I will talk about this Theoretical Patient I saw.
Patient initially found by ems lethargic and not talking.
Somehow message conveyed to us as a Medical Notification as a possible Stroke.
DNR/DNI. Thankfully veteran EMS personnel who respected the wishes of the wife and son who were with the patient but didn't have the written documents on them.
Patient well over 80s with prostate cancer. Patient lives at home with wife. He had fallen earlier after complaining of dizziness earlier. But with generalized weakness recently with a new cough. No fever noted.
On arrival, thought was lethargy was from possible sign head trauma that was significant like a traumatic head bleed. Massive ischemic stroke or Massive Hemorrhagic stroke from HTN or from trauma.
The patient did have a documented fall that was unwitnessed.
Stroke team noted a patient with agonal breathing. As did the other ED docs in the Room.
ABG now or later? hmmm. CMS guidelines for stat ct scan head w/o contrast within 30 minutes of arrival.
Sorry but the patient had no focal neurological deficits. GCS almost 3. And with the Advanced directives declared early already with the family who we spoke to, I didn't have to intubate. Or I didn't push for it or have the family rescind it the DNR/DNI.
CT scan head done stat and found no acute pathology.
ABG done and tell me what you think.
Bi-pap started, Why not?
The patient was dnr/dni. I disagree in that it being invasive.
The patient wasn't abandoned. 1 ed nurse to 2 patient ratio in the RESUS room. There was a doctor in the room watching the patient like a hawk.
What did I have to lose?
If the patient deteriorated and died, he would be made comforfable.
If he started to vomit, I would remove the Facemask and replace the Bi-pap with a Non-rebreather Mask.
I would give iv reglan or Iv Zofran as an antiemetic, and offer morphine for air hunger.
The patient now opens eyes to voice. Says his name. Recognizes his wife.
Plan to admit to Medicine, since family was agreeable to treating his pneumonia with iv fluids, iv abx and continued NIV, non-invasive ventilation as needed. . Patient with a dry cough. Not a hacking cough causing him to aspirate jelly like sputum expectorant. The critical phasestye had passed and now I can possibly transition him to high-flow nasal cannula once his mental status had improved.
Crazy part. The Neurologist on call, at home, but via telephone consult since this was a stroke team activation by ed nursing. Despite the fact the patient was confused from metabolic encephalopathy from hypercarbia. Still wanted a CT angio head and neck to rule out large vessel occlusion to the vertebral and basilar artery of the brainstem. The consultant didn't hear more than Altered Mental Status aka AMS and dizziness. Remember he was the consultant and more concerned why the patient fell and had dizziness high on his differential and major concerns.
The ED doc had another concern. Dizziness is universal code for not feeling well. And not specific to only things neurological. Likely lightheadedness from generalized weakness from recent pneumonia, not eating well. and failing to thrive at home. The stat mri brain that was also recommended was left for later.... much later and likely not to be persued.
My medical license. Not yours.
Anecdotal example. But will shape how literature differs from clinical experience and at times enhances what you think is right in the end.
You can write to me if I was wrong.
You can also read the article I co-authored with Dr. Michael Radeos in the past.
Here is the link. Thanks Life in the Fast Lane.
Reference on Emcrit.org
on Amazon. Drones don't send publications home yet.