“Even if they have underlying heart failure, if they’re volume-depleted, they need that volume. Sometimes you’ll see that it takes eight hours to get two units of blood in. That’s inadequate.” —Rajeev Jain, MD
7 For patients with a possible GI bleed and black stools, do an exam before calling in the gastroenterologist.
The exam should determine what the stool color is and whether it is heme-positive, and the patient’s blood count should be evaluated, Dr. Coben says.
Frequently, “the consultant’s the one who ends up doing the rectal exam and checking that,” he says. “Sometimes we find that [the patient is] really not bleeding,” and it was just a case of a hospitalist taking the patient’s word that they were bleeding.
Being on iron therapy or taking Pepto-Bismol can turn the stool black, and the stool might not really be black; colors can sometimes be open to interpretation.
But he cautions that colon cancer could be the cause for a GI bleed.
“We’ve had it happen a few times where this occurred,” he says. “The patient was discharged, and they really didn’t get proper follow-up, and it ended up that they had a colon cancer. It kind of delayed that diagnosis. So I think you have to be aware of [the fact that], especially in somebody over the age of 40 or 50, if they have an iron-deficiency, anemia, or heme-positive stool, the first thing you really need to exclude is a colon cancer.”
8 Minimize CT scans in early evaluation and management of acute pancreatitis patients.
“The reason for that is they tend to be intravascularly volume-depleted,” Dr. Jain says. “So [with] the IV contrast, there’s an increased risk of developing kidney failure. It’s also been associated with increased risk of necrotizing pancreatitis.”
Dr. Jain notes that when he is consulted on this kind of patient, he will order a sonogram. If it doesn’t show gallstones, and there’s no clear reason for the pancreatitis, he will want a CT scan, but he will wait a few days until the patient is fluid-resuscitated.
Dr. Jain says that this is a problem more often seen in the ED—where 90% of patients with acute pancreatitis have already gotten the CT scan—and less so among hospitalists, but it’s still worth the reminder.
A CT scan right away is justified to rule out something such as a perforation, but not in the case of classic symptoms of acute pancreatitis, he adds.
9 Actively bleeding patients?
It’s smart to give patients a unit of packed red blood cells more quickly if they’re actively bleeding. Even over just one hour is OK, Dr. Jain says.
“Even if they have underlying heart failure, if they’re volume-depleted, they need that volume,” Dr. Jain explains. “Sometimes you’ll see that it takes eight hours to get two units of blood in. That’s inadequate.”
Another point worth a reminder, he says: Two large-bore peripheral IV’s are “much, much better” than a central or PICC line to deliver IV fluid resuscitation.
Image credit: Courtesy of Washington University School of Medicine
“Sometimes hospitalists order barium studies because these can be done the same day, whereas with endoscopy, patients need to be put on a schedule and have to be NPO [nothing by mouth] overnight.” —Prakash Gyawali, MD, MRCP
10 Don’t be too quick to order barium studies, especially in patients with dysphagia.
“The problem with that is it takes much longer to do an endoscopy if barium is put in the esophagus, because we usually wait until the barium clears,” Dr. Gyawali says. “And inpatient evaluation of new-onset dysphagia should be endoscopy first, and not barium, because biopsies need to be taken to rule out eosinophilic esophagitis.