Tuesday, February 5, 2013

Trust Your Gut

On this particular night, I was in triage, my home away from home.

Do this stuff long enough, and you realize that for no discernable reason, patients with the same chief complaint all show up on the same night. Some nights you get two main flavors, others it's just one.

On this one, it was one, and the one flavor of the night was chest pain.

Four hours into the night, and we'd already triaged eight legitimate chest pain patients. The last one, in fact, was a hot STEMI (ST Elevation Myocardial Infarction - a big fat heart attack in layman's terms) soon to be headed for the cath lab. Once I got him in the room and the fire drill of getting him ready to go began, I headed back to triage to start on the next patient.

Looking at the computer tracker, I saw that the newest sign in was a 40 y.o. M with abdominal pain, nausea/vomitting. Bummer, but nothing special during the height of flu season. I already had 15 pts. on deck waiting to get back, and 5 or 6 waiting to come in for vitals and a quick look, but a lot of them were overwhelmingly likely to be of the "you aren't dying any faster than the rest of the human race" complaints. So I decided to stick my head out the door and eyeball the new guy, who I was sure wouldn't be having a fun night, just to make sure he was okay.

I looked towards the front, and saw who it had to be, guy in his PJs, trashcan between his knees, and looking thoroughly miserable. But something about the look on his face made me say "Let's bring this one in for a closer look".

I walked out, grabbed his wheelchair handles, and told him I just wanted to talk for a minute, and check on him. His female entourage (fiancee, I later learned) was 39 weeks pregnant and ready to pop any day, but that was ancillary to everything at this point.

I piloted this guy inside the screening area, hooked him up to the vitals machine, and while it cooked, I ran through the 60 second OPQRST about his pain (epigastric) - {Perk!}, he'd been feeling miserable at home since shortly after dinner, hadn't been sick prior, no history/no meds/no allergies. His pulse is slightly tachy, but nothing radical, ditto for the BP, but then I've just watched him do a couple of gloriously painful dry heaves on the trip inside, and he's a little diaphoretic. Nothing inconsistent with the Food Court Two-Step, and he's probably just eaten something that his body wants out ASAP.

But he's 40. And his pain is epigastric. So it could be gut, or it could be cardiac. So even though the chest pain team is running like one-legged butt-kickers, including with the STEMI I just took them, I still page for an EKG, just to be safe, for me, for him, for the lawyers.

I get him on the table and prepped just as the harried EKG tech zips in with the "You've got a lot of nerve" look on his face, but this guy fits the profile, so I'm not abusing the privelege, and we run a 12-lead.

"Abnormal EKG".

No elevations, but it's funky, according to the $5K electronic chipset brain in the box.

So I roll the gurney he's on back to another open room with full monitoring, because it was empty 90 seconds ago when I took the STEMI to the room across from it.

As the nurse in that section looks at me, I do the clutching-my-chest pantomine for "chest pain". His jaw drops. "You've gotta be kidding me! Another one?"

"Sorry man, he's legit. I don't order them, I just deliver them."

I see the cardiologist on call has arrived to see his guy with the STEMI, and he AND the ER doc both look at the fresh 12-lead from my latest, which I hand them as I roll past to the room.

I hear the cardiologist, one of our finest, say to the ER doc as the both look over the 12-lead printout, "That looks okay, he's stable to wait. We'll be ready for the STEMI in about 5 minutes, as soon as my team's all in."

I'm thinking that's pretty spiffy, since it's only been about 20 minutes since the page went out. Even when we're getting beat up, we shine.

My partner has triage under control, and I know my co-worker's getting hammered, but them's the breaks. Another nurse is floating, and I ask her to grab an IV set-up, while the chest pain tech and I get this guy into the empty room with a quick swap of full gurney for the empty one already there, and I start hooking him to the room monitor.

The float nurse comes in with a ready-made draw kit, and grabs the guy's right arm, while I'm sticking EKG leads on and firing up the room monitor. The guy's talking to us, and his very pregnant girlfriend takes a seat at the foot of the bed. As the tourniquet's going on his arm to pop up a vein, I'm snapping the last of the 3-leads onto the patches. The other nurse calls the guy's name. Then again, loudly. I glance over and see he's clutching her hand as she's trying to stick the IV.

Just as I look back at the monitor, I see his eyes roll back in his head, and he goes from sinus rhythm to full-on bag-of-worms classic ventricular fibrillation. His girlfriend's screaming gets everyone's attention outside rather nicely.

"Code Blue Room 6!" I yell over the other nurse's back and out the door To Whom It May Concern. Then I drop the cannula I had prepped, and swap it for a bag valve mask at 15 liters. The crash cart and even more nurses are at the bedside before I've even finished dialing the liters up, and we stick the pads on him in maybe 20 seconds. His girlfriend looks for all the world like she's going to deliver right now, and I nod to the tech to gently move her out of the already too small room.

The ED doc bustles in as she goes out, the crash cart nurse has the defib charging, we're all clear, and we shock him.

No change. Still v-fib.

The doc says to up the charge as one of the other nurses is already spinning the dial, and in seconds we're ready again. "Clear!"

Zap Number Two...resolves into a beautiful sinus rhythm, and I'm happy to confirm between bag squeezes that he has both carotid and radial pulses just like both monitors show.

Meanwhile the other nurse finished getting the IV we wanted, and drawing a full rainbow of tubes for the labs he's going to need. Most everyone else goes back about their business elsewhere. With nothing else to do, I grabbed the Code Record, documented everything we did for the 65 seconds it lasted, and just as I and the other nurse are signing it, the patient pops back fully conscious and says, "What happened?!"

"Hey pardner, you left us for a little while. Glad you're back. But I think it's safe to say we're keeping you tonight."

Then I went to the inside wait area, and told a much-relieved lady her date was back around as I walked her back to his bedside.

I passed the zone nurse, told him we saved his patient for him to work up, no charge, then headed back to triage.

The guy had another shaky few minutes later, no codes though, but as he was waiting to go to the Cath Lab next, they hooked him up to a nitroglycerin drip. That's when it hit me, as I was passing his room coming and going with other patients from triage for the rest of the department.

He was pink. Slab of ham PINK.

This was remarkable, because while I hadn't consciously noticed it, when he'd arrived he was somewhere between white and gray, by comparison to how he looked at the moment. My frontal lobe hadn't caught it, but some part of my brain had, and that had to have been what caught my notice.

The zone nurse told me later, "I'll never question your triage calls again!"

The patient, it later turned out, had a 95% posterior cardiac artery occlusion, with no ST elevations noted anywhere. If the fiancee hadn't pushed him into coming, he'd have died at home. And if I hadn't gotten him back to a room when I did, he'd have coded on the waiting room floor, with probably a much worse outcome.

His fiancee's pregnancy was the other shoe to a pending but not yet final divorce, which explained why the dude was having a heart attack. Look up divorce, marriage, and having a baby on the life stress scale, then combine the scores.

And learn to trust your gut even when you can't put your finger on why.

Of course, we got 3 more chest pains after that.

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