicians serve until they choose another specialty or other specialists work to earn additional income. Until recently, working in the ED was a difficult job with no career advancement. So, when I realized that I was so in love with more than heart attacks that I could not leave my work as an Emergency Physician, people started to ask me, “Are you sure? Do you want to work forever in an ED in Brazil? What about when you get older? Don’t you think you will get tired and burned out?”

jule santos

I don’t think so. I reply, I love my job. When you love your job, you don’t ever get tired.”

How naive I was.

Emergency medicine is tough, sometimes even painful. Deaths, we can’t help. Diagnoses of incurable diseases. Bad news. The pressure to be good, perfect, productive. Adding to that, many of us work in corrosive health systems: The result? Emergency Medicine can burn you to your core.

Being in love​ with Emergency Medicine is enough to protect us?

Emergency Medicine can burn you to your core.

Leaving the Comfort Zone

I am a curious soul. While I learned more about emergency medicine, I discovered another world with worldwide Emergency Physicians, who could understand my difficulties and help me learn remotely from them. I fell in love again with #FOAMed.

Hearing the experiences of my colleagues from all around the world inspired me to travel and meet those people. I wanted to learn with them and to compare how Emergency Medicine is in those places.

I love #FOAMED

My newly found calling took me to Sydney in Australia, such a lovely country, which had beautiful and polite people, good public transportation, beautiful scenery, and even a public healthcare system too!

I was lucky enough to spend time in an excellent hospital in NSW. I witnessed them receiving a trauma patient and listened to them as they plan patient management. I was speechless. I felt a sudden sadness to the degree that I wanted to crawl back to my mother’s womb.

When I tell this story, people often react, “You don’t need fancy stuff to practice Emergency Medicine,” but it was not what I saw there. What was it? It wasn’t the video laryngoscopy. It wasn’t the infinite bougies and disposable LMAs. That’s true: The facilities in Australia were incredible and so much more were available than back home in Brazil. But it was still the people.

When the paramedic team arrived, the whole team discussed the patient plan. They were so courteous and respectful to each other, focused only on doing the best for the patient. They were excited about the case, energized, and happy for doing their best.

I’m not saying their life is easy. I’m not saying they don’t suffer moral injury. But I’m sure they don’t show ill-will to their peers and most importantly, to their patients. I want so badly to be able to do that kind of medicine, but the realization of this new health system made me feel envious and perhaps even hopeless. Their experience was so positively different from mine.

Teamwork

I spent the next day in my room, lying depressed in bed, staring at the ceiling, trying to figure out what to do now: “How I would love to have that experience in my hospital!”

I thought a lot about what happened there. Why did it hit me so hard? I knew that not all hospitals were the same in Australia as some hospitals had problems and struggles like in Brazil. I already knew that we had hospitals in Brazil better than mine. Why did I feel so hopeless then?

Now, looking back, I can understand better. I was pushing my comfort zone further than I ever did in my entire life. I was discovering a lot about myself and my capabilities. I was achieving success through FOAM. And so, I saw my limitations, I strumbled in a deep Impostor Syndrome and lost some excellent opportunities. I was in such a fragile mindstate that I felt like the system was unfair to me.

Sad Clown

In my hospital, which is always overcrowded, I work with physicians that don’t have the mindset of Emergency Medicine. When a trauma patient arrives, it feels like a battle. Physicians challenge paramedics: ​“Why did you bring this patient here when we don’t have bed enough?”​ or​ ​“​we don’t have enough surgeons!” or “why does nothing here work?”

All too frequently, the team ends up shouting at each other.

I tried hard to spread the ideas and visions I was learning. One time, I asked for an ultrasound machine, my boss laughed in my face: “Where do you think you are?” Everybody seemed so consumed by pessimism and fatigue that they lost all hope.

I had already been tired and sad. Now, I was also feeling wronged. ...to be continued...

Cite this article as: Jule Santos, Brasil, "Why Me? The Story of My Burnout – Part 1," in International Emergency Medicine Education Project, December 30, 2019, https://iem-student.org/2019/12/30/why-me-the-story-of-my-burnout-part-1/, date accessed: January 15, 2021

My Road to Emergency Medicine

Helene Morakis

MS4 at Queen’s School of Medicine

Incoming EM resident at the University of British Columbia

My first shadowing exposure to clinical medicine was in Pediatric Emergency Medicine (EM). Before starting medical school, I lifeguarded during my studies. Over six years, I had sent a handful of children to the Pediatric Emergency Department (ED) and always wondered what happened to them. I expected the shadowing experience to be chaotic and stressful.

