Wednesday, March 14, 2007

A Nap

Got called to a nursing home for an unresponsive, found an obese woman laying across the bed, snoring respirations. Nurse says patient has been nodding off all morning, and won't respond to her at all. Plus her SAts are low. This is not like her. Deep sternal rub opens her eyes, but then she shuts them. She has a history of ETOH, drug abuse and "anti-social" personality. She also is an insulin diabetic, has HTN, CHF, asthma, and sleep apnea. I shout at her and try to get her to squeeze my hands. She gives a feeble attempt. They feel equal. I don't see any facial droop. I try to ask her some questions, but the best I get is a mumble.

We struggle to get her on the stretcher. I notice on the W10 she is on methadone. I check her pupils, but they are not pinpoint. In the ambulance I check her sugar --86. Her BP and HR are fine. I put her on the capnography and it is 64! A little high. Her sat is reading 88, but when I put her on a nonrebreather she goes right up to a hundred, so I back her down to a cannula and it holds in the 96-98 region. Her respiratory rate is between 10 and 20.

Even though I am now teaching classes on capnography, it is still new to me, and I am trying to puzzle why hers is so high. 64 and at times it goes up to 70 is serious hypoventiltation or hypercapnia if you prefer that term. But she doesn't need to be intubated. Her respiratory rate never gets below 8 and it is not irregular enough to be overly concerned. My guess is that she is just oversedated -- not that I can find any sedation on her chart, but that is not unusual. Maybe she got some extra pharmaceuticals. This one home is known for occasional drug buys by some of its younger residents with drug histories.

I just nudge her periodically on the way in. At triage, I tell the nurse that I don't know what is going on. I'm guessing she is just overmedicated. But periodically she does seem to jerk, so I don't know. I mention her ETCO2 is on the high side.

We get in the room and the nurse bangs the cast on the patient's foot by mistake. The woman suddenly opens up her eyes and screams, "Hey, that hurt. Watch it."

"Well, that woke her up," I say.

"Why don't you just leave me be?" the patient says.

"Do know why you're here?" the nurse asks.

"No, they should have just let me be. I was out of it."

"Out of it?" I say. "Why wouldn't you answer any of my questions?"

"I just wanted to sleep. What's wrong with you people? I have sleep apnea -- they know that. They wrote it on that form. Now, you went and disturbed my nap!"

I feel like an idiot, of course.

The nurse just shrugs. It's not the first time an unresponsive nursing home patient has just been sleeping.

"Can you turn the lights off, please," the patient says, closing her eyes and shifting in the bed to a more comfortable position. "And then leave me be."


I've done a little reading on sleep apnea and I guess many patients with sleep apnea suffer from hypoventilation, which explain her high readings. The jerking I saw was probably just slipping out of a stage of sleep like when you nod off and then wake up with a start, and then nodd off again.