Sunday, February 18, 2007

Writing from Work - Another Episode

Crossing that bridge,
With lessons I've learned.
Playing with fire,
And not getting burned.
I may not know what you're going through.
But time is the space,
Between me and you.
Life carries on... it goes on.
-- Prayer for the Dying (Seal)
It seems as though the only days I have time to write here are on Wednesdays and Sundays. This post is being composed while I'm at work, no less. I've done this before - if it's a reasonably slow night then I have time to write. If not, well, then I wait until Monday. So far this has been okay - we came on at 5:00PM, and it is now 7:40. One call - a 27 year-old male who has a history of ulcerative colitis, and he takes Sulfa to treat the current flare-up he is having and Oxycodone for pain. Well, he made a mistake according to his own reckoning and followed the medication with three good stiff drinks of what sounded like very expensive bourbon. I don't remember what he said the brand was; all I know is that a bottle of it would cost me a day's pay. He was pale and diaphoretic, but he was alert and oriented appropriately. He told us that he had some dizziness prior to our arrival, and abdominal pain at about a 5/10, which was his baseline after pain meds. He was able to walk (vitals were all within normal limits) so he ambulated to our rig. The one thing that struck me, more from gut feel than anything else, was that he was dehydrated - we started an IV with Normal Saline and gave him a fluid challenge of 200 ml, which he responded to quite nicely. A finger stick to check his blood glucose confirmed this; he was a little high at 165 mg/dl. This wasn't terribly alarming; I actually would have expected it to be higher than this. The patient was otherwise stable, and we had a 6-7 minute transport to the hospital.
This past week has been interesting in terms of patient transports. Our critical care shifts were just that: we had more than one critical care patient that needed to get to tertiary care facilities, both Thursday and Friday. Thursday's notable trip was a 5 month-old boy who had a left femur fracture. Mother told the ED nurse that she was changing him on a futon and he fell off. She said the distance was not more than 5-6 inches to the floor. When I received report from the nurse, she informed me that DCYF (New Hampshire Department of Children, Youth, and Families) was involved and investigating. No other injuries, no alteration of mental status, just the femur. He'd been given a total of 0.5 mg of Morphine for pain; without it he was inconsolable.
I evaluated the patient before we moved him; he was pink, warm, and dry, he appeared alert and oriented to the surroundings, and he was obviously uncomfortable. He had gotten 0.25 mg of Morphine just a few minutes prior to our arrival, but he was still a pretty unhappy camper. We moved him from the ED stretcher to ours and protected him as much as possible with rolled blankets. Mother went with him to the hospital (he went to Children's in Boston), and fortunately the transport was uneventful. The patient slept most of the way down, and when he wasn't sleeping he was looking around, not crying or fussing. Vitals were stable during transport, and when we got to Boston he went to a hallway stretcher because they were very full. I haven't gotten any follow-up yet, but it will be interesting to see what the outcome was.
Friday we had two: the first was a patient who we transported to the hospital local to his home in the Lakes Region. There are three, and of course we took him to the furthest one. This 87 year-old male with a history of two aortic valve replacements had vegetation on his current valve which became infected and spread into his blood, primarily affecting his red cells. He was on high-dose anti-biotics and was sent to the originating hospital to continue therapy. He was also alert and oriented appropriately, but he was decondititioned. He has a pertinent history positive for COPD, a CABG x 4, and he was an insulin-dependent diabetic. He had Normal Saline running KVO and needed to be on our cardiac monitor. Because of the COPD he was also Oxygen-dependent. The transport time from point-to-point was approximately 90 minutes to go 60 miles. He was stable throughout the ride. Nice man; liked to talk. I enjoyed taking care of him.
On the way back to Manchester our operations center contacted us for ETA back to town. At that point we were probably 45 minutes away, and they had another call waiting for us: from one of the two city hospitals we had to transport a ventilated patient to a hospital 80 miles away. We had a respiratory therapist going with us, so at least we would be able to manage the patient's care in a reasonable way. When we arrived, we found our patient, a 63 year-old male, positive for MRSA in his sputum, had been admitted for mental status changes due to sepsis. He'd originally been intubated at the hospital he had been transported from - later on (I don't know how many days for certain) he'd had a tracheostomy device inserted. He would track you with his eyes and respond to verbal stimuli, but otherwise had failed to thrive and be able to be taken off of the ventilator, which is why we were transporting to the facility he was going to - the receiving hospital specializes in ventilator-dependent patients and weaning them from ventilator support so as to recover fully. This transport was rather eventful; this patient was moving around like a fish on a hook. The respiratory therapist and I kept talking to him throughout the trip to keep him calm, and it was a workout. Not only that, but the trip took almost two hours - that in itself almost qualified this patient for drugs..... The therapist was good, though - her name is Pia, and she was excellent at working with our patient. She was also very funny; it was all we could do not to crash the truck on the way back.
Done for today - I'll find more things to write about, hopefully before Wednesday. :-)

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