Common Clinical Conditions

Clinical Pearls¶

Thank you to Paul Ossman, MD who created many of these clinical pearls

Alcohol Withdrawal:

Not all patients who presents for “detox” need to be admitted to an inpatient hospital for this process. We admit patient with significant risk of medical complications of their withdrawal. Low risk patients can be admitted to a supervised withdrawal at specialized ETOH treatment facility such as Freedom House or discharged to home with outpatient medications.

See the UNC ETOH protocol below for a detailed protocol to aid triage. For those patients who require admission:

Please use either the Alcohol Withdrawal Management Focused or General Alcohol Withdrawal Adult Admission order set to appropriately order the CIWA-Ar scoring and medication regimen. Mild patients should receive symptom triggered benzodiazepines, more severe patients should be considered for fixed dosing. Consider the use of clonidine for adjunctive treatment of alcohol withdrawal in patients with tachycardia and hypertension. You give 0.1-0.2 mg oral tablets q 8 hours for 3 doses to load with a #1 or #2 patch for ease of dosing. A previous UNC Hospital Medicine improvement project showed lower representation rates in inpatients who were counselled on medications to maintain sobriety prior to discharge.

Naltrexone should be offered to appropriate candidates on discharge for the maintenance of sobriety. Contraindications are cirrhosis, opiate use, LFTs > 3x upper limit of normal Dosing is naltrexone 50 mg daily for 1 month with 2 refills Document counseling in EPIC, using .lmnaltrexonecounsel and .lmdcnaltrexone

This link provides additional guidance for treatment of ETOH withdrawal from UNC Pharmacy: UNCH Guidance Document for Alcohol Withdrawal

Hip Fracture:

These patients are considered for the co-management service (please see separate co-management document for details).

Please be sure to use the Hip Fracture Order Set and Template. Chemical DVT prophylaxis (enoxaparin SQ) is generally held the night prior to a procedure and restarted prior to 24 hours post op. The reason for holding the chemical prophylaxis prior to the OR MUST be documented. Mechanical DVT prophylaxis is always done unless contraindicated and MUST be documented. Please obtain a Vitamin D level at time of admission and start empiric Vitamin D at 1000U daily if the patient is not on this medication. A statement of medical optimization is helpful to surgery. (See template)

Sickle Cell Pain Crisis:

The following guidelines apply to most sickle cell pain crisis admissions. If there are other problems such as end organ failure, acute chest, CVA, not all guidelines may apply.

Some of our more frequently admitted sickle cell patients have individualized care plans established by the UNC Complex Care Committee. These can be found in the FYI tab. They are only guidelines and allow for more consistent care among diverse providers. The clinical needs of the patient should be considered foremost in making medical decisions.

Please use the Sickle Cell Order Set We avoid bolus IV medications and use a PCA instead. We avoid IV meds if there are adequate PO options: No IV Benadryl – Oral is just as effective and does not potentiate narcotics. No IV phenergan – Oral, IM, or PR are all just as effective and do not potentiate narcotics. Zofran ODT or IV also works well for the patient active nausea/vomiting.

Acute Chest Syndrome:

Acute chest is not a variant of pneumonia and can present quite subtly. When you have a sickle cell patient with an infiltrate OR an O2 requirement (even if it is only 2L NC), add ACS to your differential.

Mild ACS: SpO2 >90% RA and a Single Lobe Infiltrate
Treatment: Supportive with close monitoring -- no transfusion unless HBG <5
Moderate ACS: SpO2 ≥85% RA and <3 Lobe Infiltrate
Treatment: Unless contraindication -- simple or exchange transfusion
Severe ACS (One of the following), Very Severe ACS (ARDS), and Rapidly Progressive ACS (respiratory failure within 24 hours after the onset): Respiratory failure present, SpO2 <85% RA OR SpO2 ≤90% despite max O2, OR 3+ lobes Affected
Treatment: ICU level care with exchange transfusion.