The supervising physician shattered all my preconceived stereotypes about emergency medicine: she listened empathetically to patients and their parents, she took the time to teach her timid mob of medical learners and she managed to stay calm while juggling multiple cases of varying acuity. I left that shift – and all of my subsequent adult and peds EM shadowing shifts – in awe. I wanted to be part of this group of skilled physicians that made meaningful short connections with patients and was eager to tackle any case that came through the door.

I wanted to be part of this group of skilled physicians that made meaningful short connections with patients.

While in medical school I found I also loved the collaborative setting, the fast pace and the challenging contrast between cases in EM. My first two EM clerkship shifts entailed performing CPR, providing patient education in English, French and Spanish (and kicking myself for not learning at least three more languages!), ruling out a stroke in a non-verbal patient, and suturing a laceration after an assault. I was hooked. The opportunity to care for patients during their most difficult moments solidified my passion for Emergency Medicine. I love the “anyone, anything, anytime” mantra shared across ED’s that I visited on electives.

The opportunity to care for patients during their most difficult moments solidified my passion.

ANY

One
Thing
Time

EM is a broad and flexible field

Being fascinated by healthcare delivery in diverse settings and motivated by social justice I was interested particularly in Global Health and Wilderness Medicine in my pre-clinical years before dedicating myself to EM. Luckily, EM is a broad and flexible field and allows me to combine all of these interests.

I have been particularly interested in the online community that is working to advance EM and recruit medical students to the growing specialty on an international scale. Learning from and contributing to projects such as iEM is motivating and I am energized by like-minded medical learners around the world. My passion outside of school in the past two years has been working with the International Student Association of Emergency Medicine.

EM community is the best!

I may be biased, but I think the EM community is the best! There is an incredibly dynamic and well-established online presence that I have found very welcoming. Along with learning tips and tricks from FOAMed gurus, I had the opportunity to reflect on the EM mindset and social issues with the FemInEM community. Going to the FemInEM Idea Exchange 2018 (FIX18) conference last year in NYC as a student ambassador was an incredible experience and made me motivated to continue connecting with like-minded EM colleagues online.

Shana Zucker medical student, LGBTQIA+ advocate, at the FIX18 conference presenting her Queericulum

When I’m not in the hospital, I like to play outside. Participating in Wilderness Medicine allows me to do so even more and I like to think about how to deliver healthcare in non-hospital environments. I love that I can continue pursuing this passion through EM. The Wilderness Medical Society (WMS) has conferences, courses and research opportunities for medical students. I am working on my Fellowship of the Academy of Wilderness Medicine (FAWM) and hoping to gain more on the ground experience and contribute to research in this field as I move through my career!

When I’m not in the hospital, I like to play outside.

Hiking King’s Throne in Kluane National Park, YT, Canada, between EM shifts in Whitehorse, YT

The excitement and variety continue after shifts in EM. Between the online medical education community, on-shift teaching, research opportunities, the world of simulation and the interdisciplinary applications of EM, it is a specialty that academically has a lot of opportunities. Shift work is challenging, but offers flexibility to pursue my hobbies outside of work. There is a general culture of work-life integration and promotion of wellness shared among emergency physicians. At my home school program, Queen’s Department of Emergency Medicine, I saw this reflected in the resident and faculty mindsets and it contributed to my own prioritization of my wellness.

EM is a specialty that academically has a lot of opportunities.

The best advice I have received about choosing a specialty has been to follow my passions. The road to EM has been a fun adventure and has given me plenty of opportunities to do so. I am excited to start residency at the University of British Columbia. With teaching opportunities, unique pathology and a high volume of trauma, the residency at Vancouver General Hospital will be a busy but incredible ride.

Vancouver, BC, Canada

I look forward to pursuing my outdoor interests and enjoying urban amenities in Vancouver between shifts. With faculty and resident involvement in Wilderness Medicine and Global EM, I see many fun opportunities lying ahead!

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Cite this article as: Helene Morakis, Canada, "My Road to Emergency Medicine," in International Emergency Medicine Education Project, March 6, 2019, https://iem-student.org/2019/03/06/my-road-to-emergency-medicine/, date accessed: January 15, 2021