Treat Your Patient

Treat your patient, not the monitor is something that most medics have heard (and hopefully most do).

We had a call for a syncopal episode. The 70 year old man had been mowing his lawn when he started to feel too warm. He went into the kitchen and sat down to take a break. He promptly passed out for about 15 seconds according to his wife who witnessed the entire event. After regaining consciousness the patient vomited rather violently.

Upon our arrival the patient was pale and very diaphoretic. Now sitting on the couch, he related the story of what had just happened to him (with his wife filling in details that the old man either forgot or didn't think were pertinent). While he talked we worked.

He was a touch hypertensive at 160/92. His heart rate was in the low 90's and his breathing was non labored. His sugar was 201 (which he blamed on his wife's homemade apple pie). He was in NSR on the monitor (for you ER RN's out there that panic if we medics don't get a pulse ox it was 99% on room air).

My patient was overweight, a diabetic, had high blood pressure and high cholesterol. He denied any chest pain or discomfort at any time  as well as any difficulty breathing. The man kept saying he was just feeling week and sweaty.

Before AMR rolled up we shot a 12 lead. The patient had a LBBB and ST elevation in leads V1 through v4. I know right now some of you are yelling that a LBBB is a STEMI imposter. Or at least in can be. According to Sgarbossa's criteria an AMI can be diagnosed if there is ST elevation ≥5 mm in a lead with downward (discordant) QRS complex. Our patient only had 4mm of elevation.

However, I am one to treat my patient, not my monitor. The patient was still pale, sweating profusely and weak. We transported him to a STEMI center just as a precaution. At the ER the MD met with me and the AMR medic and went over the 12 lead. He reaffirmed what we saw and didn't think that this guy was having and MI but agreed that his presentation was such to make a medical professional worry a little. As if on queue the patient started throwing up again and seemed to get weaker.

Not my patient any more.

Insult To Injury

A nearly 80 year old man lay awake in bed trying to take a nap. His wife, laying next to him, was worried. She didn't think he looked well. He insisted he was alright and refused any help.

About 30 minutes later the old man jump up and ran for the bathroom. Half way there he started to throw up on the hard wood floors. As he tried to round the corner to make it to the toilet the combination of emesis, hardwood floors, and inertia proved too much for him. When his wife found him passed out she called 911.

We arrived to find the gentleman hugging the porcelain god in nothing but his tighty whities. He had managed to crawl over to the toilet after waking up. We collectively decided that dignity is worth a small delay in patient care so we waited while he cleaned himself up and slipped into a bathrobe.

Out in the living room we began to get a clear picture of things. The patient had had an MI about a month ago and had several stents placed. He had only been released from the hospital a few days before. After some prodding he admitted that he had been feeling ill for a couple of hours (that really angered his wife).

The patient wasn't complaining of chest pain but did say that it felt the same as it had when he had his last heart attack. That's an attention getter. While my engineer grabbed a set of vitals I set up for a 12 lead. As soon as we were finished shooting the EKG we put on oxygen and gave him some aspirin.

When AMR showed up we gave them a report along with the 12 lead showing that he was having another MI. We moved him over to the gurney, which the stubborn old guy really didn't like, and AMR sped off to the cath lab.

Poor guy. I hope we caught this one early enough for a good outcome. I guess he's looking at several more days of hospital food. Maybe he'll be visiting the porcelain god again.

What A Month (part 2)

Day 4, Tuesday

I woke up on Tuesday morning to the sounds of my wife getting the kids ready for school. We (and by that I mean she) had kids to drop off at 0800 and 0900, a doctors appointment (she was 38 weeks pregnant at this time) at 1015, and a kid to pick up at 1120. A busy morning. When she came by the bed I told her that it was time for me to go to the ER. I was fairly certain at this point that I had appendicitis.

Around noon my wife drove me to the ER. I hobbled up to the front desk and signed in. Thankfully the ER was empty and I was on deck to be seen. A couple of minutes later I was sitting at the triage station explaining my plight to the triage nurse. Before I could even finish giving my report (yes, it sounded like I was rattling off a report about one of my patients) another RN had appeared to show me to me "room." While she did offer me a wheelchair I declined. After all, I wasn't that sick. Or so I thought.

Looking back on it I should have known that I was really sick. My heart rate was above 130. I was breathing more than 30 times a minute. I had a high fever when it wasn't being controlled by medication. The only one of my vitals that didn't look bad was my BP and I'm sure that my heart was trucking away trying to keep it that way.

