Bad experience last night in ER

[godsfshrmn]

**this post is not criticisim, nor accusing anyone. It's about my experience

I'm a transporter at a local hospital. Last night I went to make one of the very common rolls, ER -> CT. I got down there and the man's pressure was only 40 /33. It was very chaotic. The ER doc was having a lot of trouble getting a central line in his femoral artery. His HR was around 100 and o2 sat was around 95, which was weird to me. They were suspecting an abdominal aortic aneurysm. I believe that got rulled out when ultrasound finally made it down there. After filling him with fluids, his pressure got in normal range and we left to for CT. His condition was still terrible.

Something must have happened during his CT because he became almost unresponsive. Before, he was at least making attempts to talk to us about wanting 'to get knocked out please'. We had him on a monitor but it wasn't registering anything because the pads wouldnt stick on his sweaty chest. His face was very purple and very cold to the touch all over.

After the CT the doc wanted a lung scan done. We got down to nuke med and the tech refused to do it because he could not lay still, much less flat on his back. We took him back up to the ER and I had to personally get the ER doc in the room because no one seemed to care.

It was a very bad situation. I have been to codes and done CPR before, but never had an experience like this one where it seemed like the man was almost on his own. There was no direction from anyone. The transport nurse went with us, but it seemed like no one knew what to do. I tried to speed the situation up in the unloading/loading on the CT bed.

I don't know if the doc knew that this was something that could only be solved in time (I hope that was the case), but when the US showed nothing she acted like she had no clue what was causing this man's problems. Granted my knowledge is lacking and I'm only a transporter/pre-med student, I really felt bad for the man I have heard about doctors experiencing their first patient death and the stress that comes thereafter. This was my first experience with something of this magnitude. What makes it even worse is I don't know what happened to him. I worked over in my shift to help this man get the tests they wanted done. I can't stop thinking about the look on his face, his color, look in his eyes, and how cold his skin felt.
Have any of you experienced something like this?

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[albaniandoc]

From my limited experience, it sound like the usual deal in the ER. Although BP of 40/30 got to get your attention. I honestly don't know what happened. It could be anything. Obviously opening fluid wide open was an idea where to start. We get patients like that in Open Heart on ocassion, exept that they come from the cath lab with a wire sticking out of their left coronary. The BP is on the toilet and unresponsive.
By the way, chances are the ER doc was trying to get a central line started on the venous side, not the artery. Usually they stick an a-line on the artery side of circulation to measure blood pressure. Sometimes our MDs will use Cook catheters as alines in the femoral artery if they cannot get the normal alines in the radial artery.

 

[Depakote]

It's the frustration that comes with being a shadow.

You get to see and experience all the aspects of medicine, but you are completly helpless to change the outcome. This doesn't always change when you're a doctor, but at least you get to feel like you tried.

I've had a number of cases where I've fealt like that, I wish I could tell you something, but it happens, especially in ancillary fields. You'll be working with someone very sick and then you'll just have to trust in the people you work with to help them. But the fact is, people are going to die and even the best docs aren't going to save them all the time. I know, I've worked for the best docs.

I hope there's something in that ramble you can find useful or at least something you can relate to.

 

[docB]

This might get more response in the EM forum than in Topics.

 

[oldManDO2009]

how old was he? I had a patient this last weekend that died but she was very old and there was litle we could do. I would hope I would receive agressive treatment and not just diagnosis by scanning..sounds like a tough experience

 

[godsfshrmn]

I would guess he was in his late 50s-early 60s.

Yea it was bad =/ I looked up an abdominal aortic aneyursm and if that was what he truly did have, he only had 10-25% chance to live if surgery was performed. The hospital I work at is not approved for any level of trauma. IMO he should have been transported to another hospital where the facilities are more equipped to deal with a situation of this magnitude, but then again the doc probably knew what was going on. They said they did not see it on his US, and from reading on it the diamater had to be at least 5cm. I would hope they didnt overlook that because his symptoms described excatly what I was looking at, but almost everything overlaps, otherwise diagnosis would be easy!

 

[albaniandoc]

Actually, unless it is a ruptured AAA, our patients do ok. I think the survival rate is when it is ruptured. Plus the location of the aneurysm is important.
I think from a nursing standpoint the first 24-48 hours post-op are critical. A lot of complications can arise, including kidney shut down (from crossclamping the aorta) etc.
I have scrubbed a couple of emergency AAAs and those are not fun at all.
I certainly hope that is not what that patient had. Obviusly, I don't get the whole pics, since I work in the OR and rarely see how patients do long term.

 

[docB]

OK. I had initially planned to avoid commenting on this but I just can’t. I appreciate the OP’s statement that they are not pointing any fingers but there is a real feel of Monday morning quarterbacking to this thread so let’s add some perspective.

