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.


Kootz said...

I feel your frustration here. There you are, as professional as can be, in the field. Inside the doors of the ER, your judgement questioned (by nurses!!), and suddenly you find yourself feeling small. When you become a doctor, though, you'll be different. You'll remember that frustration. You'll listen to the medic's report differently. You'll treat EMS with respect. This is yet another great learning experience, and I'm really proud of you for recognizing it!!


Allen said...

I have had this happen to me a few times too. Pt forgets to take off one patch and puts on another. Remove the patches, push a little Narcan, and they usually perk right now. Good work on figuring that one out!

Medic13 said...

Don't fret, these nurses don't see the Pt in the way that we see them. They don't get to see the scene like we do. And most impotently, we only have the Pt for a short period of time, nurses and doctors can have the Pt for as long as they would like.

As for why they re-do everything we do, you must admit that there are certain medics out there (you know the ones who you wouldn't let treat you or your family....or even worst enemy) that make the rest of us look bad. Keep up the good work though. And don't forget, because your partner opened the doors does not mean that you can't finish treatment. A lot of times doing just that is in the best judgment for the patient.

Zac said...

I would have done the same thing... glucose of 600? Kneejerk DKA.

You've also got to realize that you guys are first on scene, with no idea what's going on. The reason the docs look so cool and collected is that you present them with the history, so they hit the ground running :-)