Transfusion in the Setting of ACS: Simple Transfusion: May be adequate for mild- moderate cases to raise Hb to 10 gm/dl To prevent progression to moderate or severe. Exchange transfusion: Rapid transfusion of large amounts of blood Significant decrease of hemoglobin S percentage Avoids hyperviscosity that can occur at HBG >11

Inpatient Care of Diabetes:

UNC Division of Endocrinology has been leading an effort to change the way we provide insulin treatment in the inpatient setting.

Key principles: - Basal and bolus dosing of long acting and short acting insulin is more clinically appropriate than the traditional corrective (or “sliding”) scale dosing which only treats hyperglycemia. - Long acting insulin should be given on a weight-based dosing for most inpatients who require insulin for glucose management. - Patients who are eating should be given nutritional short acting insulin in addition to a corrective scale to account for their intake. - Patients who are NPO or on clear liquids should continue to receive long acting insulin and should be considered for D5 containing maintenance fluids to prevent hypoglycemia. - Timing of dosing is critical to prevent complications. Short acting insulin with lispro/aspart should be given immediately prior to eating. - The Insulin Subcutaneous Management order set is available in EPIC to give guidance and allow you to do this properly.

Patients who are new diabetics, new insulin starts, or have significant changes in their regimens or poor baseline control should have a Diabetic Educator consult. Order (in the above order set) should be placed and their service alerted early in admission to allow time for patient to be properly counseled.

Sepsis:

Appropriate treatment of sepsis is a life-saving endeavor and one of UNCH’s Organizational Goals. The Surviving Sepsis campaign has made changes in the way we approach a septic patient and a 2015 revision has been published: http://www.survivingsepsis.org/SiteCollectionDocuments/SSC_Bundle.pdf.

We no longer use SIRS alone to identify a septic patient. A septic patient should have evidence of an infection along with hypotension, an elevated lactate or other evidence of end organ dysfunction (i.e. AKI, altered mental status, respiratory failure). The qSOFA score is a quick heuristic to identify patients. When identified, a CODE SEPSIS can be called to rapidly mobilize resources to care for patients.

Our hospital is scored on the following metrics:

TO BE COMPLETED WITHIN 3 HOURS OF PRESENTATION/ONSET OF SEPSIS*: 1. Measure lactate level 2. Obtain blood cultures prior to administration of antibiotics 3. Administer broad spectrum antibiotics 4. Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L

The Adult Sepsis Bundle order set is available in EPIC to quickly and properly order these measures.

TO BE COMPLETED WITHIN 6 HOURS OF PRESENTATION/ONSET OF SEPSIS: 5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg 6. In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings. Use .SEPSISEXAM to document. 7. Re-measure lactate if initial lactate elevated.

The nursing staff will begin using a MEWS score that will objectively identify and increase the monitoring parameters for those patients at risk:

MEWS Score	3	2	1	0	1	2	3
Heart Rate		<40	<50	<100	<110	<129	>129
Systolic Bld Pressure	<70	<80	<100	<199		>200
Respiratory Rate		<8		<14	<20	<30	>30
Temperature		<35.0	<36	<38	<38	>38.6
Urine Output	<10mL	<30mL	<45mL
LOC Score			New Agitation/Confusion	Alert	Responds to Verbal	Responds to Pain	Unresponsive
O2 Saturation < 90% : 4 points

Based on the MEWS score, the RN is guided by the following:

	FREQUENCY OF MONITORING	CLINICAL RESPONSE
0-4	Minimum 12 hours	·Continue to monitor and perform MEWS every 12 hours
Total: 5-6 Or 3 in one parameter	Minimum of 4 hours	·Notify Physician of change ·Notify charge nurse ·Consider placing a consult to Rapid Response Nurses ·Increase MEWS assessment every 4 hours with increased frequency in assessments
Total: 7+	Continuous monitoring of vital signs	·Call RRT ·Consider transferring to step-down or ICU

Perioperative Consultation:

In regards to a perioperative consult, Dr. Franklin Michota from the Cleveland Clinic asked Hospitalists, “If the surgeon is the pilot and the anesthesiologist is the copilot, who are we?” At the conference, participants were glib with responses that ranged from “flight attendant,” to “passenger,” to “in flight movie.”

