I had a lovely patient who I suspected was deteriorating.  I had nothing objective to report to the MD.  I didn’t even have anything subjective as the patient kept telling me he was fine and denied increasing shortness of breath.  Vitals and sats were fine.  Breaths sounds were coarse and crappy, but this wasn’t new for the patient.  He had sounded horrible ever since transferring to us from ICU s/p resp failure and intubation a week before.  He just didn’t look the same to me.

As the morning went on, I couldn’t help this nagging suspicion.  I went ahead and ordered a stat chest x-ray.  It showed some slight increase in edema.  The patient is still denying any complaints, although by now he looks visibly more tired to me.   Vitals stable. Cardiology’s nurse practitioner walking by, and I notify her of my gut feeling and the x-ray results.  I page the attending to let him know of the results and the NP’s order to ask him for a renal consult for any diuretic orders.  He gives me a few lab orders and the consult order.  I check back on my patient, and I can see some visible resp distress this time.  His respirations have increased, and he’s using accessory muscles.  He finally is saying, “I guess I’m not feeling too good.”  NP is still at the station, and I make her come look at him.  She gives me some  stat Lasix and ABG orders and decides he should be sent back to ICU d/t the the sudden increase in deterioration and his previous history.

Last I heard, they did not have to intubate him after all.

I finally feel like I’m in that place where I can recognize “the look” of something before it happens.

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