You are currently browsing the daily archive for August 15th, 2008.
I was told in report that she’d had a massive stroke as well as additional strokes and seizure activity and wasn’t expected to live much longer. The ER doctor had told the family that she only had six hours to live. They had accepted the idea of her imminent death and were now keeping a vigil at her bedside. The patient had been vocal about her desire to be a DNR after the painful death of her husband to lung cancer, and her family wanted to respect her wishes.
There was nothing in her chart except ER orders. Whatever imaging had been done was not accessible to me on the computer. All I had to go by was what the night nurse and family told me. They told me she had some responses to her name before imaging, and afterwards she became unresponsive. When I assessed the patient, I found her completely unresponsive. Her respiration rate was 10, and her respirations were coarse with periods of apnea. So, I was prepared for the second death of my career. The night nurse had even begun the post-mortem record for me.
I called the attending sometime after 8am to let him know of a critically high troponin as well as the family’s wish to stop all lab work. He ordered palliative care only.
By ten that morning, the family was beginning to get anxious because no doctor had been by. Of course, he hadn’t. Their attending was in his office all morning, and besides that – he expected the patient to die soon from his own report (as he had never seen her). There was also a neuro consult, but he hadn’t by either because of his own office hours.
Around noon, the family called me to the room. There were now 20 visitors. The patient was opening an eye and lifting an arm. No movement to her lower extremities even to some stimuli (pinching toes). Her responses didn’t appear to be meaningful. They wanted to know if she was getting better. I was hesitant to crush any hope, but I also didn’t want to give any false hope.
By two she was lifting her head off the pillow, opening both eyes, and moving all extremities. I paged the doctor again, but this time he wasn’t as quick to call back. The family was now very upset. Where were the doctors? Oh, and apparently the patient had said “Hey, baby” to a friend who walked in the room.
The attending finally sent someone to cover for him around 4pm. Doc #2 was filled in on the situation. He talked briefly with the family (now totaling 30) and told them that an MRI would be done to assess the injuries to her brain. After he had the results he could give them a treatment plan and a prognosis. He would also be consulting a cardiologist due to the heart attack she had suffered along with the strokes and seizures.
The cardiologist he consulted happened to come by the station a little later, but he hadn’t received the consult and was actually being covered by someone else just then. I must have looked very disappointed, because he took the chart from me saying, “Here. I’ll write you some orders.”
Just before trying to write out my reports at 6:30, MRI called asking me to bring something to sedate the patient. All I had on her profile was Ativan, so I grabbed it and ran downstairs. I make it back up at 6:50, and I hurriedly scribbled out my reports.
Neuro came at 7 pm, and he concluded that while she had suffered a stroke, her unresponsiveness came from being in a post-ictal state that was compounded by a heavy dose of valium administered as sedation for the imaging done in ER. Hence the complete unresponsiveness I found early on, and the gradual wakening throughout the day.
Ta da!
I pulled the post-mortem worksheet off the chart and threw it away before leaving.
