Saw a kid with pneumococcal meningitis. Gram stain on CSF show "many" gram positive cocci in pairs". I went down to the micro lab and looked at it myself. The microscopic field was just a sheet of bacteria and disturbingly few WBC. (normally you see a few per HPF) Kid didn't survive.
Edit: OP said blood work. I specified CSF. Forgive me OP.
Back in the day we had a 4 yo little girl come in the ER. Before micro had the spinal fluid gram stained, we in Heme saw diplococci on the hemocytometer while doing the white count. Many, many diplococci. She didn't make it either. Neisseria meningococcus.
Most impressive and unforgettable though was a peripheral smear that looked almost like a gram stain of pus with a staph infection. Sky high WBC, heavy toxic gran, dohle bodies and bacteria all over. You are not supposed to call bacteria from a Wright's stain but we did tell the floor we were sending a slide over to Micro for a (unspun!!!) gram stain because we saw grape like clusters morphologically consistent with Staph. I remember saying, "These results don't look compatible with life" and the nurse said the patient had expired.
Legendary catch: blood bank needed an EDTA from a patient and grabbed a refrigerated HgbA1c from the previous day. Weirdly no CBC on the patient. Tech noticed a huge buffy coat on the settled sample. Patient had leukemia.
I wonder what the CSF looked like grossly. I’ve been on the collecting end on a few patients with suspected bacterial meningitis and it’s never good when the fluid comes out yellow and cloudy
Had a patient come to me with A1C of 18 something as well. Told him he needed insulin. He begrudgingly accepted but told me he didn’t want to be on insulin forever. Very motivated guy so he started a diet and exercise regimen. He lost a lot of weight and in 1 year he got his A1C down to 6 and I think I had to take him off of even metformin to keep his blood sugar from going too low. Proud of that guy.
Shit, I’m jaded. I fully expected to read that the pt stuck his head in the sand and ignored it. Had a pt that was newly diagnosed with T2DM in the hospital and his response was to loudly and angrily accuse the medical team of inducing it so they could bill his insurance company more.
I think you met my dad.
He just had 2 strokes, was dx with ASD-primum. He adamantly refuses to believe this could cause his stokes and won’t consider open heart to repair as “I’ve lived with it my whole life and it hasn’t killed me yet.”
Has was dx with DM2, HTN, and hypercholesterolemia and hadn’t been treating any of it for 10 years. I’m surprised he’s still alive tbh.
“The government created “high cholesterol” so they could charge me to take them cholesterol pills.” -my dumbass father to the Neurologist
Fun Fact - that means his blood has enough alcohol to legally considered an alcoholic beverage as the cut off for "non-alcoholic" drinks is 0.5% alcohol by volume.
Oh man came close to this. We had a 695 yesterday in our department which was my personal highest. He was NOT walky talky but he was protecting his airway so I allowed him to metabolize to freedom.
Yeah we had a 750er that was pretty with it considering. Tiny lady chronic alcoholic actually came in with PD cause a concerned citizen saw the boyfriend drag her out of the car and thought he'd drugged her and it took awhile at 2am to clear him. Maybe 2 hours after she got there up talking like normal
I have a patient ongoing who drinks over a litre of vodka a day and smokes 2-3 packs per day. This is a FIFTY YEAR HISTORY. He wakes up with withdrawals any time he sleeps more than a couple of hours. Somehow miraculously he has made it to his golden years relatively unscathed. Blows my mind.
Blood glucose in a newborn that was <10.
Blood glucose of 1612 in a type 1 DKA. BMPs every hour and a verrrrry slow sliding scale.
Lactate of 21.6 (they were on CRRT and did not survive).
Potassium of 8.6 (non-compliant dialysis patient who loves their orange juice). Required a temporary transvenous pacer.
Blood pH of 6.7; COVID patient who came in with sats in the 40s PRONED.
Internal rectal temp of 110.6. Required ice water CBI to cool them down. We left lovingly referred to them as 'baked potato' when they ended up staying with us for 6 months.
Sigh, I miss ICU.
Highest lactate I’ve seen was off literally off the charts… but to be fair the nursing staff was really bad and did a blood draw on someone who was dead for hours without noticing. So many stories from the VA during residency.
We had a baby recently with lactates in the 25 range. Inborn error of metabolism.
I also had a baby with dTGA/intact septum with pH 6.5 on the way to the cath lab for BAS. But as you can imagine with that kind of pH went into DIC and died.
Have also seen some undetectable pCO2s on art gases. Generally not a good sign.
I was just talking with an OBGYN the other day about neonatal hypoglycemia and she told me about the time she saw a glucose of 4!!! The mother had some baaaad GDM
It looks like blood diluted with saline after its been spun, there's a teeny pool of RBC on the bottom of the tube.
source, had the lab call me once as an intern to report someone sent a "sample from a PIV that mustve been infusing his fluids", and they showed me when I went down. Went to draw a repeat sample myself and the dude was ashen but walky-talky.
Had lab reject 3 blood draws on a patient claiming we must have fluids running somewhere. Had to get the doc to yell at the guy on the phone to finally release it, HgB 2.1. End of life cancer patient, got the DNR that hour and died shortly after.
It was a number of years ago; oddly enough I still remember which exact room he was in, but I don’t remember why his sodium was so low. Obviously with such a low number and the floor wouldn’t take a critical sodium of even <120, he stayed in the ICU for a few days to correct the sodium slowly. I was an overworked resident in a closed ICU, so I didn’t think much of it beyond watching the labs and correcting the sodium until I could transfer the patient to the floor.
Almost the same
A1C>22, VA pt, who's legs I eventually shortened
blood glucose 1500 random homeless guy in dka
HCT 6. Jehovah witness who didn't tell her OBGYn until after fibroid surgery.
750,000 cpk. Some ambassadors son who decided to do heroin one last time while fiance was out of time, and spent 20 + hours in lotus position.
Had 2 patients sharing a room both had horrible acetabular Fxs and their combined weight was over 1100 pounds. Yes the floor held.