Up to this point I thought I had appendicitis and a flu. I hadn't really considered the chance that I could be septic. At least the ER staff was on it. They immediately drew blood for some tests (I think I gave more than when I donate to the Red Cross). Within minutes the ER MD came by for a chat. He told me that I was indeed very septic. My WBC count was well above 30,000 (above 12,000 is considered septic) and I was extremely dehydrated. While he talked my RN hung a bag of saline and two different IV antibiotics. The doc also said that I was going to be getting a contrast CT of my abdomen to find out if I really had appendicitis.

A few minutes later my RN was back with a container the size of a Super Big Gulp. It was the contrast dye that I had to drink for my CT. That stuff tastes nasty. You'd think that drug manufacturers would take into account things like taste. There's nothing like giving a nauseated patient a liter and a half of horrid tasting fluid to choke down before they can get the tests they need. It took me the better part of an hour to get it all down.

About an hour after the test the ER doc and a surgeon came in to see me. I was told that my appendix had indeed ruptured and it looked like part of my large intestine had as well. They couldn't be sure. So the plan of action was to get me into the OR as soon as it was open and to try to do a laparoscopic appendectomy. Once inside me (that's a weird statement to write) the surgeon would be able to tell if he needed to open me up and perform a bowel resection. Needless to say this really stressed me out.

I asked the surgeon how long each procedure would take. My wife was at home and I didn't want her to show up and have to wait for hours in the waiting room. He said if it was just the appendix it would only take 45 minutes. If I needed the bowel resection it would take more than a couple hours.

After signing all the waivers I waited. I called my wife and talked to her about everything. I told her when I expected to go into surgery and when I hoped to be out.

Around 2015 they came to get me to take me to the surgical suite. I sent off a quick text to my wife letting her know what time I was going in so she would know when to come.

In the surgical prep room I met the anesthesiologist. We chatted a few minutes so he could get to know my medical history. It's strange the things you notice while waiting to go under the knife. I was the only patient there and it was relatively quiet except for music coming from the OR. Once everything was readied for me they wheeled me in. I slid over to the operating table. This one only had my right arm out at a 90 degree angle. My left arm was wrapped in a sheet and tucked in close to my body.

The anesthesiologist put me on the heart monitor, pulse ox and automated BP cuff. Much like I do at work. Have I mentioned that I really don't like being the patient? He then placed an oxygen mask on me and told me to breath deeply. He told me when he was injecting the medication and then.......

....I woke up in the recovery room and the first thing I saw was a clock. It was 2330. It had been several hours since I went in. My heart started to sink as I realized that I must have needed the bowel resection.

What A Month (part 3)

Day 4, Tuesday (con't)

After a couple of moments I asked the nurse if my surgery had been done laparoscopically. She said that it had and that I would be headed for my room in a minute. Talk about a wave of relief washing over me. I was ecstatic that I only had to have my appendix removed. Later on I would try to joke with my surgeon about how I was grateful that all I needed was a simple laparoscopic appendectomy and he chided me. He said that there had been nothing simple about my surgery. I guess I was a real mess on the inside.

Day 5, Wednesday

At midnight I finally made it to my room. My wife had been there for several hours now and had assumed that I needed the more extensive surgery. She had repeatedly tried to get the nurse to call up to the OR and get some information to no avail. Fortunately for the nursing staff my wife is a patient woman.

Once in my room I was able to tell my wife what had happened. And for the next several hours I was bombarded by staff members doing all kinds of pokes, prods and checks. By 0300 I had sent my wife home for some much needed sleep. I was finally able to get comfortable enough to doze off when in walked my wonderful nurse (the one that refused to get any information for my wife). She told me she had to put the compression socks on to prevent me from getting DVTs. They would go off alternately, every 15 seconds. After 3 minutes of that I started pushing my nurse call button. When she showed up I told her the socks were coming off. She tried to protest for a moment but quickly realized she was going to lose that argument. A few minutes later I was asleep.

Let me take a minute to tell you about their new air mattresses. They are designed to keep patients from getting bed sores. They deflate and inflate depending on where the pressure points on your body are. The only issue that I had was that I was in pain. It would take me quite a while to find a comfortable spot. Then, after resting for a minute or so, the stupid bed would change pressure and shift me around to a "better" place causing me pain. That was frustrating. I should have just unplugged the thing.

By mid morning I had sunk into a routine of sleeping in small chunks. I was still getting all kinds of antibiotics and fluid replacement. For breakfast, or it could have been lunch, I got jello, lime soda, apple juice and broth. Tasty. I wasn't really hungry so I ate the jello and downed the juice.

It was that afternoon that I first noticed a little fluid build up around my abdomen. It wasn't much and I had just been through surgery. I dismissed it.

My nurses during the day were great. Very attentive and caring when I needed them and willing to skip vitals if they saw that I was sleeping. They also pushed and cajoled me until I got up and walked around the hallway. It was supposedly good for me. Mostly it just hurt.

