Thursday, February 07, 2008
With apologies to Etotheipi for the squiggily lines, I have to post this case from my night shift last night. This patient arrived via EMS with "indigestion" at 3 am and was by all accounts a real prick. He was demanding to see to doctor immediately and also demanding morphine, Versed and ice chips. This may seem like a fairly straight forward case.....but you'll love the twist! Read on.
The nurse brought me the EKG which they got immediately per protocol and since he was having an acute inferior wall MI (myocardial infarction) = heart attack, I went straight to his room. There I found a demanding, "I know more than you do" kind of patient who insisted on morphine. His heart rate was in the upper 50's at the time and his systolic blood pressure was about 100. Being astute, I figured that his inferior wall MI also involved his right ventricle so I wanted to be careful about my treatments..especially nitrates, or anything else which might drop his blood pressure. I almost ordered a right sided EKG, but the tech was already gone and I didn't want the hassle of getting her back....plus it wouldn't have changed my management.
I ordered 2 mg of morphine which the patient informed me was an insufficient dose and his pain was 10/10. I explained that he was having a heart attack, and I knew that 2mg wouldn't relieve his pain, but I was trying to "take the edge" off a bit while we got a nitro drip, aspirin, heparin and the other things started. I explained that I didn't want to MASK his pain, but rather to treat the cause, saving his heart muscle being more important to me than his pain. The cardiologist was en route and we should have him in the cath lab in the next 3o minutes or so to get his artery open. I was very patient and explanatory. He on the other hand, demanded some Versed (4mg to be precise) and more morphine ("at least 8 mg"). I knew that we were going to have serious blood pressure problems with this guy, and morphine and Versed weren't gonna help that. I really just wanted to get my low dose IV nitro drip going and see if I could help the pain and improve his overall situation.
Somehow, the nurse misunderstood me and gave the guy a sublingual nitro! The ER docs reading this already know what happened next....his BP dropped to 66/35 and his pain increased, he looked like hell, continued demanding ice chips in addition to his other drug demands He criticised us for "not addressing his pain".
I stayed at his bedside while we pushed the fluids to try and raise his blood pressure. In my nicest and most patient voice possible, I ordered 2 more mg of morphine (even as he protested that the dosage was insufficient). I sat at his bedside and in my best Marcus Welby impersonation, I explained that I'd give him every mg of morphine and Versed we had in the ER if I thought it was the right thing to do....but I didn't. I explained my limitations due to his heart rate and blood pressure. I explained that I really wanted to get nitro started, and unfortunately couldn't use Beta blockers since his heart rate and blood pressure were already so low. I understood his ice chip demands, but I explained that he'd be going to the cath lab very soon, and keeping him NPO was a better strategy at the moment. Like I said, this guy was sick as hell, but he was also a complete prick.
As a way of conversation, I asked what he did for a living (and here's why I'm presenting this case) and he told me that he was a JCAHAO (Joint Commission for the Accreditation of Health Care Organizations) examiner. Turns out he was in one of the little towns nearby doing a survey (torturing the shit out of the staff by nit-picking every little unimportant detail). Well, this was an interesting turn of events!
So, I asked him what he did BEFORE he went to work for JCAHAO (he seemed to "know" a lot about medicine, so I wondered if he was a physician in his previous life). He told me that he had previously been a hospital administrator! I couldn't help myself, nor hold my tongue....I said "so you went from being a hospital administrator to being a JCAHAO examiner"? "That's right" he said. "So, have you ever done anything useful?" was my reply.
I got a real "go to hell" look from this guy, but I figured that I could out run him, and he wasn't going to think fondly of us anyway since I wouldn't drug him up over trying to treat the cause of his pain.
Within 1/2 an hour, his pressure was 99 systolic with the fluid boluses, the cardiologist arrived, and off the guy went to the cath lab where he got two stents and reportedly became pain free as soon as his artery was opened.
So, I took a couple of lessons home from this case. First (no surprise): The JCAHAO folks don't give a tinker's damn about good or reasoned medicine....they just want the stupid pain scale addressed. Second (no surprise), many of the examiners are kooks. Third (ALSO no great surprise) even though my nurse inadvertently tried to kill this guy....as 911 has so eloquently stated....they're harder to kill than cockroaches!
For the sake of completeness.....the patient is now doing well. His door to balloon time at 3am was about 40 minutes....not excellent, but not bad either considering the time of day.
I'd have to say that this was more Karmic (if that's a word) than taking care of my dentist (who had done a root canal on me about 2 months before) when he got epididymitis!
Gearing up for another couple of exciting night shifts. Gotta nap now..........
Posted by erdoc85 at Thursday, February 07, 2008