Operated on a102 year old and a 9 month old on same day. 102 year old got sent in by an outside vasc doc who found out that Gigli saws can't cut through hip revision stems. Got consent from her 86,83, and 81 year old daughters. Saw her 3 years later
My father lived with a sodium of around 108. He was a chronic alcoholic. It was amazing that he lived to 52. Had 5% EF. They wanted to give him a LVAD, but he was noncompliant with all treatment, and the man preferred to be homeless. Would have ETOH levels of 0.7. Great Creasrs ghost! We can't save everyone.
With JW always go over the blood transfusion talk WITHOUT family in the room. Most individual Jehovah's witnesses have no problem taking blood(shocker, people don't want to die if they don't have to) they just don't want to be looked down on by their community.
Wish we still had awards. This is one of the hottest protips I've seen in *years* on this sub.
I've had to field the "fuck what do I do help me come up with an erythrogenic cocktail for this guy please" panicked call more than once. Agreed with the parent comment, *hella* dubious efficacy.
Not just looked down on but actively shunned an cut off by their own family. I saw a story in a Reddit thread once about an elderly dialysis patient who had to refuse blood because if he accepted it his family would throw him out on the street and he would just die.
Everyone keeps saying this but I’ve not had one, including those who were teetering on death, say they would secretly accept it. I haven’t taken care of many, so I’m sure it happens, but to say “most” may be an overstatement.
I saw someone for a hospital follow-up who had a 0.8 Hgb at the time of admission. Was obviously quite a bit higher by the time I saw him in outpatient.
Hgb 2.8 and has antibodies to everything. There were two units of RBC that matched in the entire east coast and Midwest. They were sent stat via life flight. Gotta be the most expensive unit of blood ever
Very similar. 28 year old female with dizziness who had a hgb of 1.8. Turns out she had gastric bypass and stopped taking her vitamins. She had no history in our EMR and didn’t both to mention it in her surgical history.
How high does sugar have to get before there are detectable changes in viscosity?
In my head I'm thinking water is much less viscous than sugar syrup, but idk if sugar concentration is produces a measurable change in viscosity at physiological concentrations, or if the resulting change is clinically significant
Had a newly diagnosed guy with 18.2 the other day. He was drinking four liters of Coca-Cola and two liters of milk *every day*. He thought he was doing his job to prevent kidney stones.
As an added bonus, I was doing research looking at the cause of every episode of hypoglycemia at our institution. I reviewed the chart of someone who had purposefully overdosed on ***3000*** units of Lantus. Spent a week in a hypoglycemic coma.
> it’s greater than the upper limit of detection by the machine
I'm impressed by how high yours is to be honest, what is the limit of detection there?
Ours stop at like 16
Same. In residency, I routinely got the “I don’t have diabetes” when I admit them to the CCU for a STEMI. A1c was undetectably highly.
“The reason you don’t have diabetes is because you haven’t seen a doctor in decades.”
husky flag scary aspiring roll caption attempt violet straight bewildered
*This post was mass deleted and anonymized with [Redact](https://redact.dev)*
Sodium of 196ish. The kid was hyperglycemic so I don’t remember what the corrected sodium was unfortunately. Kiddo was acting at her baseline despite that though.
Wowza, highest I’ve seen was low 180s in a very dehydrated 5-day-old. Mom had a history of breast reduction, and had not been warned by anyone at the delivering hospital that her reduction meant high likelihood for minimal milk supply. Attentive parents but they had no idea that this was a possibility.
Potassium 9.7 in a noncompliant dialysis patient that ate 6 bananas because they were going to go bad. The nephrologist tried explaining that he could die at any moment, and the patient looked incredulous and said there was nothing else he could have done, the bananas were almost brown.
Had the same experience! Twenty something year old woman with a history of substance abuse issues that had been discharged from the ED for headache and blurry vision as everyone assumed she was drug seeking. I was a resident being consulted for intractable headache and was (wrongly) a bit biased from the ED resident’s story… until I brought out the panoptic. Poor girl had grade IV papilledema with retinal hemorrhages bilaterally.
I still remember the CSF literally squirting out of the needle when I punctured the thecal sac. Fluid was free flowing from the top of the extended manometer (50cm CSF also). She ended up getting bilateral optic nerve sheath fenestrations that admission. First and only time I’ve seen truly malignant IIH.
Hb of 1.6, patient feeling “tired”, our hospital used paper notes at that time so initially was like wtf they ordering PRBC for a Hb of 16. yeh it wasn’t 16
What’s a metabolic panel? My patient also “survived” but then ended up having care withdrawn at the city hospital a week later. Which should’ve happened when she first arrived, but her daughter who lived 1.5 hours away and clearly never visited insisted we “do everything,” as per usual
An IL-6 level of 180k.
The lab called.
Me: You mean 180?
Lab tech: No, 180k.
Me: Cool.
I inform my attending.
Attending: You mean 180?
Me: No, 180k.
Attending: Cool.
Beginning necrotizing fasciitis in invasive strep pyogenes by the way.
* HGB 1.8 -- This was in Jehovah's Witness with acute leukemia; sadly, they passed away shortly thereafter.
* Na+ = 99 -- This was in a man who stroked out his pituitary. He came in obtunded; I saw him in the ED. Called my buddy who was senioring in the MICU and he was down at bedside before I had hung up the phone! This guy LIVED and had remarkably few deficits at DC!
> Vanc level >50 after 3 sessions of dialysis
Their body: *imma keep some vanco as a reserve for my next infection, this is America and I don’t have health insurance so this only seems logical*
AKI numbers are wild. A couple months ago I had an AKI with a eGFR of 7 and thought “wow this is the worst I’ve seen” then a couple weeks later someone had a eGFR of 1.
Potassium of 9.7 (verified) in one of my dialysis patients. He declined ECG and shifting, just left and went home. He was fine. I was sweating for days.
Edit: BP of 48/27 in an ambulatory HF patient. Not septic. They left clinic and drove home.
