The Walkby

by Sarma Velamuri, M.D. 

        On occasion patients who come in to the emergency room in a large acute care hospital who have multiple medical problems get admitted to a Hospitalist. More on this here. This is the doctor who is overall responsible for the patient’s care while they are boarded in the building.

Now there is a large number of events that takes place when I say “get admitted”.

          The patient, Angelita, first shows up in the ER with complaints of abdominal pain. This particular patient happens to have kidneys that have scarred down to a small size – less than 8 cm. So small that there is no filtering or cleaning function possible. They make urine but it’s just volume not quality. Angelita can make urine but mostly she’s passing water, not toxins. The toxins remain free to circulate in the bloodstream. The good doctors in their wisdom have learnt to clean her blood using a fancy method call peritoneal dialysis. Bear with me, I assure you this is going somewhere!  

         In peritoneal dialysis, affectionately referred to as PD, we put stuff called dialysate through a plastic tube that is near the patient’s navel into the free abdominal cavity. That’s right! We put a liquid into their belly that essentially creates a reverse osmosis plant within the patient’s abdomen; their own RO system that they get to carry around with them. Toxins absorb into the dialysate while the patient sleeps or works. After a certain period of time we suck the dialysate out with a machine and magically the toxins are now out of the bloodstream and into the trash bag. The patient Angelita says, “This system works great!” Until it doesn’t.

         The problem with putting dialysate in one’s belly is that there is a chance of introducing friendly neighborhood bacteria into a neighborhood where they are not so friendly. It’s like transplanting a shark from the lively seas of Australia into a Koi pond. A few million sharks. The shark-bacteria have a field day and set up base camp in the belly.

Allyourbase.jpg
" The shark-bacteria have a field day and set up base camp in the belly."

        Hence Angelita’s abdominal pain. She has bacteria in her abdominal cavity where they shouldn’t be, on the outside of her intestines. The doctors have a handy-dandy term for this: PD-related peritonitis.

        When Angelita arrives at the emergency room she correctly gets diagnosed with peritonitis, correctly gets antibiotics and correctly gets admitted to the medical ward because she has no fever and no change in her blood pressure. All she has is an elevated white blood cell count in her lab work and white blood cells in her peritoneal fluid.

         She gets admitted to a ward at 10 pm and turns in for the night. She then develops a fever. The antibiotics start killing the bacteria, who decide to very inconsiderately disintegrate in her belly. When they die they release a fun substance called LPS.

          LPS to the immune system is like a banderilla is to a bull. It makes the immune system really really angry. So angry that it not only attacks the bacteria but releases a stew of chemicals that hurts the body. This state of being angry is also known as sepsis. This response can be blunted if you identify the patient quickly and intervene quickly. More on this at a later date.

   
  
 
 96 
  
    
  
 Normal 
 0 
 
 
 
 
 false 
 false 
 false 
 
 EN-US 
 X-NONE 
 X-NONE 
 
  
  
  
  
  
  
  
  
  
 
 
  
  
  
  
  
  
  
  
  
  
  
  
    
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
   
 
 /* Style Definitions */
table.MsoNormalTable
	{mso-style-name:"Table Normal";
	mso-tstyle-rowband-size:0;
	mso-tstyle-colband-size:0;
	mso-style-noshow:yes;
	mso-style-priority:99;
	mso-style-parent:"";
	mso-padding-alt:0in 5.4pt 0in 5.4pt;
	mso-para-margin:0in;
	mso-para-margin-bottom:.0001pt;
	mso-pagination:widow-orphan;
	font-size:12.0pt;
	font-family:Calibri;
	mso-ascii-font-family:Calibri;
	mso-ascii-theme-font:minor-latin;
	mso-hansi-font-family:Calibri;
	mso-hansi-theme-font:minor-latin;}
 
     

 

"LPS to the immune system
 is like a banderilla is to a bull.”

            

Suffice it to say Angelita continues to get sick. The nursing assistant walks into the room to check her vital signs at 4 am. Mainly temperature, blood pressure, heart rate. The information is entered into the computer at 5 am. The nurse finds out about it at 7 am at shift change. He figures, “Yeah, she’s sick that’s why she’s in the hospital. Plus she’s already on antibiotics.” The medical record alert didn’t pick up on her clinical changes enough to trigger its in-built alert.

At 9 am the doctor rounds on Angelita. I call this “the Walk by”. One just happens to walk by a major event and the patient gets the care they need. Thankfully this particular doctor knows exactly what’s going on and she intervenes. The delay? Only about 5 hours.
Some doctors think to themselves “Yeah, she’s sick that’s why she’s in the hospital. Plus she’s already on antibiotics.”
           Of course the above is an oversimplification of the problem, of course there is more that can be done today. The point is not to blame providers or hospitals. The point is we can begin talking about it. We can begin to see what can be done. The problem with sepsis is for every hour one waits to intervene 7% of septic patients die.
          Of course Angelita did well and went home.

      

In this series we explore a series of patients who had "near misses" in the absence of real-time monitoring systems and insufficient screening at bedside. These are only examples of patient stories and contain no identifiable information. Any resemblance to anyone you know is merely coincidental. These opinions are of the author only and do not represent the company.

1 Comment