Michota’s response to these predictable and self-deprecating remarks was one of affected indignation. He questioned how we could be expected to be taken as a respected member of the team if we did not respect ourselves. He went on to add that we offer a valuable service to the patient, to the hospital, and to the team and challenged us to take another look at who we are in the above analogy.

His suggestion is that we are the mechanics. - We do not tell the pilot or the copilot when, how, or where to fly - We do not make anesthesia recommendations or "clear" the pt. - We will not be on the plane when it takes off. But: - We are there, on the ground, before and after the plane takes off and lands. - We report on the condition of the plane – whether the plane is in the best condition to fly, and under the best conditions, what the plane can handle. - We comment on whether the long-term maintenance program is adequate. - We give precise medical diagnosis. - We evaluate the extent of organ disease. - We optimize those medical conditions we can. - We assess and describe physiologic limitations and ensure adequate post-op follow-up.

In addition to optimizing the plane as best we can, we make reports:

To the pilot, we either ground the plan or declare it as ready as it can be. - "Pt is optimized to proceed to surgery without additional risk stratification."

To the copilot, we give an accurate preflight checklist - Cardiac risk - beta blockers and statins - Antiplatelets/Anticoagulants - Pulmonary risk – asthma, COPD, OSA - Liver disease – risk assessment - Hematologic review – anemia, bleeding risk - Endocrine issues – glucose management, adrenal insufficiency - Other medication issues – immunosuppressants and psych medication

Opiate Pain Medications:

As you all know, the CDC released new guidelines for prescribing opioids in the setting of chronic pain. These guidelines give us more artillery in the fight against opioid overprescribing and I wanted to take a moment to frame the fight.

We are fighting the epidemic of opioid overprescribing, over-use, and overdose. We are not fighting our patients. These guidelines are meant to provide us with the artillery to fight against myths, misinformation, and desensitization to the harms of opioids. They are not meant as artillery against our patients. These guidelines neither insulate us from the problem of opioids nor give us the green light to ignore pain. They encourage us to confront the reality that chronic pain is a tricky thing, a real thing, and a thing that we have a limited ability to treat. Acetaminophen, NSAIDs, Gabapentin, TCAs, topical agents, CBT, and DBT all have small to moderate effects and many are not without harm; however, they carry less risk than opioids. In discussing opioids with our patients, we must be honest about setting realistic expectations and align ourselves with our patients rather than against them.

Certainly, our patients may disagree and may rail against us, but in practicing our craft, our role is to be the doctor and accept the vitriol without losing what it is that makes us a professional. By using wish statements, we can communicate our empathy with patients who are visibly angry with in hopes that, on some level, they will understand why we are not willing to prescribe or continue narcotics. For these patients, it is our duty to reinforce that we are not abandoning them and it is our duty to offer and stress the importance of non-opioid therapies and addiction treatment.

The following can be useful talking points in discussing the dangers of opioids:

http://www.cdc.gov/drugoverdose/prescribing/resources.html

“In a systematic review, opioids did not differ from non-opioid medication in pain reduction, and non-opioid medications were better tolerated, with greater improvements in physical function.”
When discussing the findings of the narcotic database: “A study showed patients with one or more risk factors (4 or more prescribers, 4 or more pharmacies, or dosage >100 MME/day) accounted for 55% of all overdose deaths.”
“A study showed patients prescribed high dosages of opioids long-term (>90 days) had 122 times the risk of opioid use disorder compared to patients not prescribed opioids.”
“Studies show that high dosages (≥100 MME/day) are associated with 2 to 9 times the risk of overdose compared to <20 MME/day.”
“One study found concurrent prescribing [opioids and benzodiazepines] to be associated with a near quadrupling of risk for overdose death compared with opioid prescription alone.”
“Up to one quarter of patients receiving prescription opioids long term in a primary care setting struggles with addiction. Certain risk factors increase susceptibility to opioid-associated harms: history of overdose, history of substance use disorder, higher opioid dosages, or concurrent benzodiazepine use.”