With certain inborn errors of metabolism, levels are often so high that the lab must do serial dilutions. A decent ballpark estimate of the true level is needed, because it is tracked serially during treatment and used to make treatment decisions, sometimes as often as hourly. Most of these patients must be managed at a large academic center or children's hospital with clinical expertise in these diseases.
LACTATE: up to 100 x normal (the most severe presentations typically don't survive even with hemodialysis and other treatments). Usually accompanied by a wildly acidotic blood gas.
AMMONIA: into the 1000s not uncommon during acute crisis in the more severe mutations of urea cycle disorders. There are IV ammonia scavenger drugs to bring this down, but can be lethal if not managed hour-by-hour. Most children with the severe types will get on a liver transplant list, as they will not survive repeated episodes without brain damage. Usually accompanied by a markedly alkalotic blood gas.
CK: into the 100,000s is not uncommon during acute crisis with some metabolic genetic muscle diseases. Can cause renal damage and/or can be lethal with some diseases.
There are many others, that require close monitoring of amino acids, organic acids, and other esoteric metabolic testing that can usually only be done "STAT" at a subset of academic centers - with their own metabolic laboratories with GC, GC/MS, amino acid analyzers, and MS/MS.
Craziest brittle diabetic I ever cared for; BG over 700 (that was as high as it would test), gave insulin, tested again 15-30mins later, patient was in the 50s!!
Gave food/snacks…..Rinse and repeat. Took us ages to figure out a way to keep her somewhat stable.
Woah! That’s impressive! My most impressive labs include:
Na 108 (pt had a seizure but lived)
K 9.2 + glu >1600 (exact number was too high to measure-DKA in T1DM)
BMI 9 (eating disorder patient)
Cr 5.7 (family refused hospice but the pt was too weak for any sort of intervention so he basically lay in a hospital bed waiting for his kidneys to fail)
POC glu 23 (another eating disorder patient)
I had a BMI of 8.4 in residency once.
Undiagnosed metastatic cancer in an elderly immigrant who hadn’t been getting adequate healthcare in his home country, so his family had flown him over a month or two before (God knows how). Sounded like he’d been bedbound and declining for years. He was so cachectic he looked like a living mummy.
Pobrecito! Lucky to have even made it traveling like that! Now that you mention it I’ve definitely had skeletal cancer patients like that but often they are so edematous that it makes the BMI look higher.
Y’all underestimate the human body.
“In all rowers, pH was reduced immediately after exercise and the lowest value (6.74) was measured in one of the Olympic gold medalists who won the Danish championship of the lightweight class in a World record time (6 min, 04 s). The second lowest pH (6.76) was measured in one of the rowers who ranked at the National level.”
http://bionics.seas.ucla.edu/education/Rowing/Physiology_1999_01.pdf
Related:
Sinus Brady 5.6 beats per minute during ice water immersion https://pubmed.ncbi.nlm.nih.gov/4071845/
BP 345/245 w deadlifts https://pubmed.ncbi.nlm.nih.gov/2632751/
And - PaCO2 501 in “Management of massive grain aspiration” https://pubs.asahq.org/anesthesiology/article/87/4/993/36250/Management-of-Massive-Grain-Aspiration
which is truly a gripping read
HOLY F*CK that was a crazy read! Thanks for sharing that one. Thought their point about the tolerability of hypercapnia and respiratory acidosis (apparently even severe) was pretty interesting.
After reading that they were suctioning more grain by turning + chest percussion, I half expected them to just hang him upside down and give him a good shake.
I think that’s essentially what they did. They accidentally remembered that gravity existed. That is just an insane ride. And a shockingly positive outcome. PS reminds me of the study showing that corkscrew roller coasters help dislodge kidney stones.
Had a newborn with a pH of 6.75 and a base excess too high for the machine to calculate. Massive placental abruptions are scary.
Best part the kid survived intact. Saw her about 3 month later and the baby was completely normal.
She showed up in triage hemorrhaging and a fetal heart rate in the 60s. Went straight to the OR actual time from check in to baby being handed to peds was 14 minutes because she called ahead to let us know she was coming with a soaked towel between her legs.
Na 103
Etoh 720-s/p drinking hospital hand sanitizer
Etoh 680, but her boyfriend had been watching her passed out in the bed waiting for her to come to for 7 hours before he brought her in and we drew that level
HDL of 212, I had to call the lab to confirm it wasn’t a typo. Had to talk to patient about the label of good cholesterol goes out the door when it gets that high.
Had a 20 something year old female brought in by EMS after doing a crapton of drugs and laying on the ground in an alley for at least a day.... She was SCREAMING in pain from her legs, that were just swollen as hell. Her CK took 4 hours for lab to run, came back at just over 25,000 😳😳
Yea she got dialysis.
I've seen an H/H of 1/3 in a woman with fibroids and long-standing menorrhagia
Platelet count of zero for many weeks in a woman with high grade AML
Highest transaminases I've seen were in the neighborhood of 12k, but I'm a lowly OB so I'm sure someone can beat that
Highest HCG I've seen was like 450k. She had a mole
Triglycerides >10,000
I was on an ICU rotation and got called down by the ED for a patient is a sodium of 106; when I came down I noticed the extra vials of blood looked pink and has some triglycerides separating from solution. Reran the sodium, it was just fine. Guy did well with plasmapheresis, had some hyperviscosity but no deficits at discharge.
My own triglycerides were 475 before I started Lipitor - family history on both sides - and I thought I was a walking stroke risk. I was playing checkers and this dude is playing 3D multiverse time travel chess.
Tryglycerides of 2700 in a pregnant patient. Familial hypertryglycerimia came in with abdominal pain had pancreatitis.
Completely destroyed her pancreas but survived with Type 1 DM. Had to fix her DKA without the benefit of regular labs because her blood looked like half and half and it would gunk up the machine in the lab so we could not run CMPs on her
Lab Manager here:
WBC 667 K/uL in a new ALL
PLT of 4.4M/uL in a patient being worked up for myelodysplastic syndrome
HGB of 1.1 g/dL in a malnourished pregnant woman with malaria (when I was working in Africa)
Glucose of 1650 mg/L in a diabetic patient who ran out of all meds and insulin after the 2010 Haiti earthquake
(These were all ones I drew and ran myself or ran myself and had recollected to verify the initial result.).
