“Few diseases present greater difficulties in the way of diagnosis than malignant endocarditis, difficulties which in many cases are practically insurmountable. It is no disparagement to the many skilled physicians who have put their cases upon record to say that, in fully one-half the diagnosis was made post mortem.” – William Osler, 1885
***
“Hi! You’ve reached Crystal and I can’t get to the phone right now. Please leave a message and I’ll call you back when I can. Have a great day!” BEEP
“Uh… Hi. Mom. It’s me, Jason, again. Um.. you were right. The drugs are killing me. I’ve had a fever for weeks now that just won’t go away. I tried the clinic down the street, but they just gave me a course of antibiotics that didn’t help. I’m scared, Mom. I’m so weak I can barely move. I haven’t been able to eat for days. I’m so skinny, you may not even recognize me. I think I’m dying. I know why we’re not talking and I understand why you had to cut me out of your life, but right now, I really need my mom. If you get this message, I’ll be at University Hospital. Please come. I already called 9-1-1. The paramedics are on the way. I love you, mom. I’m sorry…”
***
“THIS IS MEDIC 2915 REQUESTING MEDICAL COMMAND” the radio calls out.
You and Shannon, your charge nurse, hustle over to the phone. You both look at each other, wondering where you’re going to put another critical patient in an emergency room that’s already bursting at the seams.
“Go ahead Medic 2915, this is the hospital”
“Hey Doc! We have a sepsis alert coming in. This kid is really sick. Late 20s-early 30s-year-old male, he looks absolutely terrible. He should have called us 3-4 days ago. Heart rate is 163, blood pressure is 65/palp, respiratory rate is 26, oxygen saturation is 84% on 4L nasal canula and he’s febrile to 103.4 F (39.7C). He’s in and out of consciousness, seems like he’s hallucinating or something. Keeps calling out to his mom and telling her he’s sorry. Lots of IV drug paraphernalia at the motel he was staying at. This is a sick one, doc. Somehow, I got a sort-of working IV and I have fluids hung wide open, but I don’t have a lot of faith in this IV. We’re driving as fast as we can; we’re about 2 minutes out. I’ll give you the full report when we arrive. Medic 2915 out.”
“Resus bay?” you ask Shannon.
“Completely full.” She responds.
“Can we move anyone out? Maybe bed 3 can go back to the main ER now that she’s sorta-stable?”
“She’s on 4 pressors and intubated, not even close to stable. She’s been waiting for an ICU bed for 2 days. We are literally out of space. Let me think.” Shannon says. “Bed 1 and bed 4 aren’t intubated yet and resus bay 1 is the biggest. We’ll move 4 into bay 1 with bed 1 and put up dividers. They’ll have to share until we get this kid tuned up. We’ll just hope no traumas come in… I’ll go let the nurses know and move beds; you let pharmacy and respiratory know we’re getting a critical resus?”
“No problem, boss” you say as you walk off.
“Hey Scott, need you in resus, we have a super sick sepsis coming in,” you say to your pharmacist. “Grab the intubation box, and can you ask respiratory to join us too? I’m gonna head to the bay, the medics were only 2 min out”
“No problem, see you there.” Scott responds.
“SEPSIS ALERT ARRIVAL, RESUS BAY 4; SEPSIS ALERT ARRIVAL, RESUS BAY 4!” the hospital voice calls out as you walk through the doors to the bay.
“Ah, my old friends Medic 2915, what’s going on?” You ask
“Hey Doc, this is the sick kid we were telling you about. He’s a John Doe. No name, no ID, nothing. I’m guessing 25–30-year-old male, extensive IV drug abuse. He’s ill. BP sucks, he’s tachy as hell, I’m really worried about him. The motel we’ve picked him up from is a known drug den, but this is bad, even for that area. There was another person in the room when we arrived. Said she was his girlfriend, but she was so high, she was of no help at all. Doubt she’ll show up, but you’ll never know. Couldn’t even give us his name. Also, the sort-of working IV we had blew on the way in, so I have no IV acces for you. Sorry! Good luck, Doc. Text me, if you don’t mind, let me know how he’s doing after your shift!”
“Alright, everyone, let’s do the things!” you say to the room. You’re watching the nurses try, unsuccessfully to get IV access. “He’s probably a tough stick, given his IV drug abuse history and lack of blood pressure,” you mention.
“No kidding,” Robin, one of the trauma nurses, tells you. “Luckily, Harry is on today and he’s the guy for IV ultrasound lines.”
“Yes, sir, no problem. I’ll get a line in him real quick,” Harry says, reaching for the ultrasound.
While the nursing team is working on IV access, your tech hands you an EKG:
Rate: 147
Rhythm: Sinus Tach
Axis: Normal
Intervals: normal PR, normal QRS duration, QTc looks ok too
Morphology: Overall, not terrible, nothing really jumping out at me here
Final Read: Sinus Tachycardia
You bolus the patient IV fluids and antibiotics and run in IV acetaminophen to help with the fever. Despite your best efforts, he still remains hypotensive. You add on additional IV fluids and start pressors.
