Thursday, September 20, 2007

Aztec Gods and Duragesic Patches

Not long ago, Peter Canning wrote about the automatic blood pressure cuffs in the hospital emergency departments. He referred to them, a bit tongue in cheek, as "all-knowing Aztec gods:" capable of discerning the absolute truth of all blood pressures. Often times our manual blood pressures will come up one thing, and upon presentation in triage, the manual machine will argue against our competence and promote an entirely different view of the patient's pressures. When forced to make a choice between the two, the triage nurse almost always writes down the machine's answer. ...Sometimes with a bit of a "yeah, right" look on her face as we stammer and argue our case.

It doesn't stop at the blood pressure machine though. Often the emergency department is an Aztec god in and of itself. We will roll in our patients on our yellow stretchers, attached to wires, cables, and tubes- yards of pink ECG paper dangling from the machine. We list signs and symptoms, pertinent negatives and whatever else to the triage nurse, then submit the patient for review. The nurses will stroll into the room, doctors usually soon after. They will re-do all that we have already done, scratch their chin and order further tests. Usually within a few hours, the results are spit out from the black box and a decision is made. We were right, we were wrong, what were we thinking. Most of the time we were right in our clinical impressions, but with a few patients it could go either way. Those critical ones where everything is crashing down in front of our eyes, where we can do little else than the basics and look for the obvious, we bring them into the brightly lit rooms and sweat it out as the verdicts are cast down from the doctors above.

I envy doctors for the time they have to consider the patient, the tools and tests they have at hand, the extensive educational foundation on which they stand. It is often that I feel as if our portion of the patient care is sloppy and convoluted. We sweat in our vaguely police-looking uniforms, struggle with inconvenient circumstances pressured with time, and are often lucky to get everything done by the time we reach the hospital doors. Once we roll into the emergency department, everything cools down and slows. Experienced and knowledgeable voices peruse what we have been able to assemble and ascertain, calmly asking pointed questions and sorting out the mess. I often walk into emergency departments with critical patients, feeling as though the first task in the trauma rooms is to re-arrange and re-do what I have done. Make sense of the clutter.

I brought a man to a local emergency department last week, confused with a blood sugar of 600. He didn't know where he was, what his name was, or what needed to be done, but he adamantly refused to go to the hospital. It was a battle in his living room, repeating my calm logical necessities to this confused man who could barely compose himself enough to look me in the eye. It took a bit of skill, I think, a bit of experience with this situation to get the man to agree to go to the hospital without a fight. I did it, though, and I was happy for that. He was still confused, and on the way to the hospital (maybe a 3 minute trip) I did the basics from my established routines. IV/Monitor/O2. He was an insulin dependent diabetic with no venous access, but I got the line.

Still though, I wasn't exactly sure what was wrong with this guy. He is sitting quietly, almost falling asleep on the stretcher, while I am thinking about DKA. I wonder if I would be able to see the result of his potential metabolic acidosis with the ETCo2, so I put it on. The number reads 64, and his respiratory rate is 10. Huh. I coulda sworn he was breathing faster than that. The hypercapnia could be the acidosis or it could be his hypoventilation. I take another look at his perscribed medications:

Duragesic Patch

The last one stands out like a sore thumb. My EMT partner wrote the list down for me, but I read it and I swear that wasn't on there last time. We are rolling into the emergency department parking lot, and a light bulb goes on above my head. Confusion. Lethargy. Hypoventilation. Perscribed narcotics. This patient is overdosed on opiates! The pupils aren't pinpoint, but they could pass as "small," and I've seen people aepnic on herion with pupils even bigger.

My partner is opening the back doors now.

I curse. Its too late now. We roll him in to the emergency department, and the patient is looking more and more like an overdose with every second that passes. The nurses think so too as they enter the room, listening to my report. "Oh, he's high. Look at him," one of the nurses says. It is so obvious. I was distracted by the argument to get him go to the hospital, the high sugar, the tough IV. Maybe if I only had another 60 seconds in the back with this patient, or had put the pieces together earlier...

They disconnect him from our wires, pull him over to the ED bed, and send a little bit of Narcan through my IV. Almost immediately the man's eyes become more clear as understanding spreads across his face. "Oh boy," he says. "I think I messed up my dosage."

He had two patches on instead of one.

Thursday, September 13, 2007

Two Patients Part Two

Priority one across town for a "general sick call." We arrived just in time to find the 62 year old man propped up in bed and finishing his supper.