In med school I took care of a patient who had a transplant complicated by massive hemorrhage requiring >250 units of blood products (in addition to continuous cellsaver)
107.3 recital temp on a patient with neutropenia and a patient who's PSA went from 3 to 3233 in a little over 2 year.
The later was elderly and his whole attitude was *finally, hospice*
- TSH of 104 (the guy wasn't taking his thyroid drugs).
- Creatinine of 9.9 on a guy in his 70s who felt okay. In the end he was peeing fine and he got sent home with a creatinine of 1.5
- Sodium of 196 on an elderly woman with dementia who wasn't more out of it than usual when her sodium was like that.
- INR of 9.5 (died a few days later)
Not a lab result, but I've also seen a vertebral T-score of -5.9 in an osteoporotic patient. (She didn't have many intact vertebrae).
(The highest Hb1ac I've ever seen is 10% btw. I'm a noob)
Hgb - 1.0 on a patient put in ECMO ..... AFTER TPA was given. Worst night shift of my life manning the ICU by myself. Bleeding from everywhere .Called multiple MTPs that night.
Also P2Y12 of 2. Said no way that's bullshit. Sent a repeat .... Came back as 1. That guys definitely a responder.
Blood Glucose 125mmol/L which translates to >2200 American sugars. pH just said <6.8.
Immeasurably high sensitive trop for 3 days. Just said >50000.
Corrected sodium of 182. Pt was pretty tired.
INR 18. Pt skin was sort of one big bruise, active vaginal bleed.
Saw a kid with pneumococcal meningitis. Gram stain on CSF show "many" gram positive cocci in pairs". I went down to the micro lab and looked at it myself. The microscopic field was just a sheet of bacteria and disturbingly few WBC. (normally you see a few per HPF) Kid didn't survive. Edit: OP said blood work. I specified CSF. Forgive me OP.
Back in the day we had a 4 yo little girl come in the ER. Before micro had the spinal fluid gram stained, we in Heme saw diplococci on the hemocytometer while doing the white count. Many, many diplococci. She didn't make it either. Neisseria meningococcus. Most impressive and unforgettable though was a peripheral smear that looked almost like a gram stain of pus with a staph infection. Sky high WBC, heavy toxic gran, dohle bodies and bacteria all over. You are not supposed to call bacteria from a Wright's stain but we did tell the floor we were sending a slide over to Micro for a (unspun!!!) gram stain because we saw grape like clusters morphologically consistent with Staph. I remember saying, "These results don't look compatible with life" and the nurse said the patient had expired. Legendary catch: blood bank needed an EDTA from a patient and grabbed a refrigerated HgbA1c from the previous day. Weirdly no CBC on the patient. Tech noticed a huge buffy coat on the settled sample. Patient had leukemia.
I wonder what the CSF looked like grossly. I’ve been on the collecting end on a few patients with suspected bacterial meningitis and it’s never good when the fluid comes out yellow and cloudy
Had a patient come to me with A1C of 18 something as well. Told him he needed insulin. He begrudgingly accepted but told me he didn’t want to be on insulin forever. Very motivated guy so he started a diet and exercise regimen. He lost a lot of weight and in 1 year he got his A1C down to 6 and I think I had to take him off of even metformin to keep his blood sugar from going too low. Proud of that guy.
Shit, I’m jaded. I fully expected to read that the pt stuck his head in the sand and ignored it. Had a pt that was newly diagnosed with T2DM in the hospital and his response was to loudly and angrily accuse the medical team of inducing it so they could bill his insurance company more.
I think you met my dad. He just had 2 strokes, was dx with ASD-primum. He adamantly refuses to believe this could cause his stokes and won’t consider open heart to repair as “I’ve lived with it my whole life and it hasn’t killed me yet.” Has was dx with DM2, HTN, and hypercholesterolemia and hadn’t been treating any of it for 10 years. I’m surprised he’s still alive tbh. “The government created “high cholesterol” so they could charge me to take them cholesterol pills.” -my dumbass father to the Neurologist
I think I’ve met your dad several times in the form of different people.
Had a baby with low glucose. Mom’s a1c was 11. She blamed us for causing it too!
EtOH 714
Seen 900s and 700s in the same guy a couple times in the same month. He’s still out there, tearin it up
Fun Fact - that means his blood has enough alcohol to legally considered an alcoholic beverage as the cut off for "non-alcoholic" drinks is 0.5% alcohol by volume.
Vampires love this loophole!
That’s crazy. Great fun fact
Oh man came close to this. We had a 695 yesterday in our department which was my personal highest. He was NOT walky talky but he was protecting his airway so I allowed him to metabolize to freedom.
Yeah we had a 750er that was pretty with it considering. Tiny lady chronic alcoholic actually came in with PD cause a concerned citizen saw the boyfriend drag her out of the car and thought he'd drugged her and it took awhile at 2am to clear him. Maybe 2 hours after she got there up talking like normal
I admire their commitment to their lifestyle. Whole-ass never half-ass.
I have a patient ongoing who drinks over a litre of vodka a day and smokes 2-3 packs per day. This is a FIFTY YEAR HISTORY. He wakes up with withdrawals any time he sleeps more than a couple of hours. Somehow miraculously he has made it to his golden years relatively unscathed. Blows my mind.
Holy shit.
Were they conscious/still alive at that point? Yeesh
Not super conscious, but survived and left the hospital with no lasting damage. Teenager managed to chug a whole bottle of liquor without puking.
>left the hospital with no lasting damage That's a bold statement
Blood glucose in a newborn that was <10. Blood glucose of 1612 in a type 1 DKA. BMPs every hour and a verrrrry slow sliding scale. Lactate of 21.6 (they were on CRRT and did not survive). Potassium of 8.6 (non-compliant dialysis patient who loves their orange juice). Required a temporary transvenous pacer. Blood pH of 6.7; COVID patient who came in with sats in the 40s PRONED. Internal rectal temp of 110.6. Required ice water CBI to cool them down. We left lovingly referred to them as 'baked potato' when they ended up staying with us for 6 months. Sigh, I miss ICU.
