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!"

1 comment:

Medicmarch. said...

To paraphrase Peter Canning, sometimes the patient we bring into the er isn't always the patient we had on scene. "Our interventions make the difference."

Also, like the old maxim goes, treat the patient, not the monitor. I would've done the same thing you did.

-MM