At the nursing home I get a quick report from the nurse (who is running the other way down the hall when we come in) which makes me think the difficulty breathing we have been called for is a patient with pneumonia or sepsis. The vitals she tells me are BP 83/34, Sats in the 80's on a cannula, and a temp of 102.8, on a patient with increasing confusion.
The patient’s family is in the way and are rude to my partner when she drops a woman’s sunglasses while trying to hand her her bag off the patient’s bed, so we can get the patient -- a 55 year old female -- onto our stretcher. There is an overall bad vibe with the family. I decide to just get the patient out to the ambulance and do everything en route.
In the ambulance, reading the W10, I discover the patient is on renal dialysis, but now I don't have the answer to the question I am later asked -- When did the patient have dialysis last? I see the patient has some communicable diseases and since we are going to a hospital that doesn't take our blood draws I am thinking I may just BLS the call in. Then I decide that would lazy and irresponsible.
Our SAT won't read, and then it comes up in the 70’s. The patient's fingers are in poor condition so I don't know how reliable the SAT is. Still I put the patient on a nonrebreather to be safe and also put on the ETCO2. I'm concerns when I see it is 53, which indicates the patient is hypoventilating(or possibly it could be due to the fever and increased metabolism). Regardless, it is not a sign of pristine health.
I see what looks like a dialysis catheter under the patient's sweater as I attach electrodes to her chest. I listen for lung sounds. I hear no rhonci, no rales or wheezes, but it is hard to get the patient to follow commands enough to take deep breaths. I check her sweatered arms for a shunt and then put an IV in her left wrist and start some fluid.
At the hospital when I try to convey my sense of the patient’s level of sickness -- she doesn’t know where she is, her SAT is low and her ETCO2 is up, she's hypotensive, although our reading at 100/50 wasn't as bad as the nursing home's, tachycardic at 112. The nurse then asks the patient how she’s doing. The patient answers in gibberish, which doesn't seem to register on the nurse. Over the phone, the triage nurse tells the room nurse who will get the patient that the patient is not tachypnic and responds to her. She apparently didn't hear me say or understand about the hypoventilating.
In the room I give an admittedly meandering report to a young doctor I have never seen before, making a poor impression for myself. I'm caught a little off guard because she has come into the room while we are trying to move the patient over, so I am talking and moving the patient at the same time sort of like walking and chewiing gum -- hard for some people, particuarly me today. I am unable to answer what the patient’s normal mental status is nor what their daily activity is. All I say is, "I don't believe this is the norm. they said increasing confusion today."
I am feeling slow and stupid -- like my four days off have robbed me of any sharpness. The new doctor now recognizes the patient as someone she has treated before and declares this is, in fact, her norm. In the EMS room, I finally see written on the W10, the patient is normally alert and oriented and ambulatory. Do I feel dumb. I wish I pointed that out to the doctor, who apparently was mistaken.
When I return to the room with my written report, the nurse announces that I have put an IV in the arm with a shunt in it. I apologize and say I didn’t feel it there, plus she gets her dialysis through her chest catheter anyway. You can feel it, she says, squeezing the patient's arm. Sorry, if I’d known it was there, I wouldn’t have put it there, I say. I’m kicking myself for not undressing the patient at the home, taking her thick sweater off and putting on a Johnny. I almost always do it, and then I don't, it bites me. Dumb. Lazy.
Another young doctor I have never seen before asks the nurse what were the patient’s SATs. I don’t know, I'd have to check the notes, the nurse says. I pipe up then, “They were in the 80s in the nursing home – we were getting in the 70’s.” The doctor is not looking at me, but continues talking to the nurse. I feel like saying what am I invisible? I continue, “In triage after she’d been on the nonrebreather for about twenty minutes, her SAT was 97. But we were also monitoring her ETCO2 and we were getting 53 for a reading, which is high. She may be hypoventilating.”
The doctor turns to me then and snaps, “Well, she doesn’t need to be on a nonrebreather then.”
I don’t say anything. A look of puzzlement comes over me. ???? There is no COPD here. No question of a hypoxic drive. Her SATs were in the 70-80 range before the non-rebreather. Her ETCO2 is 53. Besides she looks really sick.
I want to point this out to the new doctor -- and say if she is hypoventilating and has low SATs off the mask, and doesn't have COPD, she really needs the oxygen -- but when you do poorly on a call – meandering through it, and even putting an IV in a shunt arm -- when you appear so stupid yourself -- what do you say when someone says something so stupid to you.
I just turn and leave the room.
Maybe she knows something I don't know. Maybe I know something she doesn't. They’ll come to the right answer soon enough.
The thing about medicine is – you can be great on one call, and then the next be an idiot – paramedics and nurses and doctors, all of us. You have to prove yourself patient by patient. You won't bat 100, but you need to try.
In the coming year I resolve to try to do my best on each call and not to judge anyone, high or low.
