Monday, January 07, 2008

Why do some people easily dismiss a case as something so simple???

As I was saying in my earlier post, it was a toxic duty day.

I had a patient: in rehab for deconditioning following a colectomy after infection of her bowels post polypectomy. History of COPD, asthma, anxiety. She had a skin graft on her abdomen, with graft donor site from her thigh. Both had dressings. It was my first day to take care of her.

Early in the morning I changed her dressing on the thigh. She was so sensitive there, but I was gentle enough for her not to scream.

Around 10 am, she complained of abdominal cramping. Her colostomy bag usually had minimal output, since she also had very very poor appetite, per the report I received from the night nurse. Her prn meds for abdomen-related symptoms only had dulcolax supp ...what the??? What for? She does not use her rectal ampulla anymore. Everything goes to the colostomy bag. Even if you stimulate the rectal vault, that would not help. Possibly it was a protocol order entered by a nurse.

anyway, though there were other protoco laxatives, given the complicated nature of her condition and her colostomy, I wanted to make sure it was okay for her to receive a laxative. The doctor okayed. So she got it, and after a while, she felt better.

Lunchtime, her children came, and while her lunchtray was there, they were encouraging her to eat more. I dropped by to check on her...She was hyperventilating and complaining of neck pain. She wanted to lie down on the bed, and promised to eat. I got her pain pills, and in the process, checked if she had anything for anxiety. I wondered whether it was real anxiety or psychological only, as in acting like a baby in front of her any case, I gave the pain pills and antianxiety. I also asked a CNA to help me lay her down on the bed using the Hoyer lift.

She was already calmer when we were transferring her. Upon laying her down we made her turn side to side to remove the pad that we used for lifting her. Soon after that she turned pale, eyes rolled upward, skin got cold, and she was unresponsive. We called a code.

Briefly she responded to my call while I was trying to measure her BP. She was breathing, quite a different pattern, though. Not as rapid as prior to lying down, but quite rapid and shallow. But we were afraid she was having a stroke or a seizure, although there were no such history. BP initially I could not get, but at second attempt was 80/50, with tachycardia. Then the two nurses from 5th floor came and saw that the patient was already responding and pinker. They easily dismissed with CONFIDENCE, after asking me what the diagnosis was, that it was probably a vasovagal complex. I could not easily dismiss it. Delta team came (EMS) and continued monitoring and evaluating the patient, while I went out to talk to the doctor. Delta team rep followed and talked with the doctor. Initially, we were asked to just monitor the patient. But Delta team went back to her, then I followed, and learned that she had another episode, BP going down, O2 sat could not be measured because she was too cold. They finally decided to transfer her to the ER, and started a mask and IV.

I notified the doctor. I called the ER nurse to give report about the patient they will be seeing. As I gave report and reviewed the history, I saw she had an episode of torsades in November 07. That was probably it, I said.

I stayed an hour and 1/2 more to catch up with my charting on my 6 patients that day.

I received a call this afternoon as an update on that patient. It turned out she had a pulmonary embolism. Nothing that I had done (basically medications administered) could have caused it, I was assured by the unit secretary.

But I wonder how she is doing now??? The therapists in our unit who have worked with her have said that she is not a candidate for rehab.

BUT THE THING THAT REALLY IRKED ME: Those two nurses who so quickly dismissed it as vasovagal syncope. NEVER EVER consider something to simple in a complicated case unless you have observed the patient for some time after the event.

Those nurses were orienting at the same time I was. I have been working more than 6 months now in rehab, but never acted like I know everything. I know a lot more and deeper than they do because of my medical background and experience, and I could not ever allow myself to think in such simplistic terms, especially where life is concerned.

I wonder how many are like that????

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