Very odd weekend this past one. Our facility, St. Francis of the New Way, is a teaching hospital, which means we have residents aplenty. Generally, the ICU attendings do a pretty good job of teaching them not to do dumb/goofy/useless things, but sometimes things slip through. Sometimes it’s not even (entirely) their fault. Observe:
Teaching Case #1:
80-ish year old man, no history of lung trouble, big history of heart trouble. He comes over to the ICU from a telemetry bed because he’s having trouble breathing (stop me if you’ve heard this one). Despite the heart trouble, he was reasonably active before admission (if I recall, he was in with new-onset afib), but he is a DNR. Auscultation reveals markedly diminished airflow bilaterally, with wheezes and crackles in the remainder.
Do you:
A. Put the patient on some reasonable CPAP (say, 8cm H2O) as tolerated.
B. Diurese, perhaps with some Lasix, and restrict intake
C. Write an order for q6 albuterol/atrovent with first dose now and fail to give a heads-up to the nurse, RT or clerk so that the order isn’t seen for a good four hours, turning “now” into “when the patient is comfortable and sound asleep.”
Teaching Case #2:
40-something male discharged within the last week after a pulmonary embolus, admitted about 12 hours ago after waking up that morning with shortness of breath that didn’t go away. He has a history of pretty severe COPD after smoking 2 packs a day for 15 years (and maybe a touch of alpha-1) and is on home oxygen and treatments. His nurse sees him in increasing respiratory distress and calls the rapid response nurse for evaluation, who calls us to draw an ABG and do a treatment. On examination, patient is markedly dyspneic, mildly retracting, and fatiguing but still in good spirits. Breath sounds are diminished with no particular improvement after DuoNeb. Blood gas reveals a pCO2 over 90. Normal, perhaps for him, you might say, but the pH of 7.2 then laughs at you, as does his pO2 of 45. The RT covering that floor and myself both recommend NPPV and transfer from the general floor to the ICU. If you are the rapid response nurse and resident, do you:
A. Say “Absolutely, because we might end up having to intubate him” and get the patient transferred
B. Say “That was a venous draw, even though you saw it pulse into the syringe”, get a repeat ABG in an hour, dismiss that one as a venous draw too and say, “Well, he’s probably got a PE, so BiPAP is contraindicated” to the general bewilderment of everyone within earshot
C. Sit on the patient for three hours until he is as red as a stop sign, can’t speak, is using accessory muscles to the point that he looks like he’s doing crunches sitting bolt upright in the bed and is pretty much obtunded, at which point you order YET ANOTHER ABG
D. When those ABG results come back worse than the first set, call the resident and agree with him when he says “I don’t want to call the attending and wake them up for at least another hour since I don’t have anything else to discuss with them”
E. All of B,C, and D above.
