D.D.A.V.P. your S.O.A.P.

Making rounds on hospitalized patients can be easy. We’re good at sizing up a patient’s condition, moving from the subjective report of their progress to the objective findings of vital signs and physical exam, lab results and radiographic images. This is the S.O. and A. of the S.O.A.P. note.

More difficult, however, is anticipating the patient’s future needs and answering the question, “What’s next?” This is the P. of the S.O.A.P. note. We should look ahead to the next milestones the patient needs to achieve. The ultimate milestone is discharge from the hospital.

So for every patient, you should ask, “What does this patient need to make progress toward discharge?” Here’s a mnemonic I find helpful: DDAVP

D: Drains, and all lines, including Foley and wound drains, IV fluids and arterial lines. Have the Foley removed as soon as the patient can void with minimal assistance. Heplock the INT when the patient is tolerating a diet.

D: Diet, advance the diet as tolerated. For stroke patients, a swallowing study may be useful. Diabetics will need a diabetic diet.

A: Activity, which should be advanced according to the patient’s ability. When you order PT, remember the therapist cannot walk the patient unless your activity order says out of bed!

V: Vital signs. A critical care patient may need hourly vital signs and neuro checks. As they improve, you can extend the interval between checks. This may also mean moving from ICU to a regular room.

P: PO medications. Your patient may need IV medications upon admission. As they make progress, convert them to the oral route, including anticonvulsants, muscle relaxants, analgesics and others.

All these steps, DDAVP, will help your patient make progress toward discharge. Include these in the P. of your S.O.A.P. note. Every patient encounter should include the steps that will move them toward the exit!

On Call Pitfalls

On-Call Pitfalls

Things that Kill. Things that Bother.

Calls to the neurosurgery group can be divided into two groups: things that kill and things that bother. Listening for conditions that may become life threatening is a skill that comes with experience. What is “experience?” Paying attention to the things that have happened, often informed by mistakes you have made in the past!

Things that kill

MI. Specifically myocardial infarction in the post operative patient. Surgery is a stress to the body, and the patient with atherosclerotic coronary disease, for example, can be pushed over the edge simply from the physical impact of the surgical event. A cardiac event is suggested by any combination of chest pain, with radiation to the jaw or arm, with diaphoresis, with shortness of breath. Be quick to order a 12-lead EKG, cardiac enzymes, and pulse ox. If you wonder if the patient may be unstable, call the Rapid Response team for an immediate evaluation.

PE. Pulmonary embolism is characterized by chest pain around the ribs, diaphragm, or back, with shortness of breath, tachypnea, and anxiety about breathing, worse with lying, better sitting and leaning forward. Evaluate with pulse ox, ABG, chest x-ray, CT-Angiogram of the chest, and labs. Definitely call a Rapid Response whenever there is respiratory distress.

DVT. Here are the classic hallmarks of DVT: a painful, red, swollen, hot extremity. This is a little tricky to sort out on the neurosurgery service, since many of our patients have pain in an extremity to start with! So when you are called for pain in a leg or an arm, always ask: Is it swollen, red, and hot compared to the other? Order an ultrasound of that extremity to look for DVT, and unless you are sure it is not a DVT, remove the sequential compression device from the leg and keep the patient on bed rest. If a DVT is present, you’ll need to consider anticoagulation and the placement of an IVC filter.

CVA. Acute ischemic stroke presents with new-onset brain symptoms. Weakness or numbness on one side of the body, facial droop, slurred speech, confusion, and vertigo are all signs of a stroke. These symptoms are usually painless, and the patient almost always discounts their significance. Family members will often be the first to mention the changes. Any new onset stroke symptoms require an immediate CT of the head. Even in acute stroke, though, this is expected to be *normal* unless the stroke is hemorrhagic! Sometimes a follow up MRI is ordered with diffusion weighted images to prove the ischemic event. Other diagnostic steps include pulse ox, 12-lead EKG, labs including chemistry, CBC, lipid profile, and HbA1c. Risks and benefits of aspirin therapy can be weighed carefully in the post op neurosurgical patient.