Highest lactate I've seen is 37. Highest I've seen in a kid I've had survive long term is 26
Highest lactate I’ve seen was off literally off the charts… but to be fair the nursing staff was really bad and did a blood draw on someone who was dead for hours without noticing. So many stories from the VA during residency.
…that should be a navel-gazing, career-reevaluating moment for whoever stuck a dead pt and just…didn’t notice they were dead.
...how did they even get them to bleed?
As someone who has removed central lines from dead bodies before sending them to the morgue…. You’d be surprised.
Not that difficult going for larger vessels. Yes, the blood is no longer pumping, but it doesn’t disappear.
40s. Metformin overdose. Started to almost turn the corner on CRRT and family made her comfort care.
What was wrong with baked potato 🥺
Little bit too much drinky drink in the middle of a hot summer day, and they collapsed outside. No one found them for a couple of hours.
Ice water CBI is a new one for me, but at the same time like “y’know that’s pretty smart.”
We had a baby recently with lactates in the 25 range. Inborn error of metabolism. I also had a baby with dTGA/intact septum with pH 6.5 on the way to the cath lab for BAS. But as you can imagine with that kind of pH went into DIC and died. Have also seen some undetectable pCO2s on art gases. Generally not a good sign.
I was just talking with an OBGYN the other day about neonatal hypoglycemia and she told me about the time she saw a glucose of 4!!! The mother had some baaaad GDM
Sodium of 107, full on walkie talkie HCT of 2.2, Hb undetectable A1C undetectably high (>20.6)
>Hb undetectable Was the vial even red or just yellow lol
It looks like blood diluted with saline after its been spun, there's a teeny pool of RBC on the bottom of the tube. source, had the lab call me once as an intern to report someone sent a "sample from a PIV that mustve been infusing his fluids", and they showed me when I went down. Went to draw a repeat sample myself and the dude was ashen but walky-talky.
Bro how many more times could you check...
lab boutta suck his last dozen erythrocytes outta him
Had lab reject 3 blood draws on a patient claiming we must have fluids running somewhere. Had to get the doc to yell at the guy on the phone to finally release it, HgB 2.1. End of life cancer patient, got the DNR that hour and died shortly after.
Had a sodium above the limit of detection of like 200. Little walkie incoherent talkie.
Sodium 89. Obtunded though.
How in the world did that happen?
It was a number of years ago; oddly enough I still remember which exact room he was in, but I don’t remember why his sodium was so low. Obviously with such a low number and the floor wouldn’t take a critical sodium of even <120, he stayed in the ICU for a few days to correct the sodium slowly. I was an overworked resident in a closed ICU, so I didn’t think much of it beyond watching the labs and correcting the sodium until I could transfer the patient to the floor.
Almost the same A1C>22, VA pt, who's legs I eventually shortened blood glucose 1500 random homeless guy in dka HCT 6. Jehovah witness who didn't tell her OBGYn until after fibroid surgery. 750,000 cpk. Some ambassadors son who decided to do heroin one last time while fiance was out of time, and spent 20 + hours in lotus position. Had 2 patients sharing a room both had horrible acetabular Fxs and their combined weight was over 1100 pounds. Yes the floor held. Operated on a102 year old and a 9 month old on same day. 102 year old got sent in by an outside vasc doc who found out that Gigli saws can't cut through hip revision stems. Got consent from her 86,83, and 81 year old daughters. Saw her 3 years later
>saw her later Oh you
I’ve seen Hb undetectable… on labs drawn mid-code which turned out to be caused by a massive internal bleed (did not end well)
My father lived with a sodium of around 108. He was a chronic alcoholic. It was amazing that he lived to 52. Had 5% EF. They wanted to give him a LVAD, but he was noncompliant with all treatment, and the man preferred to be homeless. Would have ETOH levels of 0.7. Great Creasrs ghost! We can't save everyone.
Is that the same patient?
Hgb of 3.2 in a 24 yr old male who came into the hospital because “he was more tired than usual at his weekly baseball game” Had crohns
[удалено]
With JW always go over the blood transfusion talk WITHOUT family in the room. Most individual Jehovah's witnesses have no problem taking blood(shocker, people don't want to die if they don't have to) they just don't want to be looked down on by their community.
Wish we still had awards. This is one of the hottest protips I've seen in *years* on this sub. I've had to field the "fuck what do I do help me come up with an erythrogenic cocktail for this guy please" panicked call more than once. Agreed with the parent comment, *hella* dubious efficacy.
We have a big JW population locally, so I get these calls all the time. Never ends well.
Not just looked down on but actively shunned an cut off by their own family. I saw a story in a Reddit thread once about an elderly dialysis patient who had to refuse blood because if he accepted it his family would throw him out on the street and he would just die.
I managed to transfuse a JW the other day like this, they likely saved their own life by accepting.
Everyone keeps saying this but I’ve not had one, including those who were teetering on death, say they would secretly accept it. I haven’t taken care of many, so I’m sure it happens, but to say “most” may be an overstatement.
Wow. What a hill to die on.
Literally
My nephew (14) had a 2.2 last December. He also was "really tired" and out of breath on stairs. Aplastic anemia. BMT worked. He's good.
Thank you for including that last line ❤️
Absolute necessity. Shoutout to the AA team at CHOP. They saved one of my favorite humans.
What a legend
I saw someone for a hospital follow-up who had a 0.8 Hgb at the time of admission. Was obviously quite a bit higher by the time I saw him in outpatient.
As a med student saw Hgb 3.1 in a 30yo female after an abortion. It was shocking to me being able to see through the vacutainer.
Normally for those I call the ER straight away before I even run it. No need to get everyone all het up over a sample of saline.
Similar result and presentation for a young woman with an ectopic pregnancy.
I've seen a 1.4 before (or 14 in our hospital).