That evening I had more jello and juice for dinner. Yum. That night was a little better than the night before. At the very least the blood sucking phlebotomist didn't wake me up for a needle poke at 0400.

Day 6, Thursday

By Thursday morning my life was starting to seem like Groundhog Day. I was still in a lot of pain, I wasn't hungry, I was tired of being in the hospital and I noticed even more fluid building up around my abdomen.

This time I was a bit concerned about the fluid build up. I knew how much NS and LR they had been giving me (almost 10 liters by this point) and I knew that I was drinking a lot of water. The problem was my urine output was next to nothing.

I talked to the RN about it and she said that she'd keep an eye on it and talk to the MD about it as well. I let it go at that for the rest of the day. My surgeon stopped by while I was in the shower and just asked me a couple of questions through the door.

By that night the swelling in my belly was hitting a critical point. About 10 that night the RN walked into my room because I kept setting off the low oxygenation saturation alarm, even though I was on supplemental oxygen. She turned the O2 up to 6 LPM (I was on a cannula) and went about her shift.

It wasn't for another hour or so that I came around to start diagnosing myself. I was still only saturating at 93%. I was short of breath. I was breathing fast. I then noticed that I was breathing using only my chest and auxiliary muscles, not my diaphragm. My belly had engorged to the point where I could no longer use my diaphragm to breathe. Now I was really concerned and it was time to get a doctor.

Looking back on the experience I almost feel sorry for the nurse.

I called the RN into the room. I explained to her how I was feeling and laid out all my vitals (which she may or may not have known but I wasn't taking any chances). She tried to quiet my concerns by telling me that she would put this all in my notes and have a doctor check on me first thing in the morning. That didn't work for me. She then explained that the only doctor in the hospital (it's a small one) was the one covering the ER.

I understood that I wasn't the only patient in the hospital and that the doctor was probably busy but I needed to see her. I told my nurse that the doctor could come to me or I could go to the ER. I didn't care. I just needed to be seen. I figured that the hospital would frown on an admitted patient with difficulty breathing walking to the ER to be seen. I was right.

A short while later the ER physician walked in. She checked me out, stopped the order for all the IV fluids and gave an order for some lasix. Now we were getting somewhere.

What A Month

Day T-Minus 17, Thursday

I went in for a right inguinal hernia repair. If it sounds painful, it was. The pain lasts for weeks.

Day 1, Saturday

Honestly, I don't remember what I had for dinner. I hope it was good because it would be my last solid for over a week. Around 0300 I woke up with a touch of nausea. Something I'm not used to having. I rolled over and uneasily went back to sleep.

Day 2, Sunday

The kids starting waking up around 0730 which means we did too. As my wife got out of bed I told her I was sick. The nausea was back and had worsened. I spent the next 4 hours vomiting. Well, mostly dry heaving. And then the vomiting stopped.

At noon the pain started. My entire abdomen hurt. All over.

Sunday afternoon I spiked a fever of 103. I popped some Ibuprofen and the fever came down. I would continue to fight this fever for over a week.

I spent Sunday in my med asleep unless it was to head to the bathroom. I sipped on water when I could tolerate it. That night was much of the same.

Day 3, Monday

This day was a blur. It was spent in almost identical fashion to Sunday afternoon. There was on small difference. The pain in my abdomen was now only in the right upper and lower quadrants. The left side of my abdomen was pain free.

The thought that I may have had appendicitis did cross my mind. Going against that thought process were a couple of things. First and foremost the pain I was having was not just in my lower right quadrant. The pain started all over my abdomen and then receded to the right side. I went back and forth between thinking it was appendicitis and just left over pain from throwing up since that was the side on which I recently had surgery. Secondly, most people that get appendicitis have pain first, then nausea. And as my fall back I knew that when people have appendicitis their pain suddenly ceases when their appendix ruptures, then it returns later. My pain had never gone away. If it suddenly did, I'd would've sought medical attention.

Like the day before, I slept uneasily and sipped on a little bit of water. Maybe tomorrow I'd start feeling better....

Explosive Bodily Fluids

Just about the time I was seriously thinking about going to bed the tones sounded. We were dispatched for a 75 year old female feeling ill.

We were met at the door by the granddaughter of the patient. She led us to the back of the house where her mother was attempting to clean her grandmother. We were informed that our patient had been feeling lethargic all day. About an hour before we were called she had started having explosive diarrhea and vomiting. The daughter apologized and frantically tried to change her mother's diaper. We told her to calm down and to take her time.

A couple of weeks prior my engineer had been to our patient's house on a medical aide. She had apparently suffered an MI and had recently been released from the hospital. Even with her serious medical history we figured that it would be better for all involved if she were cleaned up a little before going to the ER.

20 minutes later my head found my pillow, but not for long.....