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- Jul 9, 2007
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saw this 4 part post on sermo. the discussion was do you hold this pt against their will and admit or ama. what do you guys think? I am sure we've all dealt with this kind of pt but this story is bizarre
A 29 year old female comes to the ER for a loss of consciousness.
According to her and her boyfriend, she was walking down the street when she began to feel dizzy. Then she fell. Her boyfriend caught her and lowered her to the ground gently, and called EMS. The patient was unconscious when EMS arrived, but came to in the ambulance and was alert and oriented on arrival in the ER.
The patient reports that for the last 3 days she has been having multiple episodes per day of loss of consciousness. She believes that they are seizures -- she reports that she takes alprazolam 2 mg by mouth 3 times daily for seizures and anxiety, and has not had the alprazolam for 3 days. These episodes started the morning after her last evening dose.
PMH: anxiety
Social: opioid dependence (denies other drug dependence or abuse). 1 PPD smoker
Meds: Methadone 230 mg po QD, alprazolam 2 mg PO TID.
After the initial assessment (as described above), my colleague (who is taking care of the patient), orders a CBC, chem 8, LFTs, PT / INR, UA, Utox, EtOH, UCG, EKG, CXR, and CTs of the brain and cervical spine.
As he is writing his initial note, the patient's boyfriend comes haring out of the room, shouting "Doc!, Doc! She's doing it again!" He goes to the patient's room, and finds her altered: she is unresponsive to painful stimulus. She is tachypneic and hyperpneic. She is diaphoretic. The radial pulse is not palpable. She had not yet been placed on the cardiac monitor (city hospital), so the rhythm is unknown. He calls for a crash cart, and she becomes apneic and limp. There is no carotid pulse. He performs chest compressions while the nurse is setting up a BVM.
After 30 seconds of chest compressions, her upper extremities start to move, and she takes a breath. She is placed on an oxygen mask. She has peripheral pulses. She is placed on the cardiac monitor, and is in a sinus rhythm with bigeminal PVCs at a rate of about 90. The blood pressure is 100/60, SaO2 is 100%, respirations are 22. The PVCs resolve after about a minute.
The abovementioned labs are drawn, and the radiographic studies are performed. Cardiology is consulted.
Over about 1/2 hour, the patient returns to an apparently normal mental status. She is told what happened, and that she needs to stay in the hospital. She refuses this and leaves against medical advice. A 12-lead EKG is never performed (city hospital). Labs are pending, the chest x-ray and CTs show no acute findings on a preliminary review by the ED physician.
The disgruntled CCU fellow leaves the ED in disgust.
A few hours after her discharge, I am called to the trauma bay for a code yellow (agitated patient requiring immediate attention). The EMS triage nurse recognizes the patient and sends in the initial treating doctor who relates the events of the first ED visit while I'm assessing the patient. I suggest that, in the interests of continuity of care that he takes the case (cough cough), but he politely refused as he feels I may benefit from some of the more unusual aspects of the case (cough cough). Anyway.
EMS says they were called for an unconscious woman and found her on a park bench. She was not responsive to painful stimulus. She had shallow slow respirations (rate 6 / minute) and constricted pupils. Her heart rate was 100. SaO2 was 85%. They didn't get a blood pressure. After the administration of naloxone 0.4 mg IV she because agitated.
On arrival, she was agitated. There were no significant secretions, and the airway seemed patent. Respirations were fast and deep (24). Lungs were clear. Skin was warm, diaphoretic, and peripheral pulses were full (120).. BP was 132/86. Her eyes were open, sure was making incomprehensible sounds, and she localized to pain (GCS 4/2/4 = 10). FSBG was 106 mg /dL.
Other pertinent findings: piloerection, yawning, retching.
An EKG showed sinus tach at 108, no ectopy or ST- T changes. The QTc was about 600 ms.
Review of the testing from the prior visit showed that the imaging studies were reassuring (CXR, CTs of brain and c-spine). The hemogram was likewise benign (WBC 6.8 Hgb 11.2 Plt 256) and the chemistry and LFTS were noncontributory except for a potassium of 3.0 mMol / L. Magnesium had not been tested. The troponin was 0.172 (normal less than 0.045).
The patient was placed on a cardiac monitor and supplement oxygen, and the labs were repeated. Over about 40 minutes, the signs and symptoms of iatrogenic opioid withdrawal gradually ceased, and the patient became calm. vitals remained reassuring (HR in the 80s, BP in the 100s/60s range, SaO2 99-100% on a nasal canula at 3 L, respirations 12-14).
The ICU was consulted and they came to see the patient.
Then, I was called to the room by the RN. The patient's mental status had abruptly changed. She had become unconscious, unresponsive to painful stimulus. She was tachypneic and hyperpneic. The cardiac monitor showed ventricular tachycardia at about 230-240. The peripheral pulses were weak, and the blood pressure was 90/50. I kicked myself for not having put on the defibrillator pads, although at least I had the crash cart standing by.
While the pads were being opened up, she became apneic. The peripheral pulses were gone. I said "****" and thumped her chest as hard as I could, which was ineffective. I started chest compressions and my PA started to ventilate the patient with a BVM while my resident set up to intubate. After about 1 minute of chest compressions, the patient started to try to push me away, and I stopped chest compressions. She tried to remove the BVM mask from her face. The cardiac monitor showed sinus tachycardia with a rate of ~120 and bigeminal PVCS with R-on-T phenomenon.
