Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Friday, May 21, 2004
    The Code

    I was sitting in my office one day last week writing referrals, when I suddenly heard words you don't normally hear in a doctor's office: "Somebody get the oxygen. And where's the crash cart?"

    Driven by curiosity, I leapt up and headed down the hall toward a tight knot of ancillary staff clustered around the door to an exam room, their stares focused on an elderly woman slumping in her wheelchair. Actually, "slumping" is an understatement; she looked like she was trying to pour right out onto the floor. J, my partner, was trying to get her out of the chair with help from one of the nurses: "She isn't breathing," I overheard. I grabbed the phone and called 911 (I've only had to do this three or four times in the course of my eight years here, and it always makes me feel somewhat phony, like I'm an actor on ER).

    "What's the patient's age?" asked the operator.
    "Uh, she looks to be in her eighties." ("Ninety-four," prompted her relative, standing in the hallway looking freaked out.) "Strike that, she's ninety-four."
    "Does she have a pulse?"
    "No pulse." ("She has a pulse, she's just not breathing!" yelled J.)
    "Sorry, yes, she has a pulse but she's in respiratory arrest," I stammered.
    "And you're a health care provider?" (Was it paranoia, or did I hear a note of incredulity in her voice?)
    "Yes, but I'm not the patient's provider. Her provider is in there with her on the floor," I fired back.
    "Okay, fine, the paramedics will be there shortly."

    I hung up with relief, snagged a radiology tech student and assigned her to go downstairs to direct the paramedics to us when they arrived. Then I joined J on the floor. By this time the oxygen and crash cart were in the room. I uncoiled the nasal tubing for the oxygen and passed it to him, then grabbed her arm and felt for a pulse. The patient's eyes were open and staring at the ceiling - at first glance I was convinced she was dead - but the pulse was nice, regular and strong.

    "Can you find any Narcan?" asked J. The patient was on pain meds for a fracture, and his theory was that she might be narcotized and therefore not breathing. I fumbled around looking for the drug, then gave up long enough to grab the bag-and-mask mechanism off the cart and toss it to him so that he could ventilate her. Within seconds her previously open eyes started to blink and focus. By the time I found the Narcan and got it into the syringe, she was doing well enough that we didn't need to use it.

    I heaved myself up off the floor and listened to the distant siren. The patient's niece was sniffling into a Kleenex. I asked her gently, "Do you know if she was using more pain meds than usual?" The answer was no. She'd felt unwell, the family had brought her for evaluation and then she passed out. When elderly people in wheelchairs drop their pressure and pass out, it's usually bad news. The chair holds them upright and they can't get flat, which means the brain is being deprived of oxygen since it isn't being perfused with blood (that's why people faint in the first place. It's a safety mechanism to get blood to the brain when your pressure drops). If the person cannot be placed in a supine (horizontal) position, they may develop a watershed stroke due to decreased perfusion in the brain. In this case, she was densely unconscious to the point that she wasn't breathing. The good news is that if you can get them flat and ventilate, they'll wake up as soon as blood gets to the brain, as happened here.

    That's really the end of the story; the paramedics showed up, loaded the patient onto a stretcher and took her across the street to the hospital. We later found out that her sodium was low, but that still doesn't explain why she reacted the way she did. We got our reminder that day that it's much easier to manage emergencies in the hospital than it is in the outpatient setting, even with a crash cart and oxygen.



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