Lastly, remember countertransference . . . or simply put, hallway-talk and gallows humor filter down to our patients. I read a piece by a patient advocate whose bio reads, “Emily Ullrich suffers from Complex Regional Pain Syndrome (CRPS/RSD), Sphincter of Oddi Dysfunction, Carpal Tunnel Syndrome, Endometriosis, chronic gastritis, Interstitial Cystitis, Migraines, Fibromyalgia, Osteoarthritis, Periodic Limb Movement Disorder, Restless Leg Syndrome, Myoclonic episodes, generalized anxiety disorder, insomnia, bursitis, depression, multiple chemical sensitivity, and Irritable Bowel Syndrome.”

Chronic Pain Patient Advocate¶

This bio was not written in jest and her words, while not medically informed, do allow for us to understand what our patients see when we allow our professionalism to slip and forget to be honest and compassionate. Her story shows how antagonism is fueled and expectations are reinforced.

Communicate with your patients, the staff, and yourself that the patient’s pain is real and it is our duty to treat this pain in the best ways that modern medicine allows. Focus on what we CAN do, rather than what we will NOT do: - We will treat pain - We will listen and support - We will use medication that is supported by evidence - We will monitor for and treat withdrawal - We will assist in tapering - We will recommend treatment programs for addiction

Delirium Screening:

The cover story for the March 2016 issue of ACP Hospitalist was Spotting Delirium (http://www.acphospitalist.org/archives/2016/03/delirium-screening.htm).

The article discussed tools that allow for delirium screening, but I could not help thinking about dogs chasing cars or as our own Dr. Kizer was quoted at a recent EBM: “Screening for dementia is like trying to catch a bear with bare hands- what do you do when you catch it”

Once a patient becomes delirious, we have already lost our most effective tool to combat it – delirium prevention. While screening and identification tools for delirium are essential for measuring the rates of delirium, our methods for treating delirium are far less effective than our methods for preventing it.

PREVENTION:

TDF (Think Drugs First): Avoid (if possible) - Benzodiazepines - Hypnotics (zolpidem) - Muscle relaxers

Behavioral: Yale Delirium Prevention Trial. NEJM 1999; 340(9): 669-676. - Orientation and therapeutic activities - Early mobilization - Adaptive equipment - Early intervention for volume depletion - Sleep-enhancement protocol

EPIC: Smart Phase Manager found under OSSMAN, PAUL D - .GERIBEERS: Instructions to geriatric patients regarding common medications to avoid - .GERIDELIRIUMPREVENTION: May be inserted within any note - .GERIDELIRIUMORDER: a way to order “The Geriatric Order set” written to reduce risk factors of delirium - Order “assess” and choose the NRS order - Insert the .phrase in the free text box

IDENTIFICATION:

“Quick” tools for identifying delirium when the above fail as shared by the ACP article: http://www.hospitalelderlifeprogram.org/delirium-instruments

“The Short CAM contains the first 4 items of the full 10-item CAM: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness. 3D-CAM is a 3-minute version of short CAM used by clinicians at the bedside that incorporates cognitive testing and patient questions. bCAM is a 1-minute version of CAM used by emergency department clinicians at the bedside. CAM-S measures severity of delirium based on the short or long CAM assessments.

FAM-CAM is designed for clinicians to use with family caregivers.”¶

IMPROV:

A novel method to interact with the delirious -- Magic Words. This American Life. 532: AUG 15, 2014. ACT TWO. http://www.thisamericanlife.org/radio-archives/episode/532/magic-words?act=2 Improv actors use the skills of improv to communicate with their mother who lives with dementia.