“Hey, Doc, what’s your plan here?” Shannon asks. “Looks like we’ve tried fluids and started pressors now, but his BP is still not great. Most recent vitals show a heart rate still in the 120s and BP is 80/40 despite a hefty dose of levophed. This isn’t going well.”
“Excuse me, I have lab on the line for you, Doc. There’s a critical result,” your clerk interrupts.
“No problem, sorry, one sec Shannon,” you say. “Hi lab, go ahead!”
“Hey Doc, is resus bay 4 super sick? I’ve never seen blood cultures pop positive so quickly. We’ve had them for under 2 hours and they’re already growing out bacteria. They’re definitely gram positive, but that’s all I know at the moment. If I had to guess, I’d say maybe Staph Aureus, but let me confirm that; I’ll call back with more info as soon as I can.”
“Well, that fits,” you respond. “Thanks lab!” you say as you hang up the phone.
“Let’s put out a page to critical care and cardiology. This kid is extremely bacturemic and has a history of IV drug abuse, I bet it’s endocarditis. When I looked earlier with the ultrasound, I couldn’t get very good windows, but maybe cards will be able to do a stat transesophageal echo on him. Shannon, Scott, we’re going to need more pressors, and let’s get him up to the ICU as soon as possible.”
“You mean board him down in the ER forever…” Shannon says as you walk off to make some calls.
***
“Hey, Doc, come look at this!” you hear the cardiology fellow call over to you. “We’re doing an emergent TEE on that probable endocarditis guy, you gotta see these images!”
“Uh.. Sure! Let me head over and take a look,” you say as the cardiology fellow pulls up the pictures for you.
“Start with this still image first, you can see a huge vegetation on the tricuspid valve:”
“Now, take a look at two of the live clips, it’s really impressive!” he tells you.
This first one (above) is a close up of just the tricuspid valve with vegetations.
This second clip (above) shows the tricuspid valve and the aortic valve.
“And he has severe tricuspid regurgitation, take a look at what happens when I put doppler flow on:” the fellow continues.
Notice here how there are colored jets flowing every direction with a valve that is not keeping flow unidirectional.
“Thanks for calling us so quickly about this case. We’re going to take him up to the OR with CT surgery and try to remove some of the growths from his valves, if we can get him stablized. Wish us luck, we’re taking him to the OR as soon as we can,” the fellow tells you.
“Good luck guys, let me know how it goes!”
Case Wrap Up:
“Hey, Doc, there’s a lady up in triage demanding to talk to an attending physician. Someone named Crystal? Said her son, Jason, is here, but there’s no Jason on our board. I tried to tell her that he’s not here but she’s very insistent…” your clerk tells you.
“No problem, I’ll take it care of it,” you tell the clerk as you walk up front.
“Hello! Doctor! Please help me,” says a slightly panicked looking woman. “I haven’t spoken to my son, Jason in 2 years. He is a drug addict and I had to cut him off. It broke my heart but, I’m a single mom and he was stealing from me. I have 2 younger children I had to protect. He’d get so violent when I said no to more money that it wasn’t safe to be around him, especially when he was high. I haven’t heard from him at all. Then, suddenly, he left me a voicemail that he has a bad fever, thinks he’s dying, and is going to your hospital. He needs me. Has he arrived? Is he ok?”
“Ma’am, what does he look like? How old is he?”
“He’s 28 years old. Skinny, brown hair, blue eyes. Has a scar over his left eye he got as a kid.”
“Ah, that’s our John Doe. Yes, he’s here. Come on into the family room so we can have a quiet place to talk, I have a lot to catch you up on…”
Recap:
Endocarditis is a very tricky disease that often goes undiagnosed on a patient’s first visit
This post explored the story behind a patient with endocarditis, next week we’ll have an evidence-based discussion on the diagnosis and management of endocarditis with my friend, Dr. Bobbi-Jo Lowie
Dr. Lowie is an assistant professor of emergency medicine and an APD of the EM residency at the University of Maryland
She is an expert in emergency infectious diseases, with a special interest in endocarditis and myocarditis
Here is an excellent resource on endocarditis if you want a jumpstart on next week!
You may have noticed this week we’ve started to accept donations.
As this project has grown, it has morphed from an every other week email into something that is practically weekly at this point. We’ve grown to almost 8000 subscribers from over 150 countries. It has been amazing - and at times overwhelming - to witness such quick growth.
Several of you have asked to support my work, so I’ve decided to accept donations, but please know, monetary support is never expected. All content will continue to be free, whether you’re a paid supporter or free subscriber.
Thank you for taking the time to read, share and be part of this project with me. I am incredibly grateful for your support and look forward to seeing where we go from here
-Lloyd
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