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Laying Hands on the Patient Who Is Unstable: Bedside Diagnosis in Medical Emergencies

      Travis Connor, a 32-year-old male, was receiving a blood transfusion for an upper gastrointestinal bleed while awaiting an endoscopy. However, he quickly developed diffuse abdominal pain and hypotension. A rapid response was activated, and house staff responded to his bedside. Attributing the hypotension to hemorrhagic shock, residents ordered a massive transfusion protocol and gave further blood products. But volume resuscitation had little effect on his hypotension, and his blood pressure continued to fall. Finally, only after the patient started complaining of itching did a young doctor pull back the patient’s gown to examine his chest and abdomen, revealing an urticarial rash on the patient’s trunk; the patient was actually in anaphylactic shock. He recovered after treatment for anaphylaxis was initiated and was transferred to the intensive care unit (ICU) for further management.
      Thankfully, poor Connor is only a simulation mannikin. His recurrent anaphylaxis contributes to the training of residents in internal medicine to handle rapid-response and code-blue activations. As instructors of the simulation program, we noticed a troubling trend: house staff were often too distracted, overwhelmed, or reluctant to examine the patient during these emergencies. Reviewing our videos, we noted that one-third of teams waited more than 4 minutes before examining the patient, despite multiple team members’ availability to do so (unpublished data). Although the simulation environment can alter clinician behavior, all teams were specifically briefed on what examination maneuvers were possible on the mannikin and instructed to perform them as needed. This delay in the physical examination led to delays in the recognition and treatment of the patient’s anaphylaxis.
      This behavior echoes a trend across modern medicine. With bedside monitors and extensive electronic medical records (EMRs), patients are easily reduced to a virtual corpus of data. This phenomenon is referred to as the “iPatient” by Dr. Abraham Verghese.
      • Verghese A.
      Culture shock—patient as icon, icon as patient.
      Physicians are too accustomed to learning about patients on the electronic medical record that they forget the value of a physical examination. The iPatient is common in critical-care settings, where advanced and invasive monitors obviate and even hinder the physical examination. In one study, only half of physicians reported the physical examination to be useful in the management of a patient in the ICU, and more than half of ICU attendings and fellows did not consistently examine their patients.
      • Vasquez R.
      • Vasquez Guillamet C.
      • Rishi M.A.
      • et al.
      Physical examination in the intensive care unit: opinions of physicians at three teaching hospitals.
      As in the ICU, there are many challenges to examining a patient during emergent situations. First, the responding team is likely unfamiliar with the patient, so rapid orientation to the situation and information-gathering distracts from the examination. A noisy and crowded room limits auscultation and physical access to the patient. Patients who are unstable require emergent interventions before diagnostic maneuvers; the more unstable a patient is, the less a doctor can afford to perform a physical examination. Urgent radiographs force us to leave the patient mid-examination. Lastly, there may be a reluctance to fully expose a patient who is awake and possibly offend his or her modesty in front of large crowds.
      Still, a focused physical examination has value in medical emergencies. As demonstrated by the introductory scenario, a single crucial finding can alter a patient’s management and outcome long before labs are drawn. Dr. Jonathan Sevransky notes that in today’s era of advanced diagnostics, the physical examination is rapid, low-risk, and economical. Despite lack of data regarding sensitivity and specificity regarding individual maneuvers, its availability makes it crucial in the initial evaluation of patients who are unstable.
      • Sevransky J.
      Clinical assessment of hemodynamically unstable patients.
      Other small studies have found some utility of the physical examination in distinguishing different types of shock.
      • Hiemstra B.
      • Eck R.
      • Keus F.
      • van der Horst I.C.C.
      Clinical examination for diagnosing circulatory shock.
      Here, we propose an approach to the physical examination for common emergent inpatient scenarios. These are designed to be rapid and high yield to avoid sacrificing attention to stabilizing measures. We have included ultrasound as a useful adjunct to the physical examination. The Society of Critical Care Medicine recommends bedside cardiac ultrasound in the evaluation of all patients who are unstable for assessment of cardiac function, presence of a pericardial effusion, and fluid responsiveness.
      • Levitov A.
      • Frankel H.
      • Blaivas M.
      • et al.
      Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—part II: cardiac ultrasonography.
      Lung ultrasound is also recommended for patients with hypotension or respiratory failure to evaluate for edema, pneumothorax, or pleural effusion.
      • Frankel H.
      • Kikpatrick A.
      • Elbarbary M.
      • et al.
      Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—part I: general ultrasonography.
      Ultrasound examination is limited by operator experience and availability. However, basic ultrasound training is becoming more common in residency and fellowship training, and variety of new handheld ultrasound models are portable and unobtrusive.

