Tuesday, March 4, 2014

Dr. Orthochick: Rapid Response

I was on call the other day and i got paged by the Rapid Response Team around 11 at night, which really freaked me out. Normally if the RRT calls you, it's because something's wrong with your patient. And whereas 75% of the time it's not a big deal, I still don't want any of my patients to get in trouble with anything on the off chance the RRT is actually doing something important.

RRT: Hi, this is Linda with the Rapid Response Team
Me: Hi, it's Orthochick from ortho returning a page?
RRT: Yes, we have a patient, Ethel Roberts
Me: I'm sorry, I don't know her. What procedure did she have done?
RRT: No, she was admitted a few days ago for pneumonia and we just got called because she has altered mental status and she's hypoxic. But they did an xray of her knee two days ago and it looks like she has a distal femur fracture so we were wondering if you would mind checking it out?

Just another reason to hate the Rapid Response Team.

Anyway, since i was awake I went to check out the situation. The patient was hypoxic and either altered or demented, I have no idea since I had never seen her before. She couldn't answer questions, I couldn't do much of a physical exam, and truth be told, I don't know why an xray was ordered of her knee in the first place. Fortunately, it was and it showed a horrible fracture. It was around a total knee prosthesis and the whole knee had broken off and there were bone chips everywhere and the titanium part of the knee replacement was floating around. That's a big problem because it means you probably have to do a distal femoral replacement, which is a huge messy surgery with a lot of blood loss, recovery time is forever, and if you're old it's not going to end well. But the problem is, if you don't fix the fracture, the patient is going to have horrible pain and it's never going to heal. So really, it's not an easy decision to make in an older person with lots of medical problems.

Since I had no information from the patient, I started picking through the chart to find something about when she had the knee replaced etc etc etc and I stumbled across this gem in the physical therapy notes:

Pt is not eligible for PT because, according to MD, she has less than 5 days left to live

So just to recap: At 11 o'clock at night I get consulted for a broken bone in a woman who has not only been in the hospital for several days, but who has had a known fracture for two days. And the perfect time to do this is when she has less than a week to live?

I honestly do not know what they were expecting me to do about this patient, but on the plus side, I really have no qualms about proceeding with nonoperative management


  1. and I thought it was only me, working for the government, that had these types of situations.

  2. As a PT, that PT note makes me cringe.

  3. I don't know about your hospital, but our RTs are awesome. I quite cherish them. I say this as a resident.

  4. Wow that is a truly bizarre consult! I have to say, though, that as a resident I always found the rapid response team very helpful. Compared to when I was in medical school where our hospital did not have a rapid response team and if you had a patient tanking there was no way to get appropriate resources fast short of calling a code...

  5. Yes RTs can be awesome, but she was talking about the RRT (Rapid response team), not the RT(respiratory therapist). Why the heck are they calling an RRT on this patient in the first place?!

  6. I wonder if her MD ever spoke to the family about a DNR. If a DNR was on the chart, then the RRT and a code wouldn't be called. The symptoms would be treated until the inevitable happens.