Spinal cord compression and cauda equina syndrome. An epidural hematoma after a spinal procedure is a neurosurgical emergency. In the cervical spine this can follow anterior or posterior surgery. The hematoma compresses the cord causing severe local pain along with weakness, numbness, and spasticity in the extremities, with increased reflexes and sustained clonus. In the lumbar spine an epidural hematoma may compress the cauda equina causing severe local pain and numbness in the saddle region or in the legs, with weakness and depressed reflexes. Either case is a neurosurgical emergency and must be evaluated with immediate plain x-ray to visualize the bone structure and urgent MRI to image post op fluid collections, CSF, and the neural structures.

Drug allergy. A true drug allergy can be a life threatening emergency with anaphylaxis or hemodynamic shock. The lip swelling of angioedema or a macula-papular rash on the chest and trunk can herald an allergic reaction. Treatment begins with stopping the offending agent, a real trick since you usually don’t know which drug is the culprit! So you go with percentages: phenytoin and antibiotics are well known for causing allergic reactions. The next step of treatment is steroids and antihistamines to suppress the body’s allergic response. Above all, you must be mindful to protect the patient’s airway at all times.

Things that Bother

The vast majority of your calls will be for issues of comfort. I’m not minimizing these, but they occupy a different level of urgency. They are important in the patient’s recovery in that they can be obstacles to the patient’s physical progress. Here are the most common.

Pain. An inordinate amount of pain can signal an urgent problem like an epidural hematoma in the immediate post op patient, or infection days to weeks after surgery. After you have ruled out worrisome causes of pain, treat it using the standard drugs in your armamentarium: narcotics, muscle relaxants, anticonvulsants (like gabapentin), antidepressants (like amitriptyline), and sometimes a short course of steroids. Physical options include an ice pack to the surgical site. The PT/OT can instruct the patient in proper body mechanics to reduce pain with movement. The main idea is to control the pain well enough to allow physical progress in recovery.

Nausea. Pain can be nauseating, and the drugs used to treat pain can be nauseating! Nausea may reflect a post operative ileus that can occur after exposure for anterior lumbar surgery. Diagnostic evaluation with KUB can demonstrate an ileus. For the nauseated patient, limit the diet to ice chips or clear liquids until the gut is in better spirits.  Antiemetics and prokinetics are the medications most useful to keep on board, and in severe nausea these can be ordered around the clock for a period as a preventative. A physical technique to help prevent vomiting is slow, steady breathing. If vomiting is imminent, prevent aspiration by having the patient in a side-lying position or elevate the head of bed.

Constipation. There, I’ve said it! This is the number one complication of any hospitalized patient, and you will soon become an expert in preventing and treating constipation. Keep in mind that managing constipation in the *hospitalized* patient is different from the primary care setting. You’ll use docusate (Colace) in all hospitalized patients. Be quick to add polyethylene glycol (Miralax) and senna (Senokot) nightly for mild constipation. Bisacodyl functions like a stick of dynamite in the gut, and you’ll prefer the suppository route to “put the medicine right where it needs to work.” An enema is another option.

Itching. Itching can be an annoying but benign side effect of some medications like narcotics, or it may be a much more significant signal of an allergic reaction. For mild itching, a systemic antipruritic like diphenhydramine or hydroxyzine is useful. I avoid topical antihistamines and steroids because I don’t want my patient slathering medicine around a surgical incision. Blisters will appear with Stevens-Johnson syndrome, which is a life threatening emergency.

Call for help

As a neurosurgery beginner, you won’t have the experience, so learn from the experience of others. Keep your handbooks handy, both neurosurgery and medicine. Be quick to call your attending physician or a seasoned peer for advice. There are dangers and pitfalls lurking everywhere. As the saying goes: Learn from the mistakes of others—you won’t live long enough to make them all yourself.