Personality Disorders:

Groves JE. Taking care of the hateful patient. N Engl J Med. 1978 Apr 20; 298(16): 883-7.

The article is far more helpful and detailed, but the abstract is as follows: “Hateful patients" are not those with whom the physician has an occasional personality clash. As defined here they are those whom most physicians dread. The insatiable dependence of "hateful patients" leads to behaviors that group them into four stereotypes: dependent clingers, entitled demanders, manipulative help-rejecters and self-destructive deniers. The physician' negative reactions constitute important clinical data that should facilitate better understanding and more appropriate psychological management for each.

Clingers evoke aversion; their care requires limits on expectations for an intense doctor-patient relationship.
Demanders evoke a wish to counterattack; such patients need to have their feelings of total entitlement rechanneled into a partnership that acknowledges their entitlement--not to unrealistic demands but to good medical care.
Help-rejecters evoke depression; "sharing" their pessimism diminishes their notion that losing the symptom implies losing the doctor.
Self-destructive deniers evoke feeling of malice; their management requires the physician to lower Faustian expectations of delivering perfect care.
Dependent Clingers:

“Clingers escalate from mild and appropriate requests for assurance to repeated, perfervid, incarcerating cries for explanation, affection, analgesics, sedatives and all forms of attention imaginable. They are naïve about their effect on the [provider], and they are overt in their neediness . . . What is common to them as a group is their self-perception of bottomless need and their perception of the [provider] as inexhaustible … when the [provider’s] stamina is exhausted, a referral for psychiatric examination maybe adamantly put forth in frustrated tones that the patient (correctly) interprets as rejection. Psychiatric referrals made in this context are destined to fail utterly.”

Relationship: Initial genuine gratitude leads providers to feel special and sometimes even powerful; however, as the relationship involves, the boundaries of time and appropriateness are pushed. The provider morphs into an “inexhaustible parental figure” and the patient morphs into an “unwanted, unlovable child.”

Guidelines: - Early intervention is best - Tactful and firm intervention is necessary - Remind the patient of “not only human limits to knowledge and skill but also limitations to time and stamina.” - Written instructions placed in the hand of the patient with specific reminders about acceptable modes and frequency of contact is very helpful as an exit strategy. (Firm exits are better than fake pages) - “This approach is not cruelty or rejection. It is in the best interest of patient care to protect the patient from promises that cannot be kept and from illusions that are bound to shatter.”

Application to Opiates: - Limitations of medicine – Wish statement: “I wish we had medication that could provide the relief opiates do without the harms they pose” - Setting conversation limitations. Firmly state, “We will no longer discuss opiates as part of our daily conversation.” - Giving written resources for addiction treatment and/or prescriptions for adjunct medications (Tylenol, NSAIDs, Gabapentin, Cymbalta, etc.) on exit: “I understand you do not want to discuss addiction counseling. Here is a list of local resources for you to read through and utilize. I will check in with you tomorrow and will be asking if you have particular questions. So long.”

Entitled Demanders:

“Demanders resemble clingers in the profundity of their neediness, but they differ in that– rather than flattery and unconscious seduction– they use intimidation, devaluation and guilt-induction . . . Such patients often exude a repulsive sense of innate deservedness as if they were far superior to the [provider]. This attitude is to shield them from the awareness that the [provider] seems to have power over life and death. Obviously, this sense of the innate and magical entitlement to everything that is wanted is depressing (and therefore often enraging) to the busy [provider] who may have had to surrender many dreams of omnipotence and omniscience over years of training.”

Relationship: “The [provider] becomes fearful about reputation, enraged that the patient is not cooperative and grateful and – eventually– secretly ashamed, as if the patient’s devaluating demands were realistic.” For the patient, entitlement functions in the way “that faith and hope serve in better adjusted ones.” We want to “point out suddenly and devastatingly that the patient has earned little . . . and deserves little. But this course would be an assault on the very psychologic foundations that supports such a patient. Entitlement is such a patient’s religion and should not be blasphemed.”

