Tuesday, January 8, 2013

Three was the Magic Number

I sent a patient to the emergency room for chest pain three days in a row until they finally uncovered the problem:  pulmonary embolism.  She would have died if not treated.  As a nurse, you need to use your training and knowledge to guide you, in spite of what other health care providers may tell you.  You then need to advocate for your patient.

Like many conditions, pulmonary embolism, or a blood clot in the lung, does not present itself with classical, obvious, textbook symptoms.  This is unfortunate because blood clots in the lungs are life-threatening.  As a result, pulmonary embolism is the second leading cause of sudden death in the United States.  Take a psych patient with a pulmonary embolism, and you are statistically predisposed to miss the diagnosis and result in the patient's death.

In the psych business, people tend to not believe people who reside at a psychiatric care facility.  (Unless it is the administration looking to screw over the least favorite employees.  Then the wild, physically impossible tales are prosecuted.)

The background:  50 year old woman, no significant medical history, slightly overweight.  Poor historian; evasive.  No family or friends listed in the chart.  Patients states, "I have no family.  I have no friends.  I am all alone."  Residing at the psych hospital since July of 2012; pending placement in a group home.  Psych diagnosis:  schizo affective disorder.  Usual behavior is calm, cooperative.  Shows little emotion.  Keeps to herself.  Compliant with medications:  Depakote, Risperdal, and Cogentin.

Day One:  Night shift reported that patient did not sleep and sought staff attention for cups of water, which was unusual for patient.  Easily redirected back to room.  By 8:00 am, patient had refused morning medications and breakfast.  When asked why, patient stated, "I have chest pain.  I don't want to move or do anything."  Vitals:  Blood pressure 120/76.  Heart rate 130.  Respirations 20.  Temp 98.0.  Pulse oxygen 95% on room air.  Patient stated that chest pain started last night and worsens upon exertion or movement; denies shortness of breath or pain when breathing.  No other complaints.  Denies radiating pain.  Nitro 0.4 sublingual given; reported some relief.  I take off her sneakers and find that her right foot is swollen and hot.  She replies, "It's been like that for years.  It doesn't bother me."  Sent to emergency room with paramedics.

Day Two:  Patient was returned to the psych hospital on the evening shift the day before with a diagnosis of "chest pain."  Night shift reported that patient stayed in bed, not sleeping, complaining of chest pain if asked. Patient ate breakfast and took due medication, stating that she felt better.  Vitals were within normal limits; heart rate was around 80.  By noon, patient would not get out of bed to eat lunch, stating, "The chest pain is worse.  I can't move."  Temperature was elevated to 102.  Right foot is still hot and swollen.  As I am examining the foot area, another nurse comments, "You are always looking for people to have something wrong with them.  Not everyone is perfect like you."  This highlights what I am up against.  I was not looking for imperfections to make me feel better about myself.  I was looking (and finding) signs of a circulatory problem to help guide me in figuring out what was causing the patient to have chest pain.  Paramedics did not want to take patient to hospital, explaining, "We did this yesterday.  She is just depressed an anxious.  You are supposed to fix that."  I explained that the complaint of pain and lack of compliance is not typical of the patient.  Paramedics took patient, explaining, "We're only taking her again because this time she has a fever."

Day Three:  Patient was returned to the psych hospital on the evening shift the day before with a diagnosis of "chest pain."  Night shift reported that the patient stayed in bed, immobile, complaining that the slightest movement caused more pain in her chest.  Upon seeing me, the patient started to cry and said, "I am dying here.  I am having a heart attack and nobody will help me."  Blood pressure 140/90.  Heart rate 120.  Respirations 12.  Temperature 99.2.  Pulse oxygen 96% on room air.  I sent her out again, telling the paramedics that we would be doing this every day that I worked until the patient's pain is treated.

The emergency room called around lunchtime:  pulmonary embolism.  Admitted to ICU.

Administration doesn't like me and most of my coworkers are nasty and against me- on a good day.  Combine the usual hostility with fighting for this patient, and I had three bad days.  When the diagnosis finally came in, did anyone applaud me or apologize for giving me such a hard time?  No.  OF COURSE NOT.  I don't do what I do for acclaim, but it would be better for all involved if my coworkers would work with me instead of harassing me and interfering at every turn.

There is a second part to this story, which I will tell in another post.

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