I loaded her with amiodarone and started the drip. The PVCs resolved.
I told the ICU to come and get her.
A 29 year old female comes to the ER for a loss of consciousness.
According to her and her boyfriend, she was walking down the street when she began to feel dizzy. Then she fell. Her boyfriend caught her and lowered her to the ground gently, and called EMS. The patient was unconscious when EMS arrived, but came to in the ambulance and was alert and oriented on arrival in the ER.
The patient reports that for the last 3 days she has been having multiple episodes per day of loss of consciousness. She believes that they are seizures -- she reports that she takes alprazolam 2 mg by mouth 3 times daily for seizures and anxiety, and has not had the alprazolam for 3 days. These episodes started the morning after her last evening dose.
PMH: anxiety
Social: opioid dependence (denies other drug dependence or abuse). 1 PPD smoker
Meds: Methadone 230 mg po QD, alprazolam 2 mg PO TID.
After the initial assessment (as described above), my colleague (who is taking care of the patient), orders a CBC, chem 8, LFTs, PT / INR, UA, Utox, EtOH, UCG, EKG, CXR, and CTs of the brain and cervical spine.
As he is writing his initial note, the patient's boyfriend comes haring out of the room, shouting "Doc!, Doc! She's doing it again!" He goes to the patient's room, and finds her altered: she is unresponsive to painful stimulus. She is tachypneic and hyperpneic. She is diaphoretic. The radial pulse is not palpable. She had not yet been placed on the cardiac monitor (city hospital), so the rhythm is unknown. He calls for a crash cart, and she becomes apneic and limp. There is no carotid pulse. He performs chest compressions while the nurse is setting up a BVM.
After 30 seconds of chest compressions, her upper extremities start to move, and she takes a breath. She is placed on an oxygen mask. She has peripheral pulses. She is placed on the cardiac monitor, and is in a sinus rhythm with bigeminal PVCs at a rate of about 90. The blood pressure is 100/60, SaO2 is 100%, respirations are 22. The PVCs resolve after about a minute.
The abovementioned labs are drawn, and the radiographic studies are performed. Cardiology is consulted.
Over about 1/2 hour, the patient returns to an apparently normal mental status. She is told what happened, and that she needs to stay in the hospital. She refuses this and leaves against medical advice. A 12-lead EKG is never performed (city hospital). Labs are pending, the chest x-ray and CTs show no acute findings on a preliminary review by the ED physician.
The disgruntled CCU fellow leaves the ED in disgust.
A few hours after her discharge, I am called to the trauma bay for a code yellow (agitated patient requiring immediate attention). The EMS triage nurse recognizes the patient and sends in the initial treating doctor who relates the events of the first ED visit while I'm assessing the patient. I suggest that, in the interests of continuity of care that he takes the case (cough cough), but he politely refused as he feels I may benefit from some of the more unusual aspects of the case (cough cough). Anyway.
EMS says they were called for an unconscious woman and found her on a park bench. She was not responsive to painful stimulus. She had shallow slow respirations (rate 6 / minute) and constricted pupils. Her heart rate was 100. SaO2 was 85%. They didn't get a blood pressure. After the administration of naloxone 0.4 mg IV she because agitated.
On arrival, she was agitated. There were no significant secretions, and the airway seemed patent. Respirations were fast and deep (24). Lungs were clear. Skin was warm, diaphoretic, and peripheral pulses were full (120).. BP was 132/86. Her eyes were open, sure was making incomprehensible sounds, and she localized to pain (GCS 4/2/4 = 10). FSBG was 106 mg /dL.
Other pertinent findings: piloerection, yawning, retching.
An EKG showed sinus tach at 108, no ectopy or ST- T changes. The QTc was about 600 ms.
Review of the testing from the prior visit showed that the imaging studies were reassuring (CXR, CTs of brain and c-spine). The hemogram was likewise benign (WBC 6.8 Hgb 11.2 Plt 256) and the chemistry and LFTS were noncontributory except for a potassium of 3.0 mMol / L. Magnesium had not been tested. The troponin was 0.172 (normal less than 0.045).
The patient was placed on a cardiac monitor and supplement oxygen, and the labs were repeated. Over about 40 minutes, the signs and symptoms of iatrogenic opioid withdrawal gradually ceased, and the patient became calm. vitals remained reassuring (HR in the 80s, BP in the 100s/60s range, SaO2 99-100% on a nasal canula at 3 L, respirations 12-14).
The ICU was consulted and they came to see the patient.
Then, I was called to the room by the RN. The patient's mental status had abruptly changed. She had become unconscious, unresponsive to painful stimulus. She was tachypneic and hyperpneic. The cardiac monitor showed ventricular tachycardia at about 230-240. The peripheral pulses were weak, and the blood pressure was 90/50. I kicked myself for not having put on the defibrillator pads, although at least I had the crash cart standing by.
While the pads were being opened up, she became apneic. The peripheral pulses were gone. I said "****" and thumped her chest as hard as I could, which was ineffective. I started chest compressions and my PA started to ventilate the patient with a BVM while my resident set up to intubate. After about 1 minute of chest compressions, the patient started to try to push me away, and I stopped chest compressions. She tried to remove the BVM mask from her face. The cardiac monitor showed sinus tachycardia with a rate of ~120 and bigeminal PVCS with R-on-T phenomenon.
I loaded her with amiodarone and started the drip. The PVCs resolved.
I told the ICU to come and get her.