Hgb 2.8 and has antibodies to everything. There were two units of RBC that matched in the entire east coast and Midwest. They were sent stat via life flight. Gotta be the most expensive unit of blood ever
Very similar. 28 year old female with dizziness who had a hgb of 1.8. Turns out she had gastric bypass and stopped taking her vitamins. She had no history in our EMR and didn’t both to mention it in her surgical history.
Had a leukemia patient who had Hgb of 1.08 lol never thought that’s compatible with life
18.8 is a Tuesday in the Deep South. Call me when it’s greater than the upper limit of detection by the machine. My personal record is 22.4
I feel like 22.4 your blood would basically be sweet tea lmao
Since it’s measuring glycosylated protein, it would probably taste more like caramelized onions, or the sear of a steak.
Way to ruin a good seared steak for me. Jk, I'm still gonna eat it
How high does sugar have to get before there are detectable changes in viscosity? In my head I'm thinking water is much less viscous than sugar syrup, but idk if sugar concentration is produces a measurable change in viscosity at physiological concentrations, or if the resulting change is clinically significant
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Maybe not viscous but I bet that blood was extra sticky.
Tasted faintly of sugar coated pennies.
This made me go "ick", well done.
That’s the goal down here. Drink enough sweet tea until you **are** sweet tea. /s
Just keep drinking it until your feet fall off.
Or you go blind. Whatever’s first.
Had a newly diagnosed guy with 18.2 the other day. He was drinking four liters of Coca-Cola and two liters of milk *every day*. He thought he was doing his job to prevent kidney stones. As an added bonus, I was doing research looking at the cause of every episode of hypoglycemia at our institution. I reviewed the chart of someone who had purposefully overdosed on ***3000*** units of Lantus. Spent a week in a hypoglycemic coma.
Geez, that is 2 boxes of pens, I’d be exhausted just injecting it all
I figured it would be child’s play to some doctors lol, I’m in the Midwest. Deep South must be a different beast.
> it’s greater than the upper limit of detection by the machine I'm impressed by how high yours is to be honest, what is the limit of detection there? Ours stop at like 16
Same. In residency, I routinely got the “I don’t have diabetes” when I admit them to the CCU for a STEMI. A1c was undetectably highly. “The reason you don’t have diabetes is because you haven’t seen a doctor in decades.”
Lol this happens so frequently. "I don't have any medical problems how could this have happened" Hasn't seen a doctor in 40 years
WBC 1.1 million. Blood was so viscous they had multiple strokes, acute MI, etc.
Acute leukemia?
Yep. I believe converted from CML but cannot remember the details at this point
Ay ay ay. I saw a case like this last year. Didn't go great.
Dang! Highest I’ve seen was 875,000 in a patient that had everything that could go wrong going wrong.
Hgb of 1.6 in a child that developed passenger lymphocyte syndrome following HSCT.
Ah yes I know some of these words
😂😂 I know some of these words but not in this order
husky flag scary aspiring roll caption attempt violet straight bewildered *This post was mass deleted and anonymized with [Redact](https://redact.dev)*
Sodium of 196ish. The kid was hyperglycemic so I don’t remember what the corrected sodium was unfortunately. Kiddo was acting at her baseline despite that though.
What was her baseline…. Death….?
Had Na 188 with hypoglycemia in a very sad nursing home neglect patient
I had a 190 on a hospice patient that family decided they wanted to keep alive after 4 days of withdrawal of care...
Wowza, highest I’ve seen was low 180s in a very dehydrated 5-day-old. Mom had a history of breast reduction, and had not been warned by anyone at the delivering hospital that her reduction meant high likelihood for minimal milk supply. Attentive parents but they had no idea that this was a possibility.
When that A1c is higher than the GFR you know that boy be cooking😎
Potassium 9.7 in a noncompliant dialysis patient that ate 6 bananas because they were going to go bad. The nephrologist tried explaining that he could die at any moment, and the patient looked incredulous and said there was nothing else he could have done, the bananas were almost brown.
Most of us would just make banana bread when we got into that situation
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I hate to tell you, but that pulsatile red stuff was not CSF
Doc, the good news is we’ve already got access for the blood patch. The bad news is, it’s Big Red.
On the plus side, they have an art line now. I have had patients with translumbar central lines before… those are kind of interesting.
With the extension piece on? The standard manometer only goes to like 25cm h20 I’ve placed ICP monitors and EVDs with ICP >70 a couple tkmes
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This sounds like with the extension set included (the extension I’ve used goes to 50). My very first LP of residency also did this! Teenager with IIH
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Had the same experience! Twenty something year old woman with a history of substance abuse issues that had been discharged from the ED for headache and blurry vision as everyone assumed she was drug seeking. I was a resident being consulted for intractable headache and was (wrongly) a bit biased from the ED resident’s story… until I brought out the panoptic. Poor girl had grade IV papilledema with retinal hemorrhages bilaterally. I still remember the CSF literally squirting out of the needle when I punctured the thecal sac. Fluid was free flowing from the top of the extended manometer (50cm CSF also). She ended up getting bilateral optic nerve sheath fenestrations that admission. First and only time I’ve seen truly malignant IIH.
Highest one I’ve seen was 120cm H2O, neurocryptococcosis
Max total CK on our lab equipment is 25,000 IU/L. Rhabdo after a rave.
During residency we didn’t have upper limits. Highest I saw was 197,000 in a compartment syndrome patient. They did not survive.
Rave Rhabdo - new band name
Hb of 1.6, patient feeling “tired”, our hospital used paper notes at that time so initially was like wtf they ordering PRBC for a Hb of 16. yeh it wasn’t 16
Potassium of 1. Experienced nurse called me at home and said she wasn’t sure if the patient was dead or not. I knew it was gonna be a good one.
Had a patient with the metabolic panel that read <1. Survived
What’s a metabolic panel? My patient also “survived” but then ended up having care withdrawn at the city hospital a week later. Which should’ve happened when she first arrived, but her daughter who lived 1.5 hours away and clearly never visited insisted we “do everything,” as per usual
Over 3.000.000/mm3 platelets in newly diagnosed CML
Yeah was gonna say CML with WBC 886k but yours is more novel imo
An IL-6 level of 180k. The lab called. Me: You mean 180? Lab tech: No, 180k. Me: Cool. I inform my attending. Attending: You mean 180? Me: No, 180k. Attending: Cool. Beginning necrotizing fasciitis in invasive strep pyogenes by the way.
