Save of the Month! September 2012

This was an elderly woman with acute change in Mental Status, who was brought in by EMS, who had called them because the family had not heard from her for several days. When the patient was brought in Rashida jumped on her right away realizing how sick she was. The patient felt warm and was tachycardic and Rashida got a rectal temp right away, even thought the patient was very obese and this was difficult to do.

The temperature turned out to be 102.7 rectally. Rashida immediately cultured her up and started appropriate antibiotics to cover sepsis and meningitis: IV Vancomycin, Ceftiraxone and Ampicillin. Rashida astutely noticed that the patient had mild twitching of her face and arm and gave her IV Ativan twice before the twitting stopped. She got Neuro to see the patient but by the time they came, the patient was no longer twitching and the Neuro consult felt that this was not seizures, and did not agree with Rashida that Fosphenytoin IV should be started. However, Rashida felt stronger that the patient could have “non-consulsive status epilepticus” especially since the patient had a history of Ca and she pushed for and got a bedside EEG. Meanwhile the CT scan was done and was  negaive for bleed or for an obvious mass and there was no shift. The urine and chest x-ray showed no signs of infection, so Neuro wanted her to have an LP but Rashida had gotten a great history by calling up family and found out that the patient was on Coumadin for a PE and checked the INR which was almost 5 and rightly decided that the patient did not need a stat LP as there was risk for a paraspinal hematoma and she already appropriately covered the patient for meningitis with appropriate antibiotics. The EEG showed ongoing seizure activity and Rashida gave more ativan and wanted to start the woman on Fosphenytoin and this time Neuro agreed, but because the patient was very obese they wanted to use a very hight dose of it, but Rashida questioned this dose because the patient was very elderly and to be safe it would be better to start low and go slow, and on further review of the case, Neurology agreed with her.  Rashida also pushed and got the MICU to agree to admit her.  By the time I was leaving the ED that night the patient was much improved and was waking thanks to Rashida.

Rashida did all of this while taking care of many other very ill patients.

In my mind, Rashida saved this patient’s life.

Congrats Rashida!

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.