Sunday, March 23, 2008

Happy Easter!

Before I start, I have to thank my friend ee for putting me back up on her blog roll. I thought for some reason I was persona non grata in her blogspace, but it turns out I was a victim of the web ghosts that lurk out there.....

Happy Easter indeed! It is a beautiful day up here in my part of the world. We have bright sun, the temps are in the mid-40's, and the snow is finally starting to melt on my lawn and the rest of my driveway. Hopefully it will all disappear before June 1st.

I haven't had a chance to talk about the past week at work. It's been really kind of strange; not a lot of call volume, but I've dealt with some really sick people. This past Friday was one of those kind of tours - we only did 5 calls during the shift, but of them, two were really worrisome. One was an 85 year-old male in respiratory failure. Resident at a local nursing facility (that in itself is a problem for other reasons), history of COPD and CHF, guppy breathing at about 40/minute when we arrived on scene. The LPN on staff told us that it was a sudden onset approximately 20 minutes before they called for help. His O2 sat was 56% on 4 L/min my a nasal cannula. He was not moving air with his respiratory effort, and he could talk in 1-2 word spurts. He was air hungry. Immediately he went on CPAP - thank God we carry that as in every case that I've used it we've been able to save a patient from having to be intubated. He was quite hypertensive plus he had 2-3+ pedal edema, and he was tachycardic at a rate of 130. He got 0.4 of NTG en route, and I watched his sat come up into the low 90's, his heart rate come down into the 110's, and his systolic pressure go from 240 down to about 200 between the CPAP and the nitro. I held back on giving him Lasix because of a conversation I'd had with an ED physician recently about Lasix and respiratory failures - he had told me that it is almost non-productive to give because of the amount of time it takes to act, 20-30 minutes in most cases. On top of that, we had a 7 minute transport time. Before we left I checked on him - he was moved onto a BiPAP machine, he was still working but not nearly as hard as before as his rate was down to 22-24. His pressure was down to 160/88, and he looked much more relaxed. Good thing.

The other one that I had trouble with (and still do) was a call we received to the assisted living facility next door to the above nursing home for a psychiatric problem. I was thinking hard about that one because I know the facility - as assisted living goes, it's one of the best in the area, the residents are quite independent and able to do a lot for themselves, but there are both limited nursing staff and security on the premises. We arrived and were met by a security officer who was, for lack of a better term, bouncing like a superball. He led us to the apartment where the patient was, and inside I found three nurses, two of them from the facility (both LPN's) and an RN from the local Visiting Nurse Service. Within probably 30 seconds the two facility nurses were gone. I have never seen people rabbit out of somewhere as fast as these two did. The RN from VNS stayed for a bit; she gave me a rundown on what was going on with this patient, an 87 year-old female who'd recently been released from the hospital as an in-patient. She'd been treated for pneumonia and influenza, and both the nurse and family members (who didn't show up) seemed to think her mental status had changed since the hospital stay. She'd shown evidence of paranoia in her behavior, as evidenced by the way she was treating the staff and this nurse, who I'll call Patti. She'd told everyone to stay away from her and wouldn't answer Patti's initial attempts to see her. It was apparently a scheduled visit, so I'm told. Anyway, both my partner and I tried to talk to her - alert and apparently oriented, lying on her bed in a bathrobe, lights off, the radio on. I'd gotten a little further than my partner did, but she rebuffed both of us, telling us that she knew we were part of some conspiracy to take her away from her home. At that point my instincts kicked in and the alarms started going off in my head. Knowing how the body can change with someone who is elderly, especially if there is some sort of pathological process going on, I decided to call medical control at our resource hospital because, frankly, I didn't know what else to do. In good conscience, I couldn't leave her like that.

I got in touch with Dr. B - he's the medical director for the emergency room as well as the on-duty medical control doc for the night. I told him what was going on and what I thought was happening with her; my impression was that this wasn't some sort of behavioral problem as much as it was a residual medical problem that had developed during the pneumonia course and decided to pop its head up. He talked with another one of the docs while I was on the phone with him, and they both agreed with me that she needed to be seen. Their thought about getting her transported was best case that her DPOA would force the issue. Problem is she didn't have one. Worst case was getting law enforcement involved and putting her in protective custody. I didn't think that would work, but after multiple attempts to talk her into going with us, I relented and asked for the police to come.

After 10-15 minutes of waiting - Patti was still with me - a police officer showed up. Female officer, one that I happen to know. I filled her in on what was going on and asked her to help me try to get her to go with us. I have to mention that once the cop showed up, Patti left... Anyway, the officer started talking with the patient - asked her all of the same questions I did - did she want to hurt herself, did she want to hurt anyone else, did she know what day it was, etc. Unfortunately, the woman was dead-on - all of her answers were consistently right. After consulting with her supervisor, the officer told me there was nothing they could do unless there was documentation for an involuntary committal to the hospital. That certainly didn't exist, so the cop left, leaving me and my partner with this patient.

I went back into the room and talked with the patient some more - she had actually calmed down by that point and was willing to talk to me. I had no real choice but to listen; after all, it is a moral obligation that I have to do what is in the best interest of my patient. So I listened. This is a woman who is simply tired. She didn't want to be bothered by anyone anymore, especially her family, who she thought was waiting for her to die so they could claim their inheritance. She didn't appear to be delusional to me; actually she was quite matter-of-fact in her speech. She told me she wasn't depressed or intending to hurt herself; she just was waiting to die in her own bed. Hearing her say that was extremely alarming for me, but she re-iterated that she wasn't going to take her own life. And she wanted no part of being transported to the hospital. When I told her what I thought was going on with respect to her well-being, she laughed and said, "of course you think I have a medical problem. It's your job. But trust me, dear, I don't. I'm just old and I want to die. Here. In my home." She also told me she thought I was being honest with her and she appreciated it, but she didn't want to go with me.

I had no choice at that point. I had to sign her off.

As I write this I am still bothered by the interchange. We were on scene for nearly 90 minutes doing everything we could to help this person. It's tough; sometimes no matter how much you want to help someone they want no part of it.

More to write later on. My company has arrived for Easter dinner.


EE said...

Guppy breathing!

Jason Dittle said...
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Jason Dittle said...
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Jason Dittle said...
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