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Saturday, January 12, 2008

Most Drs are patient, but some just intubate

To be fair to the nurses and the doctors in my last post who were eager to intubate the patient who tried to kill herself with a massive amount of a certain drug I can't remember the name of, I did leave one very important key point out. I was suffering from lack of sleep yesterday, and from massive burnout, so you have to cut me some slack here.

When the patient was first transferred to her new bed in CCU she had no gag reflex when I suctioned her airway to remove a massive amount of secretions that had accumulated there. Then she provided no response to the sternal rub. She was out. That, coupled with the fact she was agonal breathing, the nurse and the patient's physician decided the patient should be intubated to protect the airway.

Technically speaking, that was not a bad idea. However, I knew for a fact the patient was not like this an hour before, and that's why I thought maybe there was something else we were missing that might prevent her from needing to be intubated. So I did a blood gas while the nurses called the patient's physician.

When I noticed the gases were not exceptionally well, I called the patient's RN from the laboratory and informed her Dr. Krane should be notified with these ABG results since this was her patient in her, and I told the nurse I'd rush down to ER and show her myself. Then, en route, I decided I would just go up to the CCU to be with the patient, and, lo and behold, when I got up there Dr. Krane was standing alongside the patients bed.

"Holy cow," I said, "How in the world did you know we needed you? And how did you get up here so fast?"

"I was just concerned about the patient," Dr. Krane said, "And I wanted to make sure she was okay for you guys."

"Well, I'm very impressed."

Then she stunned me with this: "Give a breathing treatment."

Oh, come on. Here the patient is crashing and you want to give a breathing treatment? Like a good boy, I set up the treatment and fitted the mask on the patient's face. This ought to cure her of all her ailments.

Then Dr. Krane provided us with some information we did not receive in report. "I just talked to the husband, and he informed us that she (the patient) uses her rescue inhaler 5-8 times per day."

Aha, well, that makes more sense. "Well," I said, "In that case she probably uses it 10-16 times per day, because it's usually double what they say."

"True," she said.

Dr. Krane and I watched over the patient, literally, for the next 30 minutes, and I kept watching the clock and the entry way to the CCU for any signs of the doctor who said he would be here any minute. I prayed he was really late.

As she watched over the patient, eyed the numbers on the monitor which showed a heart rate of 126 but otherwise normal vitals, I wondered if she thought she had overlooked something in ER. Was she sleeping the last 6 hours the patient was down there and too lazy to check in on the patient and the nurses didn't pick up on the fact the patient was failing?

"You saw this patient in ER," she said, "Did you notice she was labored?" Perhaps I'm right.

"No," I said, "She wasn't labored at all. What do you think?"

"Well, I think she's going to be fine with the breathing treatments. I think that she hasn't had her bronchodilator in well over 12 hours, and her body responded to the transfer to the floor by having an excacerbation of asthma." She continued to look at the patient, and only occasionally looked up at me. "I think if we just be patient here we won't need to intubate."

"I really like that idea," I reassured her, as though it mattered what I said.

"What do you think of this doctor," she said. I figured she was referring to Dr. Seamon.

"I don't know Dr. Seamon very well," I said, "But I think he'll want to intubate as soon as he gets here regardless, and he'll want a massive tidal volume like 1000 or something stupid like that." Dr. Krane laughed.

Seriously, while I think she does order some stupid treatments, she is really nice. I didn't always think that way though. I've learned to keep an open mind about people I meet while working, and not take anything they say personally. Many people I talk to can't stand her because she is such a control freak.

"I think she will be fine," she said.

"Well, did she have a gag reflex in ER?" I asked.

"Yes, we tried to put in an oral airway, and she definitely responded."

I hesitated a second, as I didn't want to ask a stupid question, then I decided the heck with it. "Why do you think she's has no gag reflex all of a sudden?"

"I think the (drug she took) has peeked. In ER she was just lying there almost obtunded, but she was comfortably breathing. She was in a deep drug induced sleep."

"How long is that drug supposed to last?"

"I know she does cocaine and other stuff too, but poison control said about 24 hours. We can't know for sure how long it will last, but if we monitor her very closely we should be able to avoid intubation. However, that's my opinion, and I won't have jurisdiction over this patient as soon as Dr, what's his name? gets here."

