Wednesday, April 22, 2009

Interesting Patient.....

Had an interesting encounter not long ago. Some of you may know that I moonlight at a smaller, rural ER, which is staffed solely by PA's. No MD's onsite. I was there the other day and got a page from EMS. They were bringing in an elderly female that was over the age of 90, and was in acute respiratory failure with an SAO2 of 79% on scene, and a RR of 26. Apparently she had a history of chronic dementia, and had experienced an unresponsive episode five days earlier, where she remained unresponsive for about 5 minutes. The staff at the nursing home apparently thought that this was not important, as they did not send her in at that time. Since then, she has had a worsening cough, increasing confusion, and "choking" episodes with every meal.

Well, on the morning I saw her, she apparently had ANOTHER period of unresponsiveness that lasted about 3 minutes. She had a DNR order, but no DNI order.
I ask my nurse to draw up the 100 of sux, and 10 of etomidate. I grab the airway cart, and start organizing my things. I make sure we have BiPap ready too. She gets to the hospital, and EMS had placed her on a 100% non rebreather, and her sats were now about 89% or so. She was concious, talking, and a bit confused about what all the fuss was about. Her exam reveals an intact neuro exam, an irregular pulse, and rales in the right lower lobe. Otherwise within normal limits for age.

I get an EKG, hmmm. That's not good, she's had a history of intermittent paroxysmal AFib in the past, but now, or at least, sometime in the last two months since her last EKG, she has had a substantial anterolateral infarct. She has subtle ST depression, but inverted T waves in all of her anterior and lateral leads. Troponin= 0.16 (normal range at this lab-0.1) Creatinine is normal, so can't blame it on renal function. Certainly NOT an acute STEMI though.

Portable CXR shows a rather large RLL pneumonia. I order 750mg Levaquin.

I go out to talk to the family and discuss what happened, and what my findings are. We are discussing whether or not they might want a cardiology consult, and possible subsequent cath, when I get a panic value.

Sodium= 118

Okay. So I call up to the regional hospital, where the ER doc, listens to the presentation, and says "Well, sh*t, you've done the whole eval, can't we make her a direct admit?" My response was "Sure, but she'll need a unit bed".

I get on the phone with the intensivist, who, after hearing the report, says "You know, I'm wondering if this patient can just go to the floor".....

My response..."Seriously? Did you listen to ANYTHING I just said?" To which, she says, "Oh yeah, you did say she was in respiratory failure, and she's hyponatremic right?" Me...."YEAH". "Okay, yeahhhhh, I guess she could come to the unit?"

I mean, WTF? You guess? I know she's a DNR, and the nurses were a little freaked about her EKG, which BTW, wasn't even close to my biggest concern, but someone who is not on a DNI order, who is in respiratory failure secondary to a likely aspiration pneumonia, and is profoundly hyponatremic, needs a unit bed.

Just an interesing encounter. Last I heard, she's doing great.


Anonymous said...

Sound more like a TV soap opera series to me.

The Happy Hospitalist said...

heart cath? ARe you kidding me? I wouldn't even think of offering a heart cath. A 90 year old heart with a prolonged hypoxemic episode would cause certain ischemia in anyone. She infarcted previously. Infarct over.

Are you going to stent her and cause a head bleed from the plavix? She's demented. She's approaching end of life from natural causes.

The last thing on my mind when I see DNR is to consider intubating. Especially at 90 years old. I wouldn't even consider it.

And I agree with the intensivist on this one. ICU is not appropriate nor is intubating.

In fact, hospice is the only right course of action.

physasst said...

And if she had been a DNI, I would agree with you, but her family wanted her evaluated by cards, and wanted her tubed if needed. I held off on tubing her specifically BECAUSE intubating a 90 year old is not ideal.