02 March 2010

Medical Unknowns Part 1

I have a two part story that I'm going to post this week. However, this one requires some audience participation.

I like to get feedback from time to time on my assessments and handling of a situation. I don't mind constructive criticism the least bit and at times I actually encourage it... o.k. need it

So if you would, read the following part of the post and tell me a couple of things:

1) What would be your working diagnosis?

2) Would you have done anything differently?...what?

I'll post the second part Thursday evening before I leave for the meet-up in Baltimore...so here we go!

I’m sleeping the other morning and I’m jostled awake by the tones dropping for a station out in the county. Possible heart attack or seizure dispatch advises.
Surely somebody would know the difference given the location of the call I think to myself. It was at an assisted living facility that houses mostly functionally MR residents.

Anyway, the volunteer station is not able to muster a crew so I haul it up off my little nap-mat and head to the truck. My partner, who happens to be my wife this morning, and I saddle up and head on out through the city to the call. We don’t get to work together much unfortunately, but when we do I like it just fine. ;)

I’m notified over the radio that the nurses think a resident is having a heat attack or something. Regardless of what it is, it sounds serious I’m told.
I push it kinda hard because we’ve got right about a 10min. response time from where we are in the city to the scene. There’s not a lot of traffic out at 5 o’clock on this morning so we make pretty good time.

We arrive on scene at the home and pull around to the side entrance. Oddly enough the refuge for these people who need help with their ADL’s is an out of service church building converted to a home…of sorts, but hey, it works.
As I pull up I notice a nurse; RN, LPN, CNA…I don’t know, she was wearing scrubs…she is motioning frantically for us to come on in. I grab my I.V. kit and the monitor, my partner/wife grabs the jump bag and we head in to the facility. Down the steps to the basement level we go, twisting and turning through the halls around obstacles following this frazzled lady who can not take the time to tell me what in the world is going on.

I enter a room that has three beds arranged in a Tetris like fashion. On the bed to my left I see a man in his 50’s wearing nothing but his skivvies and a t-shirt, being, or attempting to be, restrained by a well meaning staff member. This guy was giving her hell. He was trying to get up and she was trying to hold him to the bed. He’d go up and she’d push down. It was kinda comical watching it for a second because it looked like she was pushing the guy down onto a spring and he would just pop back up. To add to the humor of the occasion, every time she would push him down she’d say “Jim, stay still” or “Jim, please be still”. Well Jim wasn’t having any of this.

“What’s going on this morning?” I asked holding back a laugh.

“I think he’s having a heart attack or something”, she started. “He woke up while we were dressing Larry” she said motioning to a half-dressed man watching intently from across the room, “and just grabbed his chest…he started trying to get up but he just looked like he was in so much pain and I told him to just lay still and we’d get him to a doctor.”

“What kind of medical history does he have?”

The nurse behind me chimes in and says, “Well, he is retarded and he is a diabetic…we checked his sugar after we called ya’ll an it was 162.”

Retarded huh? Now, is that subjective or objective? C’mon lady…this ain’t my first rodeo, I’ve been in this place before.

“What’s he normally like…his personality…how does he interact?”

“Oh, he’s real nice. He don’t give us no problems at all…he just likes to help out and watch T.V.”, I’m told with a voice of utmost assurance.

I told the other staff member to let him go and I grabbed Jims left hand with mine. “Sit on up here big guy”, I said as I helped him to the edge of the bed. “What’s going on with ya this morning?” I asked trying to elicit a response.

Jim just sat there on the edge of the bed kind of rocking back and forth a little and looking around the room while chewing on his tongue it looked like. I noticed that he was breathing rather hard but attributed that to the ultra light-weight UFC match I had just witnessed. He wasn’t diaphoretic and really showed no signs of distress other than the fact he seemed to be a little agitated.

“Jim, are you hurting anywhere…anything not feeling good”, I asked with no response.

Jim stopped rocking and looked up at me with big ‘ol tired eyes and expelled a big huff of air. With strength I didn’t expect he stood up and stood still for a second as if he was getting his bearings about him.

He stepped off on his right foot and headed towards the door that leads to the hallway. “Where’re going there buddy?” I asked and followed behind holding to his arm.

Now I’m trying to get into his mind and figure out what’s going on. I’ll give him all the leeway he needs so as to not agitate him and try building some report’. What must he be thinking right now? He’s probably scared…or is he mad? Does he have a clue as to what’s going on?

Jim headed out the door, turned to the left and started down the hall. “Where’s the bathroom?”, I ask curiously.

“Right down there…at the end of the hall”, the nurse says

Jim moves on with a slow and steady gait, moving on past the curios looks and gazes of the other residents. Well, maybe we’re getting somewhere now I think to myself.
Ol’ Jim here just has to pee, pure and simple…but why isn’t he talking?

Just when I thought we were about to put and end to this call just by letting the guy go pee, he walks right past the bathroom door to the end of the hall. There is an old church style bench there against the wall that faces the direction we just came from and we head towards that. By his arm I lead him to the bench and ask him to sit down, he shrugs a little and flairs his elbows out a bit trying to shake us off. O’ boy!

I certainly didn’t want it to get this way but I just couldn’t let him wander around aimlessly after being told that his mental status is altered from normal. I need to figure out what’s going on; is this a stroke…was their glucometer off of something?

I finally get him to sit down and my partner/wife is getting a lancet and strip ready. I’m attempting to do a stroke assessment when out of nowhere this guys stomps his feet and flings his arms and lunges up at me with his head into my gut. Damn, that hurt. I can’t let this guy just get up and go running off at this point because something’s not right here. I put my forearm across the back of his neck and try to push him down to the bench he’s sitting on. This guy is strong and starts bucking like a wild bull or something, flailing his arms and stomping his feet. I can’t say for sure if he actually “hit” anybody but he was wearing me out just trying to restrain him.

Complicating the event even more was the insistent shrill voices of the staff pleading with Jim to “stop” and to “calm down”. They were making me want to have a fit.

While all this is going on I tell my partner to go ahead and try getting another glucose reading while I try and hold him still. You can just imagine the battle that ensued over that; I think she did end up getting hit in the process while pricking his finger.

Glucose level 147. Well hells bells…what is up with this guy?!? He finally manages to stand up and I just back off and tell everybody to just stand back for a minute. Then he just sits back down as if it’s all over.

I get my cell phone out so I can call the ER attending physician for orders for Haldol. One thing I know for sure; I want to get this guy evaluated and find out what’s going on. I don’t have a cell signal in the basement of this building and they don’t have a cordless phone either. So against my better judgment I run upstairs and outside to call the ER. I’m not too concerned for my wife’s safety at this point; we’ve got two teenage boys and I know what she’s capable of handling. That firery red hair packs a mean punch all by itself.

O.K., so there we have it. What do you think was going on here? What did I miss? What would you have done differently?

1 comment:

  1. Very interesting now you got me wondering if you got to give the Haldol or not. But anyway, I was thinking about checking the sugar level again the whole time reading this till i got to the bottom because you know how some people can be when it comes to giving proper pt. care. But the questions i would have asked was when he last ate? What medications is he on and when and how much did he take? also do they know of if he maybe fell that morning? But really with just the information given you cant make a proper diagnoses and if hes not co-operating with you then you cant do a correct Cincinnati stroke scale. But the guy could be just having a bad day due to his mental challenges. This does sound like a tough call and not sure but cant wait to read the next part to this story.