"Dr. Seamon."

"I thought you guys said he would be here any minute." She smiled.

"That's what he said.

Now, fast forward over what I wrote yesterday to the intubation. As soon as we turned the patient on her back she started fighting. When the anesthesiologist started to insert the tube, the patient fought vigorously and even sat up -- twice.

She was obviously no longer under the deep, dark influence of the drug. And she had an obvious gag reflex. That, coupled with the good repeat ABGs, made me wonder if the patient didn't need to be intubated after all. But Dr. Krane was no longer in control, and I had transferred my beeper to my relief.

While watching all this, and assisting in holding the patient down so she didn't whack some nurse or my fellow RT in the head, I watched as the anesthesiologist drew up a white medication via syringe. These doctor's are very intense on intubating this patient. Are they forgetting to look at the big picture?

I audaciously tossed out an idea, "Um, you guys might want to disagree with me here, but I just wanted to toss this idea out. Since she appears to be responding to your efforts here, do you think we still need to intubate?"

"Oh definitely," Dr. Seamon said without hesitation, "We need to protect the airway."

My coworker, while holding cricoid pressure with one hand and bagging with the other, looked at me with a funny grin and rolled his eyes. We RTs, you know, have no control. And it's not that we don't want to take care of another vent patient, it's more that we wonder if sometimes, just sometimes, hospital staff get over aggressive with some patients.

After a lot of tinkering, finally the patient was intubated, and the airway secure. Dr. Seamon said, "Let's see, I think a tidal volume of 750 should be good, a respiratory rate of 14 and, oh, how about 50% oxygen."

My coworker looked at me, cocked his head and rolled his eyes. I knew exactly what he was thinking. "I calculate a tidal volume of 600 for this patient, and definitely no more."

"Well," Dr. Seamon said, "I learned to go by weight, and this patient weighs 230 pounds."

"No!," my coworker chimed, "We go by size..size definitely. How tall is this lady."

"I was told she's 5 feet 3 inches," I said, "and I calculate 350 to 600 is the tidal volume range based upon our ventilator protocol of 6 to 10 millimeters per kilogram of ideal body weight." There, that should help you out Dave.

"Okay, well, start out at 700 tidal volume then," Dr. Seamon ordered.

Dave rolled his eyes again, and made no effort to hide it from Dr. Seamon.

I laughed audibly. I'm sorry, but I was very tired, as I had been at work 13 hours at this time. Nobody but Dave noticed I was laughing, though. I looked at each person in the room, and they were all intense with their respective tasks.

I couldn't hold it in any longer. I wished Dr. Krane was still here, because she had a clue.

Later, as I was finally giving Dale report, he said, "What the hell tidal volume do you figure for this patient."

"Max 600, but with her asthma I'd go lower."

"Good, because the vent was set at 500, and that's what I used."

"I thought it was cool you showed frustration to Dr. Seamon," I said, "but I had that discussion earlier with him and I didn't care what he said, because he doesn't have vent privileges here, and we have our protocol. I was just doing to set it at what I wanted, and hope the Internist agrees with me when he gets here.

"Right on," he said, and smiled. "I just give up."

We have to keep in mind here, however, that the medical field is an art that is based on science. And there is often more than one right answer. Thus, while I disagreed with this intubation, I could still be wrong.


the anonymous therapist said...

Man...sounds like there's a Jerk Virus making the rounds among some sets of MDs lately. Good for you for sticking up for what you knew was right. Just because he's got MD after his name doesn't mean he knows everything.

JeRRTep said...

We have a patient that frequently comes in begging to be intubated...stays on the vent approx 12 - 24 hrs, comes off the vent and is placed in step-down...comes in only after I (suspect) a hard weekend of partying...can't breathe...after a weekend like that...needs help...and he gets it...EVERY TIME!

doesn't have a job, claims to be homeless - no bill can find him - and vented every time...go figure..

I've never been a "partier" and I personally like breathing on my own..I have a job, I pay my bills and I live the straight and narrow...

so this always just floors me that people can do this and get away with it....

I can't wait to go to med school...
ohhhhhhhhh the things I will do...but not so much to my patients, I figure all these doctors that are writing useless orders will be needing docs of their own someday...and ohhhhh do I want to do TID abg's just for mere curiosity on those patients of mine!!!


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