Wednesday, March 3, 2010

Surprise

The incident recounted below is true, but the patient biography has been somewhat altered to protect identity. Details have been changed, and maybe fluffed a little. Federal privacy rules, you know, the ever popular HIPAA.

It had gone on for several weeks. He just didn't feel right. Dizzy, sometimes. Weak. Sometimes very thirsty. Sometimes his eyes wouldn't focus right, the newspaper or television would get all blurry. He hated going to the VA Clinics. He always had to wait. He always ended up next to the craziest man in the waiting room. He just wasn't right, though. He would go after his half day of work at Wal-Mart. It had been long enough--it was time to get things looked after.

He arrived at 1400--too late to get in to see the Nurse Practitioner in the Same Day Care Clinic. He couldn't get in with the Blue Clinic either, his primary clinic--they were full. It was likely he would be seen in the Emergency Department. Starting around 1530 or so, they would start seeing the people who couldn't get in to see the NP in Same Day Care--if they weren't too busy with urgent cases--who still wanted to be seen today. He got a drink of water, settled in with his book. He was lucky. The young Iraqi vet next to him was sweet and sane--good grief, the same age as his youngest son.

Soon, someone called his name. He got up, carefully, as the dizziness had returned, steadied himself and walked to the ED entrance. They showed him to a bed, said someone would be right with him. The bed was pretty nice after the waiting room chairs. He kicked off his shoes and made himself at home. Not long after a nursing technician came over and began checking his vital signs. A nurse came over too. "Check orthos if you would Dennis." she said to the tech, "The report I got said that he says he has dizziness sometimes."

The nurse watched the tech put the mid 50s year old Black man through his paces--checking his pulse and blood pressure lying down, sitting up and standing. He appeared to have no dizziness subjectively. She would look at the numbers when the tech presented them to her. Dennis was good; if there was an obvious abnormal, he'd bring it to her attention right away. Sitting at the computer, she pulled up the ED roster for the day, and picked his name out. She reviewed the initial triage note, and the history. Nothing remarkable, in fact, a pretty healthy guy. Some high blood pressure, the scourge of the Black community, takes meds for it, a history of depression. He is overweight. Time to go talk to the patient, the record has told all it can tell.

She greets him, calling him by name. He is alert, oriented, sensible. There is no appearance of drug or alcohol use, no "ETOH on body", no buggy eyes--he is sober. He recites the history of weakness, dizziness, "not feeling right" He denies any GI problems, infections, fever. Physical exam is unremarkable. Skin turgor is good. Skin is warm and dry. Mucous membranes are moist. Lungs clear, abdomen soft, active bowel sounds, no swelling in the feet or ankles. Mostly these subjective symptoms. The nurse will present his case to the ED doctor, after popping a quick nurse's note in the computer. Dennis has put the orthostatic vital sign set in the computer--they are unremarkable.

The nurse walks over to the doctor's area. The day ED doctor is going to be done with his shift in 20 minutes. The evening doctor has not yet arrived. The nurse presents the patient's case to the doctor. He seems distracted. He pulls the patient's record up on the computer, looks at the screen. The nurse directs attention to the negative orthostatic vital sign test. The doctor says, "Put in a saline lock. I'll order some meclizine [an anti vertigo medication] for him."

The nurse returns to the patient, explains that the doctor will be right over and that he wants an locked IV line in the patient. The patient is cooperative, verbalizes worry over his symptoms. The nurse gloves up, puts a tourniquet on the patient's left arm. The patient continues to talk. "...and you know, sometimes my eyes just get all blurry..." The nurse is listening, replying, as she palpates a vein, and then preps the skin. She doesn't mind if patients talk while having blood drawn or getting an IV placed--it helps keep the mind occupied. In fact, the nurse thinks, let's draw some blood with this IV start, just in case. She explains to the patient that she will draw about a teaspoon--12 cc--of blood with the IV start, just in case it's needed. He nods his understanding.

He's not sure why they need the IV line, but he is glad that his blood is being drawn. There just has to be something going on. Maybe they won't discover it this late afternoon, but it's a start. He has grandkids and he wants to be able to keep up. The nurse skillfully punctures the skin, and before he knows it, the pain is done and an IV line is in his arm. The nurse is holding a syringe with blood in it. She finishes securing the IV line, and moves to a cart not far from his bed with the blood filled syringe. He sees her fill four tubes with caps of various colors with his blood, put labels on each and deposit them one by one in a plastic baggy. "Hey, Dennis have you seen the glucometer?" she says.