Guidelines: - Recognize how vulnerable these patients are to counterattack. It is not useful to attack or undermine the patient’s entitlement. - Support the entitlement, but “re-channel it in the direction of the indicated regimen.” - Avoid being bullied into defensive medicine - Avoid complicated debates - Attempt to engage in a “tireless repetition of the theme of acceptance that the patient deserves first-rate medical care.” - Honesty

Application to Opiates: - Instead of “No opiates for you!” “You are absolutely entitled to the best care available and opiates are not part of that care.” - Instead of “Why the heck won’t you take your Tylenol and gabapentin?” ”You are absolutely entitled to pain control and I encourage you to work with your team to utilize every medication and treatment we are using at our disposal.”

Manipulative Help Rejecters:

Unlike some of the more obvious personalities, rejecters are not seductive or grateful. They are not overtly hostile, but they “appear to feel no regiment will help,” yet they continue to return or refuse to leave. Groves describes them as “smugly satisfied,” and observes the “patient’s pessimism is directly proportional to the provider’s enthusiasm.” When near discharge, it is not uncommon to encounter a “cascade of new symptoms.” Sometimes these patients appear masochistic and demonstrate behaviors that are consistent with secondary gain or even Munchhausen. Despite these traits, they often deny depression.

Relationship: Groves describes the patient-provider dyad as an “Undivorceable marriage with an inexhaustible caregiver” where their symptoms are “an admission ticket.” He goes on to detail a “Pathologic dependency presents in one of its extremes as manipulativeness– an intense, covert, contradictory, self-defeating attempt to get needs met. It is the behavioral manifestation of the need for the patient to get close to but at the same time to maintain safe distance from sources and emotional support . . . Such patients seem to have a deathly fear that which they most crave”

Guidelines: Remember one’s role and duty -- care directed at the problems for which you can offer help, NOT the patient driven drama

Do not focus on the “solution” to the patient’s need/fear¶

Set limits on unrealistic expectations Set limits on demanding hostility Use consistent and firm language

Use gentle and simple reasoning¶

Set up close follow-up to assuage feelings of abandonment and focus on continued relationships and maintenance rather than cure

Application to Opiates: Frame or reframe the discussion AWAY from the opiates and toward the issues for which you are trained to offer help

Assure continued support and combat fears of abandonment¶

Focus on what you have to offer rather than what is being denied: addiction treatment, mental health support Frame additional support as adjuncts rather than replacements

Self- Destructive Deniers:

“Deniers display unconsciously self-murderous behaviors, such as the continued drinking of the patient with esophageal varices and hepatic failure.” These folks stir up malice, are not independent, and “are using the defensive denial in an attempt to survive.” They are “profoundly dependent and have given up hope of ever having needs met. Such patients seem to glory in their own destruction. They appear to find their main pleasure in furiously defeating the physician’s attempt to preserve their lives.”

Relationship: This population is exceptionally challenging, as they seem to resist care the more we attempt to give it. We must admit “without shame or self-blame that they provoke in their caregivers the fervent wish that they would die and ‘get it over with.’” We are caught between the “ideal of rescuing the patient on one hand and the unwanted wish for the patient to die on the other.”

Guidelines: Realize that what we can offer is “Quite limited” Attempt to reverse what we can – including depression Resist abandoning the patient “Work with diligence and compassion to preserve the denier as long as possible, just as one does with any other patient with a terminal illness.”

Application to Opiates: Continue to offer support Do not take it personally Recognize the limitations of options that past behaviors have created Lack of facilities Lack of providers and prescribers Pain may be incurable given options Do not forget to offer hospice when appropriate

UNC Hospital Medicine Alcohol Detoxification Protocol¶

YES

NO NO NO NO

YES

NO NO NO YES

NO

YES YES¶

NO