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Posted Oct 22 2008 4:53pm
I went to do an ABG on room air followed by a DuoNeb tx on a 62/m. The.nurse was drawing labs and getting a history. He is a 100 pack year smoker with no medical history and no regular doctor. He said he hasn't needed a doctor before. He has been sob for a few days and today it
was bad enough to bring him to the er. Vitals 100, rr 20, spo2 on ra is 92%. I get the blood gas (on the first attempt, I want you to know) and the ph & pco2 are unremarkable, but the po2 is only 54. I went back to start his tx and his is surprisingly pretty clear, not diminished at all, like I had expected. When I was finished, I put him on a 4L nasal cannula.

Two hours later, the er calls me for another tx. The patient looked the same, still a little sob. Vitals are the same, however, this time I swear I hear some fluid in his lungs. Now the xray report is back...mild CHF, blunted costophrenic angles, blah, blah. This is at 1500 and now his is admitted (waiting for a bed) with tx ordered q4 & prn.

At 1730, I was giving a tx to the cutest kid (not an important detail of this story, but he really was cute) in the room next door to the above patient when I overhear Dr F asking him of he wants another tx. So, I peeked around the corner to see what's going on. The patient tells the doc that he does NOT want a tx right now.

As I'm listening to their conversation, I actually LOOK at the patient & see the following...

  • An obvious increase in his work of breathing
  • A heart rate of 135
  • A respiratory rate of 40
  • An spo2 of 88%

So, I asked Dr F if he wanted me to give him a tx anyways. I am shot down. Okaaaayyyy, you're the doctor and against my assessment and better judgement, I walked away.

But I couldn't get over his obvious decline so I turned back around to talk to the pt myself. In professional medical terms, he looked like shit. I told him that his tx is due at 1900, but he can have it early and he agrees, thank God, but it didn't help.

This tx did nothing for him, and now his lungs sound, horrible. He sounds like a washing machine, so I went to talk to his nurse. She kind of blew me off (what do I know, I'm 'just' an rt), but I was persistent and told her that be was going to end up intubated if this wasn't addressed. She said,"I wonder if he needs lasix"

You think? Wow! You are briliant.

She went to talk to Dr F and I went to the department to give report & go home.

Sure enough, not 5 minutes later, we are called for a stat abg. The night therapist went & I waited for him so I could see the results.

When he came in to run the blood, first thing out of his mouth is,"this guy looks like shit"

As soon as he put the blood in the machine, the er calls and wants to intubate him!!! I knew it!!! They sat on him all day & now he's being intubated!!!

So, like tired dayshifters, we left. So I'll update you on him next week when I go back to work.

So for my bit of advice...

CHF needs lasix, not albuterol/atrovent.

Thank you.

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