WebM&M: Case Studies

This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a  peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services. During follow-up several days after discharge, the patient’s primary care provider noted that the PICC dressing was due to be changed and needed to be flushed, but the outpatient setting lacked the necessary supplies. An urgent referral to home health was placed, but the agency would be unable to attend to the patient for several days. The primary care provider changed the dressing, and the patient was referred to the emergency department for assessment. The commentary summarizes the risks of PICC lines, the role of infection prevention practices during the insertion and care of PICC lines, and the importance of patient education and skill assessment prior to discharge home with a PICC line.

A 65-year-old female with a documented allergy to latex underwent surgery for right-sided Zenker’s diverticulum. Near the conclusion of surgery, a latex Penrose drain was placed in the neck surgical incision. The patient developed generalized urticaria, bronchospasm requiring high airway pressures to achieve adequate ventilation, and hypotension within 5 minutes of placement of the drain. The drain was removed and replaced with a silicone drain. Epinephrine and vasopressors were administered post-operatively and the patient’s symptoms resolved. The commentary discusses risk factors and consequences of latex allergy in hospital and operating room settings, common latex products that trigger allergic reactions  and hospital safety practices that can limit the risk of latex exposure.

A 55-year-old man undergoing chemotherapy for acute myeloid leukemia was admitted to the hospital with a fever, neutropenia, and thrombocytopenia but physical examination did not reveal a focal site of infection. Blood and urine cultures were obtained, and he was started on IV antibiotics. His fever persisted and the cross-covering physician, following sign-out instructions from the primary team, requested repeat blood cultures but did not evaluate the patient in person. During rounds the next morning, the patient reported new oral pain (which had begun the previous day) and on physical exam was found to have mucositis. The associated commentary discusses the importance of in-person assessment in the hospital setting during cross-coverage and the value of structured, validated hand-off tools for communication among multidisciplinary teams.

 A 3-month-old male infant, born at 26 weeks’ gestation with a history of bowel resection and anastomosis due to necrotizing enterocolitis, was readmitted for abdominal distension and constipation. He was transferred to the pediatric intensive care unit (PICU) for management of severe sepsis and an urgent exploratory laparotomy was scheduled for suspected obstruction. The PICU team determined that the patient was stable for brief transport from the PICU to the operating room (OR). During intrahospital transport, the patient had two bradycardic episodes – the first self-resolved but the second necessitated chest compressions and intubation. The patient was rapidly moved to the OR where return of spontaneous circulation occurred within five minutes. The associated commentary describes the risks associated with intrahospital transport (particularly among pediatric patients) and critical processes that should be put in place to mitigate these risks via clear communication and structured decision-making among the intrahospital transport team. 

A 44-year old man with hypertension and diabetes was admitted with an open wound on the ball of his right foot that could be probed to the bone and evidence of diabetic ketoacidosis. Over the course of the hospitalization, he had ongoing hypokalemia, low magnesium levels, an electrocardiogram showing a prolonged QT interval, ultimately leading to cardiac arrest due to torsades de pointes (an unusual form of ventricular tachycardia that can be fatal if left untreated). The commentary discusses the use of protocol-based management of chronic medical conditions, the inclusion of interprofessional care teams to coordinate management, and the importance of inter-team communication to identify issues and prevent poor outcomes. 

An elderly woman with a history of dementia, chronic obstructive pulmonary disease, hypertension, and congestive heart failure (CHF) was brought to the emergency department and found to meet criteria for sepsis. Due to her CHF, she was admitted to a unit with telemetry monitoring, which at this institution was performed remotely. When the nurse came to check the patient's vital signs several hours later, she found the patient to be unresponsive and apneic, with no palpable pulse. A Code Blue was called, but the patient died. Although the telemetry technician had recognized progressive bradycardia and called the hospital floor several minutes before the code, he was placed on hold because the nurse was busy with another patient. While he was holding, he observed worsening bradycardia, eventually transitioning to asystole, and tried to redial the unit, but no one answered.