"...my eyes get all blurry." Isn't that what diabetic patients whose blood glucose has gotten out of hand tell me all the time? the nurse thinks to herself. Hey, I've got blood, let's check it out. The nurse fills the vials, carefully leaving a tiny amount of blood in the syringe. She gets the glucometer, scans her badge, scans the patient's arm band. "We'll take a bit of this blood, test your blood sugar." she tells him. Carefully, she puts a drop on the strip, sticks the strip in the machine. Waits for "the longest 30 seconds in nursing" to pass for the glucometer to read out. Finally, a reading. The nurse lifts the machine up to read it: 569. 569? Maybe I made a mistake--there's a little more blood in the syringe--let's do it again. She scans everything again, drips the blood, waits. This time the reading is 563. Well, the blood did sit, while she chased down the glucometer. Let's do it again, this time with fresh blood, I'll have Dennis do it. Meantime, I'll go talk to the doc. I don't even want to mention it to the patient much, until I am sold the reading is accurate. On the way to the doctor, she explains to the patient that she is going to get some blood by finger stick and check the result against the one she got using the blood in the syringe. The nurse tells the patient that the readings from the syringe blood were all very high and she wants fresh blood to verify the results. "Has anyone mentioned diabetes to you ever?" "No." the patient says. "Does it run in your family at all?" "I'm not sure." he says. Crossing with the tech, she reminds him to clean the patient's finger well, maybe have him wash his hands. If his sugar is that high, he'll be spilling it in his urine, and if his restroom hygiene is poor, he could have sugar on his hands that would corrupt the result.

The nursing tech comes over. He has the patient go to the sink, wash his hands. He lies back down. The tech sticks his left middle finger. Diabetes. Diabetes? Is that it? That would explain a lot. He remembers when his cousin was diagnosed, after he became unconscious at home. Was there more diabetes in the family? For him, they had mentioned it once, in relation to his weight. Other then that, no indication. The tech looks at the machine--it has a reading. He asks, "It it still high?" "Yes," the tech says, " in the 500s. I'm going to let the nurse know. She's over talking to the doctors right now."

The evening ED doc is on. He is a thoughtful and thorough practitioner. The nurse is glad to see him. She sits near him, waits for him to finish what he is doing. Finally, he is done, and turns to her. "John Doe in bed 7," she says, "came in with a number of vague symptoms--dizziness, weakness, not feeling right, blurry vision at times. Dr. Daytime had me place an IV and he ordered meclizine. When I placed the IV I thought I would draw blood just in case, and along the way I checked the blood sugar. I got 569. Dennis is rechecking it with a finger stick because the blood sat for a little while in the syringe before I got the glucometer." Dennis comes over, hands the nurse a piece of paper with the new reading--559--and says, "Still high." The nurse thanks him, turns to the doctor. "Well, I'll be supposing you'll be wanting a CBC, a CMP, and an acetone--and some urine to check." The doctor is grinning and says, "Yes, that will do, the routine ED labs and an acetone." He pauses. "That was a good catch, there. What was it that tipped you off?" "The blurry vision. I've had diabetics with high blood sugar tell me they couldn't see well when their sugar was high." The doctor and nurse stand up together. "Well," says the doctor, "I better talk to the patient. It's likely we will have to admit him tonight." The doctor turns to the nurse. "Seriously, that was a very good catch. He could have left here with that high sugar, gone home, and been in serious trouble." The nurse smiles back, blushes a little, nods. She says, "Well, let me have the clerk order the labs, I'll send the blood and have the patient pee and we'll get things going."

3 comments:

Ann T. said...

Dear The Observer,
Wow, what a catch. This is what i notice:

1. he says no history of diabetes then remembers his cousin. I think most people don't know how to answer the questions they get.

2. The active listening did the trick. And the experience.

Great catch by the nurse, and i love that very patient patient too.

Wonderful story!
Ann T.

Capt. Schmoe said...

Good catch indeed.

the observer said...

Ann and Capt.

Why shucks and thank you.

I forgot to remember the HIPAA disclaimer required of anyone blogging stories from health care encounters--it's there now. The changes needed don't detract from the story...or the outcome.

The Observer