Called for difficulty breathing to a nursing home. Second time in same day called to the same nursing home for same complaint, had same nurse, asked the same question. What is the patient’s norm? The nurse shrugs and turns to an aide who says, she don’t speak, but she converse. Does she have any history of respiratory problems? The nurse shrugs. I’ll have to look in her chart. All I know is she has dementia.
The woman is in her 80’s and breathing rapidly and shallowly. They have her on a non-rebreather at 4 lpm. They say they can’t get her SAT above 80. They can’t tell me how long this has been going on, but they seem to think it all started this afternoon. Her lungs are very junky. She looks like she is getting very tired. Her daughter is in the room, holding the woman’s hand. We have to ask the daughter to move so we can get the stretcher in. We move the patient, quickly to our stretcher, attach at nonrebreather at 15 lpm, and head out down the hall. I stop at the nurses’s desk and ask for the paperwork. The nurse is very flustered, but finally has the papers together and hands them to me. I scan them quickly. Name, DOB (which I hadn’t noticed was missing from the first patient I had taken in earlier), Social Security number, history, meds. No respiratory history? I ask again. Again all it says is severe dementia.
Let me check the chart, the nurse says. No, no respiratory history she says. We speed down the hall and out to the ambulance. The patient’s daughter is still holding the woman’s hand, walking rapidly beside us. She wants to ride with us. I say it will have to be in the front. She says she’ll take her own car then. I tell her we are going to do a few things in the back before we leave.
While she stands outside the ambulance and looks in through the side window, my partner tries to get a blood pressure and I hook the patient up to the ETCO2, pulse oximeter and try to get a line. Her respiratory rate is in the 30’s. It seems a little slower than it was initially. Her ETCO2 is in the low 20’s. I can’t get a SAT and my partner can’t get a pressure. He tries to hook her to the monitor. I think I am in with my IV, but get no flash at all. I try again and again no flash, but am sure I am in. The leads won’t stick to the patient and I can’t get a reading. I flush the IV and it is good. I am conscious of the time on scene and the woman watching us. And my patient’s tiring breaths. Let’s just get out of here, I say to my partner, as I try again to get the electrodes to stick. I start to get a rhythm, but loose it almost immediately.
We go lights and sirens. I get out my intubation kit. Her resps are almost agonal now. I shout to my partner to patch to the hospital and tell her the patient is in respiratory distress and that I am intubating. What! He calls. We shout at each other as I disconnect her nasal cannula ETCO2 monitor and hook the ET capnography filter to end of the ET tube and slip in a thin stylet. Just patch for me, I shout.
I see her chords and pass the tube. I look at the monitor I have no wave form. I must have missed I think. I pull back a little, and then again go through the chords. I have no wave form, but I am not certain now she is breathing. I grab the ambu bag and give it a squeeze and up pops a wave form. I’m in. I secure the tube and start bagging. Her End tidal is 30, but then it soon drops to 17.
My partner is having the following conversation with the hospital:
Partner: “I have a patient unresponsive, respiratory distress, my partner is intubating.”
Hospital: “What are the vitals?
Partner: “I’m driving.”
Hospital: “What is her history?
Partner: “I’m driving the ambulance! My partner is intubating. We’re almost there.’
Hospital: “What’s her rhythm?”
I can feel the bump of the hospital driveway. I’m looking at my patient. The monitor is still not reading the leads. She looks like she is dead. The end tidal is very low. I reach over and do some compressions. I shout to my partner, but he is already out of the ambulance.
He opens the back door. Standing behind him are the patient’s daughter and another family member. His eyes widen when he sees I am doing CPR. He turns and waves to the crew of an ambulance parked in the lot. With their help we get the patient on a board, slaps some pads on – the patient is asystole -- I can check my lung sounds – equal right and left, nothing in the belly, and get a round of drugs in, one epi and one atropine, and then we are wheeling her in.
"You have paperwork?" the triage nurse asks.
In my pocket," I say and nod to my front pocket.
He plucks the papers as I pass.
In the room, I tell the story. Dementia only history, sudden onset dsypnea, agonal breathing. “She just coded as we pulled in,” I say.
“What’s her code status?” the doctor asks.
I stop for a moment. “I don’t know. I’m assuming full code they didn’t give me any DNR papers or say anything.”
He calls for another round of epi and atropine.
The triage nurse sticks his head into the curtain, and hands the doctor the papers he took from me. The doctor studies them. His eyebrows go up. In the small box labeled code status, it says
DNR.
Ooops.
"Sorry," I say. "They didn't give me any other paperwork or say anything."
“Its not valid without the proper papers anyway,” the doctor says. “You had to work her.”
He has the tech stop compressions. The patient is asystole. I walk out of the room.
When I go to drop my paperwork off, I make certain I go the long way so that I don’t have to pass the family room where the patient’s relatives are waiting.
***
Here’s the trend summary I printed out after the call, which pretty much tells the story of her declining respirations.
The period of apnea includes my taking her off the end-tidal cannula, attaching an end-tidal ET filter to the tube, and then intubating.