An elderly man with a complicated medical history slipped on a rug at home, fell, and injured his hip. Emergency department evaluation and imaging revealed no head injury and a left intertrochanteric hip fracture. Although he was admitted to the orthopedic surgery service, with surgery to fix the fracture initially scheduled for the next day, the operation was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. He ultimately underwent surgery and was discharged a few days later but was readmitted several weeks later with chest pain and shortness of breath. He was found to have a pulmonary embolism; anticoagulation was initiated. The patient's rehabilitation was delayed, his recovery was prolonged, and he never returned to his baseline functional status.

In a simulation exercise conducted in an institution that felt it was prepared for patients with actual or suspected Ebola, a man presented to the emergency department with symptoms of nausea, vomiting, and fever. He had recently returned to the US from Sierra Leone. The nurse initiated an isolation protocol and the critical care team all donned personal protective equipment. During transport, confusion about which elevators to use potentially exposed 30 staff members to Ebola. Additional issues occurred including breaching sterile technique while inserting a central line and confusion about the process to transport the patient's blood to the lab.

An elderly man was being prepared for discharge after being hospitalized for an exacerbation of congestive heart failure. His nurse failed to notice that the tubing of the patient's sequential compression devices (in place to prevent DVT) was caught on the bed wheel and had unlocked the bed when she raised it. When the patient attempted to get up later, the bed rolled out from under him and he fell, breaking his hip. One week after surgery, the patient experienced a cardiac arrest from a massive pulmonary embolism and died.

Hospitalized for alcohol withdrawal, an elderly man was feeling "cooped up" by hospital day 6 and left the floor without informing any providers. An hour later upon return to his room, he complained of new arm pain. While off hospital grounds, the patient had fallen and broken his arm.

Following a lengthy hospitalization, an elderly woman was admitted to a skilled nursing facility for further care, where staff expressed concern about the complexity of the patient's illness. A few days later, the patient developed a fever and shortness of breath, prompting readmission to the acute hospital.

A woman undergoing treatment for myasthenia gravis via PICC developed extensive catheter-related thrombosis, bacteremia, and sepsis, and ultimately died. Although the PICC line was placed at one facility, the patient was receiving treatment at another, raising questions about who had responsibility for the line.

Admitted with a congestive heart failure exacerbation, an elderly man acquired an infection around his peripheral IV site, accompanied by fever, chills, and back pain. Likely secondary to the infected peripheral IV catheter, the patient had developed methicillin-resistant Staphylococcus aureus bacteremia and an epidural abscess.

A patient with Guillain-Barré syndrome received more than the recommended number of plasmapheresis treatments. When the ordering physicians were asked why so many treatments were given, they both responded that the patient was improving so they felt that more treatments would help him recover even more.

Following surgical repair for a hip fracture, a nursing home resident with limited mobility developed a fever. She was readmitted to the hospital, where examination revealed a very deep pressure ulcer. Despite maximal efforts, the patient developed septic shock and died.

An emergency department worker develops chicken pox following an exposure during one of his shifts.

A man diagnosed with chronic hepatitis C was treated with interferon and ribavirin by his internist without referral for a liver biopsy or the appropriate blood tests. Treatment was continued for months despite the patient developing pancytopenia and continuing to have a high viral load, raising questions about physicians practicing outside their areas of competency.

A week after successful pacemaker placement, an elderly man developed chest pain and was admitted to the hospital without having an urgent echocardiogram. Although providers felt that he "looked fine," the patient became acutely hypotensive, developed ventricular tachycardia and pulseless electrical activity, and required emergent resuscitative measures for cardiac tamponade.

A patient on palliative chemotherapy was given intravenous vancomycin for methicillin-resistant staphylococcus aureus (MRSA), despite a rising creatinine level, and went into acute kidney failure.

A man returns to the emergency department 11 days after hospital discharge in worsening condition. With no follow-up on a urine culture and sensitivity sent during his hospitalization, the patient had been taking the wrong antibiotic for a UTI.