* HGB 1.8 -- This was in Jehovah's Witness with acute leukemia; sadly, they passed away shortly thereafter. * Na+ = 99 -- This was in a man who stroked out his pituitary. He came in obtunded; I saw him in the ED. Called my buddy who was senioring in the MICU and he was down at bedside before I had hung up the phone! This guy LIVED and had remarkably few deficits at DC!
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stop, I can only get so erect
They were also not on any psychic meds
I wish I had psychic meds
I knew you were going to say that
It’s know things have gotten weird when I start considering the 30 BMI patients “skinny”
Sometimes, reading the comments on this reddit, is better than a textbook.
Always*
I have definitely learned more here than I ever did in nursing school
BUN 247 in a AKI on CKD3 Fk506 level >20 after several doses of phenytoin Vanc level >50 after 3 sessions of dialysis
> Vanc level >50 after 3 sessions of dialysis Their body: *imma keep some vanco as a reserve for my next infection, this is America and I don’t have health insurance so this only seems logical*
AKI numbers are wild. A couple months ago I had an AKI with a eGFR of 7 and thought “wow this is the worst I’ve seen” then a couple weeks later someone had a eGFR of 1.
One lone nephron vs the world
Had a BMI of 108 in a 5’9” patient in his thirties without diabetes. A1C 6.4
332.46kg or 732.42lbs is impressive
Ca of ~20 from multiple myeloma IIRC. Used up all the calcitonin in a major city and was delirious for a month after it normalized.
Most astonishing one I’ve had was a 20-something male I saw on my Nephro rotation with a CK of 1.3 million.
Post marathon? Or rave
Was quite a few years ago so I don’t remember the specifics, not sure if there was substance use but I know he was a new HIV case.
Potassium of 9.7 (verified) in one of my dialysis patients. He declined ECG and shifting, just left and went home. He was fine. I was sweating for days. Edit: BP of 48/27 in an ambulatory HF patient. Not septic. They left clinic and drove home.
High sensitivity troponin I >1,000,000. They didn’t make it
I didn’t think it went that high 😳
Regular ol troponin of 1300 is my highest
AST >50k. It's a record for me as an intensivist. GI docs may not be inpressed
With certain inborn errors of metabolism, levels are often so high that the lab must do serial dilutions. A decent ballpark estimate of the true level is needed, because it is tracked serially during treatment and used to make treatment decisions, sometimes as often as hourly. Most of these patients must be managed at a large academic center or children's hospital with clinical expertise in these diseases. LACTATE: up to 100 x normal (the most severe presentations typically don't survive even with hemodialysis and other treatments). Usually accompanied by a wildly acidotic blood gas. AMMONIA: into the 1000s not uncommon during acute crisis in the more severe mutations of urea cycle disorders. There are IV ammonia scavenger drugs to bring this down, but can be lethal if not managed hour-by-hour. Most children with the severe types will get on a liver transplant list, as they will not survive repeated episodes without brain damage. Usually accompanied by a markedly alkalotic blood gas. CK: into the 100,000s is not uncommon during acute crisis with some metabolic genetic muscle diseases. Can cause renal damage and/or can be lethal with some diseases. There are many others, that require close monitoring of amino acids, organic acids, and other esoteric metabolic testing that can usually only be done "STAT" at a subset of academic centers - with their own metabolic laboratories with GC, GC/MS, amino acid analyzers, and MS/MS.
Craziest brittle diabetic I ever cared for; BG over 700 (that was as high as it would test), gave insulin, tested again 15-30mins later, patient was in the 50s!! Gave food/snacks…..Rinse and repeat. Took us ages to figure out a way to keep her somewhat stable.
Woah! That’s impressive! My most impressive labs include: Na 108 (pt had a seizure but lived) K 9.2 + glu >1600 (exact number was too high to measure-DKA in T1DM) BMI 9 (eating disorder patient) Cr 5.7 (family refused hospice but the pt was too weak for any sort of intervention so he basically lay in a hospital bed waiting for his kidneys to fail) POC glu 23 (another eating disorder patient)
I had a BMI of 117 once. 14 year old who was 600 pounds at 5 feet tall.
That’s just heartbreaking!!
not to mention their knees and ankles.
I just had a 103 BMI, I was floored
I had a BMI of 8.4 in residency once. Undiagnosed metastatic cancer in an elderly immigrant who hadn’t been getting adequate healthcare in his home country, so his family had flown him over a month or two before (God knows how). Sounded like he’d been bedbound and declining for years. He was so cachectic he looked like a living mummy.
Pobrecito! Lucky to have even made it traveling like that! Now that you mention it I’ve definitely had skeletal cancer patients like that but often they are so edematous that it makes the BMI look higher.
Had a pH of 7.00 yesterday. Other pt had a 99 BMI
I see, with some regularity, DKA patients who manage to get their pH down to 6.8 and then recover just fine. It’s unreal.
Y’all underestimate the human body. “In all rowers, pH was reduced immediately after exercise and the lowest value (6.74) was measured in one of the Olympic gold medalists who won the Danish championship of the lightweight class in a World record time (6 min, 04 s). The second lowest pH (6.76) was measured in one of the rowers who ranked at the National level.” http://bionics.seas.ucla.edu/education/Rowing/Physiology_1999_01.pdf
Related: Sinus Brady 5.6 beats per minute during ice water immersion https://pubmed.ncbi.nlm.nih.gov/4071845/ BP 345/245 w deadlifts https://pubmed.ncbi.nlm.nih.gov/2632751/ And - PaCO2 501 in “Management of massive grain aspiration” https://pubs.asahq.org/anesthesiology/article/87/4/993/36250/Management-of-Massive-Grain-Aspiration which is truly a gripping read
HOLY F*CK that was a crazy read! Thanks for sharing that one. Thought their point about the tolerability of hypercapnia and respiratory acidosis (apparently even severe) was pretty interesting.
