Sunday, January 08, 2006

When Your Patient Gets A "Two-For-One" Deal

One thing?

I can think of a million things I would have like to have said to a few doctors over the years but I was too young and intimidated. Now that I am of a certain age and incapable of intimidation, I realize it just isn't worth the effort.

Doctors just don't seem to yell as much anymore.

One, the working relationship between doctors and nurses has changed into more of a collegial partnership.

And two, I was dancing to the Bee Gees when they were still in diapers. Perhaps they are respecting the elders.

Anyway, this nurse in the ad feels confident that she can tell her doctor about acoustic ceiling tiles without stepping on any toes.

Was noise pollution an issue back then?


Many, many years ago I learned that things are not always what they seem to be. Especially in emergency medicine. Here's an old story of a case that taught me never to assume anything.

Patients will often come into the ER self-diagnosed. Often they are right. The asthma exacerbation. The recurrent migraine. They've been there, done that and gotten everything but the T-shirt.

So, when a patient anxiously enters the department and with muffled voice says they are having an allergic reaction and their throat is closing off, it gets your attention. This is the definition of "immediate bedding".

Family reports that two weeks before, this middle-aged patient had significant facial puffiness following ingestion of an OTC (over-the-counter) medication. Patient self-medicated with Benadryl and no medical attention was sought. (Patient had no other medical problems and denied tobacco or alcohol consumption. They didn't have a primary physician, having not needed one before).

Not believing that the reaction was caused by the OTC med, the patient took it again that day. Within minutes the throat sensation was noted. Again, Benadryl was taken (twice the recommended dosage on the bottle) but when it did not work, they presented to the ER for treatment.

To say the patient was anxious was an understatement. They lay upon the gurney as stiff as a board. I've seen rigor mortis that wasn't that tight. No stridor, no wheezing, no tripod position, no facial swelling, just a thick, muffled-sounding voice that seemed difficult to produce and a look that could almost be described as panic.

The patient did note that in spite of the fact they were still uncomfortable, the throat was somewhat better. Perhaps the Benadryl was working. The ER doctor was at the bedside and the patient was diagnosed as having an allergic response and was treated appropriately.

I explained the medications calmly, reassured the patient that they would be feeling better in just a few minutes, perhaps a bit shaky from the medication, but certainly improved. The family was at the bedside. I left the call bell within reach and because I was covering the cardiac beds that shift, I went to check on my other patients.

I was summoned to the bedside of my patient with the allergic response within five minutes.

"Should I be having chest pains?" my patient asked. "My throat feels better". The monitor showed mild sinus tachycardia. I asked the patient to describe what they were feeling. Sharp, intermittent and mid-sternal with radiation to the left shoulder. No nausea, no diaphoresis, no SOB. I went to the ER doc thinking that what this patient needed was some Vitamin "A" (aka Ativan, given for anxiety). An EKG was requested. Of course it would be - I was embarrassed that I didn't just do it myself, but I was fixated on "allergic reaction".

Occasionally there is a moment when an EKG shows up on the screen that produces an "uh-oh" response from the technician - something isn't right. Well, I happened to be the technician doing that EKG and my response as it printed off the machine was "Oh s***!" It was BAD.

Twenty minutes later the patient was having a cardiac cath and three stents put in his coronary arteries, one of which was 100% occluded.

Was the patient really having an allergic reaction? Was the closing throat a symptom of the MI? What about the angioedema two weeks previously, seemingly related to the same medication taken by the patient that day? Was it just a fortunate circumstance that this essentially healthy individual happened to have his MI right in the ER?

I never learned the answer to those questions. I do know the patient did wonderfully and was discharged without complications.

But I still get a twinge of anxiety just thinking about that EKG!


At 1/09/2006 12:28:00 PM, Blogger Jessica said...

I had just finished reading your blog when I decided to read the comments for the past week. I haven't been very active on my blogging this past week because I didn't want to push the carnival down, before the end of the week. Anyway, I read your comment and thank you so much for reading my blog. I would love it if you would link to my blog. What is a blog roll? Please forgive my ignorance. I still feel like such a newbie at all of this. lol

Will you do a favor for me? Will you read my blog on "Oh the things you'll hear"? That would be the greatest kindness you could extend. And, if you think it's important enough to discuss, perhaps you could mention those things to your friends in the ER dept? Perhaps you'll be able to help change that situation? I know you're busy and I've posted way too much here already. Thank you so much for reading my blog. It means the world to me, honestly, because when I started this, I was hoping that the medical community would come and read and maybe even, dare I actually wish it?, change their perceptions and attitudes toward migraneurs? lol And, I mean that as a generalization, because from reading your blog, I can tell that you would not be rude to patients. Keep up your blogwork. It's really good and I'm enjoying reading it. I'm going to go back and read some more, now. lol

At 1/09/2006 08:40:00 PM, Anonymous Anonymous said...

yeah - i think society in general and medicine in particular has become much less hierarchical and rigid.

At 1/09/2006 08:52:00 PM, Blogger Gypsybobocowgirl said...

Great story! I read a chart today of a patient that came in post MVA--they did eight hours of surgery, and the patient coded promptly in the ICU where the EKG showed one of those "oh, sh**" STEMI's. When I read the H&P, he had a history of VTach and AMI in the what came first the MVA or the MI? Did he wreck because he had VTach? Or, did he have an MI from prolonged anesthesia? (No EKG prior to surgery). We'll never know--he didn't have a good outcome.


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