She was out of it. When she fell into a deep sleep she went apneic and her spo2 dropped to 72%. The RN tried to awaken her, but she would not respond. And when she finally did respond, she had no clue who she was nor where.
The doctor, correctly, opted for BiPAP. I was a head of the game and already had the BiPAP ready to go. Keep in mind here this lady was completely either obtunded or out to lunch for over two and a half hours.
So, I go to put the mask on her and she wakes up and is completely defiant about putting "that damn mask on my face." She writhed her head this way and that, grasped with her hands. I had the RN hold her hands thinking she simply wasn't with it and was just reacting. But, as it turned out, she was as alert as my 3 month old in the middle of the night when you expect her to be sleeping.
I was surprised by her reaction here mainly because she was so OTL for so long. I tried to wake her up before I put the mask on, and she never even twitched. So I figured I'd put the mask on real quick and be done with it.
But, that's not how it went down. So here I'm standing watching this lady flail, and screaming how much she didn't want my BiPAP.
I was thinking, "It's amazing what a little scare with the BiPAP mask can do to a person. It can wake up a person, change her mental status."
I pulled back the BiPAP mask; no point in forcing it on someone who is fully awake and defiant. I certainly don't want to traumatize the lady any further. I don't want to be inhumane. I shut off the machine and listen to the discussion between RN and patient.
"We need to put you on the machine because you stopped breathing when you slept," the RN said.
"No I didn't," the patient said.
"Yes you did."
"No. I'm just fine."
"No you are not. You need help with your breathing."
"Well, I'm fine now."
"Yeah, you're fine now, but when you sleep you have trouble breathing."
"So, I'm fine now, so leave me alone."
"So," the RN says, "When you stop breathing again, can we put the mask on you then?"
"Only if I stop breathing for two hours again."
"Well, it doesn't work that way."
"We can't let you go 2 hours without braething."
"Well, I don't want that mask."
"Okay, well, if your heart stops beating, do you want us to put a tube in your throat to help you breath then."
"Why don't you try it now so I can see if I like it or not."
That's where I had to leave the room.
It was a sweet old lady and she was so cute. And she had no clue. The sad part about it is that she had no family, no person to help her make decisions. She should have been a DNR patient I thought. It should have been discussed before now. It may have been. I highly doubt even under the sanest of moments this lady may not have a clue about what we are referring to in an attempt to help her survive another day.
Or are we only seeing a lady in her weakest moments. Perhaps on a normal day she's sharp as a whip. That's the thing about working in the medical field, sometimes we only know what's right before us, yet we have to consider everything -- including that of which we have no clue.
Then again, it may have been the hypoxia talking. Or, better yet (and this is why I backed off instead of forcing it upon her as some might have done), perhaps she was simply overwhelmed by the moment. I mean, what would you think if you suddenly woke up to a huge mask blowing air in your face?
As, an hour later, she let me put the BiPAP on her and hence it is still on with the patient who is sleeping comfortably. It's amazing what a little TLC can do -- and the help of a wonderful nurses assistant.
Sometimes you know what's best for the patient, yet you have to become creative in how best to take the next step.