      General Examination

      The physical examination starts with circulation, airway, and breathing. A patient who is awake and phonating is satisfactory on all three measures. For others, palpating a pulse while assessing airway and air movement determines the need to begin advanced cardiac life support (ACLS) resuscitation. A quick neurologic screening, assessing mental status, speech, and obvious motor asymmetries, guides further evaluation.

      For the Patient in Respiratory Distress

      Visual examination evaluates the patient’s work of breathing. The upper airway should be examined for any swelling and suctioned to evaluate for obstruction. The trachea should be examined for deviation. Auscultation should be done at the apices and bases if possible. After auscultation, lung ultrasound can be performed if further indicated.

      For the Patient With Hypertension

      Pulses should be constantly monitored for patients who are unstable. Examination of the extremities and capillary refill time can help distinguish between different types of shock. The patient should be exposed, revealing abdominal distension, melena, other sites of active bleeding, or rashes that suggest an allergic reaction. A passive leg raise test can be both diagnostic and therapeutic for hypovolemic shock. A focused ultrasound examination should be performed to look for intraabdominal or pleural fluid collections. If ambiguity remains, a focused bedside echocardiogram should be performed to identify cardiac pathology and volume status.

      For the Patient in Arrest

      Pulses should be monitored continuously to ensure high-quality chest compressions and to detect return of spontaneous circulation. Lungs should be auscultated during rescue breaths and pulse checks to rule out pneumothorax or mainstem intubation. Echocardiography can be helpful in determining underlying cardiac function and the presence of pericardial effusion; the subcostal view provides excellent visualization even during ongoing chest compressions. Lung ultrasound is a useful adjunct to auscultation during compressions.
      This approach is not meant to be comprehensive. Inpatient emergencies are by nature heterogeneous situations that defy standardized management. However, these suggestions present a rapid screen to guide further interventions. Although we have made strides in our diagnostic tools and technologies, basic physical examination maneuvers still have a place in the management of emergent situations. Rapid-response and code-blue activations are precious moments in today’s practice that bring us to the patient’s bedside, and we should take every advantage that the bedside offers.

      References

        • Verghese A.
        Culture shock—patient as icon, icon as patient.
        N Engl J Med. 2008; 359: 2748-2751
        • Vasquez R.
        • Vasquez Guillamet C.
        • Rishi M.A.
        • et al.
        Physical examination in the intensive care unit: opinions of physicians at three teaching hospitals.
        Southwest J Pulm Crit Care. 2015; 10: 34-43
        • Sevransky J.
        Clinical assessment of hemodynamically unstable patients.
        Curr Opin Crit Care. 2009; 15: 234-238
        • Hiemstra B.
        • Eck R.
        • Keus F.
        • van der Horst I.C.C.
        Clinical examination for diagnosing circulatory shock.
        Curr Opin Crit Care. 2017; 23: 293-301
        • Levitov A.
        • Frankel H.
        • Blaivas M.
        • et al.
        Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—part II: cardiac ultrasonography.
        Crit Care Med. 2016; 44: 1206-1227
        • Frankel H.
        • Kikpatrick A.
        • Elbarbary M.
        • et al.
        Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—part I: general ultrasonography.
        Crit Care Med. 2015; 43: 2479-2502