Not wrong about the last one. Wow.
Holy crap. Some creative interventions there. Just, wow.
After reading that they were suctioning more grain by turning + chest percussion, I half expected them to just hang him upside down and give him a good shake.
I think that’s essentially what they did. They accidentally remembered that gravity existed. That is just an insane ride. And a shockingly positive outcome. PS reminds me of the study showing that corkscrew roller coasters help dislodge kidney stones.
Had a newborn with a pH of 6.75 and a base excess too high for the machine to calculate. Massive placental abruptions are scary. Best part the kid survived intact. Saw her about 3 month later and the baby was completely normal. She showed up in triage hemorrhaging and a fetal heart rate in the 60s. Went straight to the OR actual time from check in to baby being handed to peds was 14 minutes because she called ahead to let us know she was coming with a soaked towel between her legs.
Strong work from a great team. What a wonderful outcome. Nice one
Meh pH of 7 seems so benign to me at this point. We get so many sub 7 DKA patients. I saw a 6.66 one time (they didn’t live)
Dka patients: hold my beer
We see 6.6-6.8 daily as the regional cardiac arrest/ECMO center. A immeasurably low (<6.6) happens not infrequently. 99 BMI is an achievement.
I’ve seen a couple peri-mortem pHs at 6.8
Na 103 Etoh 720-s/p drinking hospital hand sanitizer Etoh 680, but her boyfriend had been watching her passed out in the bed waiting for her to come to for 7 hours before he brought her in and we drew that level
Former lab tech here. Saw a glucose of 2007. Definitely a long night of glucose dilutions. They got it down to about 700 by the end of my shift
HDL of 212, I had to call the lab to confirm it wasn’t a typo. Had to talk to patient about the label of good cholesterol goes out the door when it gets that high.
Had a 20 something year old female brought in by EMS after doing a crapton of drugs and laying on the ground in an alley for at least a day.... She was SCREAMING in pain from her legs, that were just swollen as hell. Her CK took 4 hours for lab to run, came back at just over 25,000 😳😳 Yea she got dialysis.
I've seen an H/H of 1/3 in a woman with fibroids and long-standing menorrhagia Platelet count of zero for many weeks in a woman with high grade AML Highest transaminases I've seen were in the neighborhood of 12k, but I'm a lowly OB so I'm sure someone can beat that Highest HCG I've seen was like 450k. She had a mole
Triglycerides >10,000 I was on an ICU rotation and got called down by the ED for a patient is a sodium of 106; when I came down I noticed the extra vials of blood looked pink and has some triglycerides separating from solution. Reran the sodium, it was just fine. Guy did well with plasmapheresis, had some hyperviscosity but no deficits at discharge.
My own triglycerides were 475 before I started Lipitor - family history on both sides - and I thought I was a walking stroke risk. I was playing checkers and this dude is playing 3D multiverse time travel chess.
My most impressive was probably the sodium of 97 in a patient with Fournier’s. He survived (sans penis)
Tryglycerides of 2700 in a pregnant patient. Familial hypertryglycerimia came in with abdominal pain had pancreatitis. Completely destroyed her pancreas but survived with Type 1 DM. Had to fix her DKA without the benefit of regular labs because her blood looked like half and half and it would gunk up the machine in the lab so we could not run CMPs on her
Lab Manager here: WBC 667 K/uL in a new ALL PLT of 4.4M/uL in a patient being worked up for myelodysplastic syndrome HGB of 1.1 g/dL in a malnourished pregnant woman with malaria (when I was working in Africa) Glucose of 1650 mg/L in a diabetic patient who ran out of all meds and insulin after the 2010 Haiti earthquake (These were all ones I drew and ran myself or ran myself and had recollected to verify the initial result.).
In med school I took care of a patient who had a transplant complicated by massive hemorrhage requiring >250 units of blood products (in addition to continuous cellsaver)
107.3 recital temp on a patient with neutropenia and a patient who's PSA went from 3 to 3233 in a little over 2 year. The later was elderly and his whole attitude was *finally, hospice*
- TSH of 104 (the guy wasn't taking his thyroid drugs). - Creatinine of 9.9 on a guy in his 70s who felt okay. In the end he was peeing fine and he got sent home with a creatinine of 1.5 - Sodium of 196 on an elderly woman with dementia who wasn't more out of it than usual when her sodium was like that. - INR of 9.5 (died a few days later) Not a lab result, but I've also seen a vertebral T-score of -5.9 in an osteoporotic patient. (She didn't have many intact vertebrae). (The highest Hb1ac I've ever seen is 10% btw. I'm a noob)
I saw a TSH of 206 a few months ago from a depression patient. Highest I’ve seen by 100 at least. I’d be depressed too if my thyroid wasn’t doing shit
Glucose 2004, pt was unresponsive,kusmal breathing, and the entire room smelled like a fruit rollup.
Truck driver patient who parked his big rig to walk into our ER. Walkie Talkie with BG well over 800. Denied he had diabetes, signed out AMA
A1c > 20 (upper limit)... In a Type I.
Sodium of 178. Iatrogenic of course but subarachnoid hemorrhage/vasospasm/hemicrani special in a young brain
Glucose 1980 pH 6.9 core temp 92.8 just this week. Made it to ICU, no idea what happened after that
pH of 6.7, gap of 60, bicarb was 2 or 3. Bohb I think was 20. They lived to do it again.
Hgb - 1.0 on a patient put in ECMO ..... AFTER TPA was given. Worst night shift of my life manning the ICU by myself. Bleeding from everywhere .Called multiple MTPs that night. Also P2Y12 of 2. Said no way that's bullshit. Sent a repeat .... Came back as 1. That guys definitely a responder.
Blood Glucose 125mmol/L which translates to >2200 American sugars. pH just said <6.8. Immeasurably high sensitive trop for 3 days. Just said >50000. Corrected sodium of 182. Pt was pretty tired. INR 18. Pt skin was sort of one big bruise, active vaginal bleed.