Firefighters already on scene were taking the man's vitial signs, so I took a report from a family member in the hallway. The patient has been feeling "tired" for about 3 weeks now. He is normally fairly active, but as of late he has hardly found the energy to do much more than sit in bed, watch TV, and read. He doesn't have any particular pain or discomfort, no shortness of breath, no problems with appetite, fluid intake, or bowel movements.

I try to scare a complaint other than "tired" out of the story, but despite my probing questions there truly seems to be little else. The man smiles at me and thanks us for arriving so quickly. He apologizes for having to call 911, "but this weakness just wont go away."

The firefighters report the vital signs to me as BP 90/50, HR 60, RR 20. The man looks a little bit pale, but there is nothing that really screams "sick" about his presentation. We get the stair-chair and wheel the man out to the stretcher, telling a few jokes along the way.

Mostly out of boredom, and partly because of the reported blood pressure, I decide on a whim to work the patient up instead of passing off to my BLS partner. It is a 10 minute drive to the hospital, so I decide to do everything en route and we start on our way.

Sitting on the bench seat I take another set of vital signs.

...And then I take them again to make sure I heard right. The blood pressure is more like 76 over 30, and the heart rate rate, well... I'd better put him on the monitor.

I stared disbelievingly at the monitor for a few seconds, turning my head back and forth between the patient and the yellowish screen. The patient looked fine. ...Like anyone you might see walking down the street. And yet the numbers told quite a different picture. Heart rate hovering between 28 and 32, a dangerously low blood pressure.

The patient sat on the stretcher looking at me. He had asked for a few extra bath blankets, and there he was, buried in cloth pulled snug to his chin, watching as I reached for the yellow medication bag.

He clears his throat. "Is there something wrong?"

Tuesday, September 11, 2007

Two Patients

I am looking at two different patients. One, expressed through the yellow glow on my Lifepack 12, seems well. The other, sitting in front of me, is the sickest person I have seen in a while.

The woman sitting in front of me is the picture of disease. She is pale and thin, sweaty and doubled over in respiratory distress. She is an IV drug abuser, and it shows. Her arms are bruised up and beaten, veins scarred and driven deep into the depths of her pale, washed-out skin. She is heaving with every breath, textbook in her tripod position. Her lips betray a bit of blue, and her lung sounds wheeze harshly on both her intake and exhaust of shortened breath.

All the while my monitor sits beside me, still and calm. Without a trace of anxiety, the numbers coldly spell out facts measured through colored wires. The oxygen saturation sits pretty at 93%. Heart rate 100. Blood pressure 138/72. End tidal CO2 is 52 with a slightly sloping waveform. The numbers are enough to raise an eyebrow, but the stronger point seems to be the disproportion between the patient and the monitor. I briefly consider tracing the wires to make sure they don't detour to some other, less distressed patient.

The woman doesn't give me much time to think about it. She grabs my leg and squeezes tightly. "Do something, do something," she pleads. Her eyes are sunken in and sickly, but her demeanor is earnest in every way. Everything I have learned and everything I have seen tells me that this patient is sick, sick sick. ...And yet my monitor quietly submits it's objection.

We are in the back of the ambulance and my EMT partner is sitting near the airway seat, gloves on and ready for me to make a decision. For a moment we sit there, her watching my head turn back and forth between the patient and the monitor. I am thinking about paramedic school. The patients I have seen and the advice I have been given. What lesson applies to this situation? I remember it clearly: "treat the patient, not the monitor." The advice seems plain, and I remember the concept sounding reasonable and legitimate. ....But the saturation is decent! She's not even that tachy! The waveform is barely sloping!

I look at the patient one more time. She is looking really sick. I let out a sigh, and ask for the yellow medication pack. My EMT sets to work, following the predefined path of the critical patient that we have both seen before. We are treating her as such, I have decided. In goes the epinephrine, 0.3mg of 1:1000 concentration, IM. Continuous neb treatments as I search enroute to the hospital for IV access. I cant find any. She's used all of her veins up.

By the time we reach the hospital, the patient has changed much more than the monitor has. Heart rate has come down maybe 10 points, the oxygen saturation up 5% or so. Her end tidal is hovering around 48. The patient, though, is a different person. She no longer looks nearly as sick, and while her sticky sweat still covers pale and sickly skin, she manages to irk out a smile. Her lung sounds betray diffuse wheezes, but nothing like what I was hearing before.

At the hospital the nurses and docs look at me, puzzled. Even the code summary from the objecting lifepack 12 argues against my case.

"But doc," I argue, "You shoulda seen her!"