Humbling...

WARNING:  Medical Terminology and Advanced Medical Discussion

For the most part I am a low-key person.  Often my co-workers comment on my "quietness" or my "calmness" during perceived crisis.  I attribute this aspect of my personality to my years of experience.  Specifically to when I was working in the pre-hospital environment.

People call 911 for help, they go to an Emergency Department....  People expect responders and providers to remain calm, take charge, and help to rectify whatever situation is at hand.

A little secret... most responders/providers are first and foremost concerned about their safety.  One does not just rush in!  They typically want to be part of the solution, not become part of the problem!  When I was an instructor for a Public Safety/Governmental organization, I emphasized what I called the "STOP" principle when responding to, coming onto a scene, and addressing a problem:

S = STOP!  Literally, stop.  Take a breath, prepare to prepare.
T = Think!  What is the situation, what has to be done, and where are the escape routes if needed.
O = Observe!  What is the actual situation, environment, hazards, immediate priorities.
P = Plan!  Identify the first three things that need to be done, call for help if needed, and identify the exit.

The above process can literally occur in a few seconds, or can take a few minutes, depending on the situation.  More importantly, it can be applied to anything an individual experiences.

Now, last night was busy in the Emergency Department.  Every bed/room was filled and flex/hallway beds were in use.  I was assigned to the flex/hallway beds. I had six patients I was caring for.  I declined accepting a seventh, based on the acuity or needs of the current assignment/load.  I am flexible, and will take on added responsibilities as needed.  Yet I will not cross a personal line, when patient safety becomes compromised.  Later in the evening, I took on a seventh patient.

Within the HIPPA guidelines, I had an ill person with non-cardiac chest pain, a confused person s/p surgery with multiple comorbidities, a person with an acute mental status change related to Alzheimer's disease, a person with heart palpatations that had a cardiac history and comorbidities, a person that had a neurological history who experienced a syncopal episode, and a person that had a reaction to a suspected toxin.  A lot of medical lingo, I know... needless to say, it kept me busy for quite a few hours!

Later I took on another patient that experienced a fall and had no complaints, just literally a bump on there forehead.

Now, out of all of these patients, the one that I originally prioritized as the least concerning, the one that was not going to suddenly become unstable, or need a lot of interventions... ended up being the sickest patient I had, and was admitted to the Intensive Care Unit!  In retrospect, I was so busy that, although I looked at lab results, I didn't connect two things. 

I was reviewing the patient's chart, lab results, etc, in preparation to calling report to the floor nurse, when I finally saw it, connected it, and had a STOP moment!  All of the treatment so far had been appropriate, an elevated blood sugar requires IV fluids; this patient had received 2 liters of fluids.  It was this pesky, often overlooked and misunderstood number on the Basic Metabolic Panel, or Chem-7 that caught my eye!  This patient's Glucose was 350, the CO2 was 15!  High Glucose, low CO2... this patient was probably in Diabetic Keto-Acidosis (DKA)!  A look at the urinalysis... yep... spilling glucose and ketones!

An added STAT ABG (Arterial Blood Gas) confirmed it!  A brief conversation with the ED Physician and a call to the admitting/accepting Physician, a continuous Insulin infusion started, and this patient was admitted to the ICU!  Luckily, it was an early DKA and no further aggressive electrolyte replacement was needed.

I missed it initally, the ED Physician missed it too.  I was just happy that it was caught and identified!

And the patient that had the fall, the one with a bump on there forehead... you know, a "goose egg"...  ended up having an ICH (intra cranial hemorrhage)!  A small sub-dural bleed/hematoma...  was transferred and flown by a Med-Evac to Phoenix!

The purpose of this post...

I was humbled last night. 

As an experienced ED Nurse, I was once again reminded that as a medical professional, patients don't read the textbooks!  Every patient is unique, every presentation is different.  And atypical results/findings are God's little reminder that we really don't know everything!