This was my first experience with something of this magnitude.

You encountered a very sick patient in the ER. The ER is a target rich environment for that sort of thing hence the name. Spend more time in the ER and you will see more sick patients and some deaths. That’s what the ER is for.

The hospital I work at is not approved for any level of trauma. IMO he should have been transported to another hospital where the facilities are more equipped to deal with a situation of this magnitude, but then again the doc probably knew what was going on.

There was a suggestion that a patient with a AAA (or maybe a PE, MI, other) should have been transferred to a trauma center. It appears you are erroneously defining “trauma” as meaning “very severe.” That’s not what it means. “Trauma” refers to patients who have suffered acute injuries. Trauma patients can be severe or minor but they have all been acutely injured by things like car accidents and gun shot wounds. A pt with a AAA, even a severe one that is rupturing, can be cared for at a hospital with vascular surgery and an ICU. If the center in question has these then not only would it be inappropriate but illegal due to EMTALA to transfer this patient to a trauma center.

Yea it was bad =/ I looked up an abdominal aortic aneyursm and if that was what he truly did have, he only had 10-25% chance to live if surgery was performed.

Be careful extrapolating stuff you look up to real cases without any context. Remember what they say about "a little knowledge." It sounds as though AAA was appropriately evaluated by US and ruled out as the cause of this episode. Based on the fragmented info available I would next move on to MI, PE and thoracic dissection. Pt patient had a CT scan but we don't know for what. It sounds like this was followed by a nuke med VQ for PE so they were working that differential. We don't know what the EKG showed or the initial chest x ray which are both crucial. Why a VQ rather than a CT chest with contrast? What was the creatinine? My point is that sick patients can be mysterious and require lots of work up to diagnose. If they are hypotensive it's hard to give them proper analgesia without bottoming them out.

I suggest that when you run across a sick patient again you ask the nurse what's going on. The nurses will know why tests are being done and why pain meds are or or not being given an so on. Understanding why these things are being done may reduce the feelings you had that everything was chaotic.

 

[albaniandoc]

Excellent post docb. Thank you

OK. I had initially planned to avoid commenting on this but I just can’t. I appreciate the OP’s statement that they are not pointing any fingers but there is a real feel of Monday morning quarterbacking to this thread so let’s add some perspective.

You encountered a very sick patient in the ER. The ER is a target rich environment for that sort of thing hence the name. Spend more time in the ER and you will see more sick patients and some deaths. That’s what the ER is for.

There was a suggestion that a patient with a AAA (or maybe a PE, MI, other) should have been transferred to a trauma center. It appears you are erroneously defining “trauma” as meaning “very severe.” That’s not what it means. “Trauma” refers to patients who have suffered acute injuries. Trauma patients can be severe or minor but they have all been acutely injured by things like car accidents and gun shot wounds. A pt with a AAA, even a severe one that is rupturing, can be cared for at a hospital with vascular surgery and an ICU. If the center in question has these then not only would it be inappropriate but illegal due to EMTALA to transfer this patient to a trauma center.

Be careful extrapolating stuff you look up to real cases without any context. Remember what they say about "a little knowledge." It sounds as though AAA was appropriately evaluated by US and ruled out as the cause of this episode. Based on the fragmented info available I would next move on to MI, PE and thoracic dissection. Pt patient had a CT scan but we don't know for what. It sounds like this was followed by a nuke med VQ for PE so they were working that differential. We don't know what the EKG showed or the initial chest x ray which are both crucial. Why a VQ rather than a CT chest with contrast? What was the creatinine? My point is that sick patients can be mysterious and require lots of work up to diagnose. If they are hypotensive it's hard to give them proper analgesia without bottoming them out.

I suggest that when you run across a sick patient again you ask the nurse what's going on. The nurses will know why tests are being done and why pain meds are or or not being given an so on. Understanding why these things are being done may reduce the feelings you had that everything was chaotic.

 

[godsfshrmn]

I sorta had an idea of the situation (again, im a student ). I wish it were handled better. He didn't have a chest XR, and his abdomen CT was done without contrast. The doc did have the blood work called in as each test was completed, and blood was drawn a second time just before we left. The VQ scan, was not done in the NM department, but I think they were going to give a portable a try. This was when I left. Thanks for clearing some things up! It made me realize how little I know about medicine and how far I have to go I think, without realizing, some of the scripted ER had gotten into my thoughts. There is no flow chart on how things will happen or what to do (in general).

What are patients classified as when they are in a condition such as his? Do the typical terms such as 'critical' apply here?

 

[docB]

"Critical" would be a reasonable description for this.