Background: The Modified Early Warning Score (MEWS) is a physiological scoring system developed to identify patients in early stages of clinical deterioration and prevent delays in proper care. It consists of systolic blood pressure, heart rate, respiratory rate, temperature and level of consciousness. Higher MEWS are associated with greater mortality and need for intensive care. [...]

Background: A LEAN principle is that front line staff provide value as defined by the customer (the patient). Within a LEAN framework, an A3 is both a way to understand your problem and a tool to organize multiple PDSA cycles into one cohesive and visible structure. While the literature cites many examples of PDSA cycles [...]

Background: Code Blue events, or in-hospital patient emergencies, often require advanced cardiac life support (ACLS) and unfortunately can end in loss of life. Defining and measuring outcomes is an essential step for improvement in any process, but especially for a process as critical as Code Blues.  In our institution, Code Blues are run by a [...]

Case Presentation: A 73-year-old Caucasian male presented with worsening fatigue and dyspnea for several days. His comorbidities included remote history of essential thrombocytosis controlled with aspirin, hypertension, chronic kidney disease, and mitral valve repair. He was admitted to the medical ICU for acute hypoxic respiratory failure requiring mechanical ventilation. His physical exam was remarkable for [...]

Background: Hospital based providers are often tasked with leading cardiopulmonary arrest resuscitations known as code blues. This responsibility can be stress provoking and poorly executed without appropriate training resulting in poor patient outcomes. At our academic medical center, internal medicine residents on their inpatient hospital based rotations are responsible for this assignment. The process of [...]

Case Presentation: A 47 year old female with a history of depression and remote Roux-en-Y gastric bypass surgery, presented for an elective laparoscopic gastrectomy due to hypertrophic pyloric stenosis causing complete gastric remnant outlet obstruction. Her home medications included duloxetine, pantoprazole and alprazolam. Vital signs on admission revealed blood pressure 147/83 mm Hg, pulse 80 [...]

Case Presentation: A 55-year-old male with a history of coronary artery disease, left ventricular (LV) mural thrombus, tobacco use, and recent thalamic, splenic, and renal artery infarcts, presented with two weeks of worsening pain and cyanosis of his left third and fourth toes, associated with claudication. He denied numbness or loss of strength. He denied [...]

Case Presentation: A 38-year-old female presented to the emergency department with profuse vomiting, fever, chills, lightheadedness, dizziness, and the inability to tolerate oral intake. She had been in her usual state of health until two hours after returning from a doctor’s appointment where she received methylene blue intravenously. Past history included hypothyroidism, postural orthostatic tachycardia [...]

Case Presentation: A 79 y/o obese male with a history of hemochromatosis on scheduled phlebotomies, hypertension, afib, and hyperlipidemia presented to the ED for the third time in a week with chief complaints of nausea, syncope, and diaphoresis. Vitals signs were normal on presentation. Preliminary investigations were unremarkable except for glucose of 48. The patient [...]

Case Presentation: This patient is a 34 year old female presenting to the ED complaining of progressive weakness,SOB, bloody vomitus, and tarry stool. She had PMH significant for established diagnosis of Bean Syndrome. On presentation she was normotensive, 113/72mmHg but tachycardic 102. Labs revealed acute microcytic anemia H/H 6.7/23.6 MVC 70.9 prior to transfusion. She [...]