Beyond the Threshold
Any situation that requires an ER physician to go outside and retrieve a patient is usually going to be complicated and time-consuming, and I would wager that it is also more likely to end badly. Here are some examples with which I am personally familiar:
1) Two police officers unload an agitated psychotic crackhead on the ramp. Naked, sweating, yelling and struggling violently, he is a handful to say the least. Make that 10 handfuls: a beefy male ER tech is restraining each leg, the two officers are securing the torso and neck, and a male nurse has the pelvis when I finally go outside to see what I can do. This guy has five strong men on him and he's still bucking and kicking. Suddenly, he stops fighting. Is he playing possum? I check for his pulse, finding nothing. We carry him into the ER and begin CPR. He remains in asystole and fails to respond to any interventions. Another patient struck down by a "rare and controversial condition."
2) I hear a commotion at the ambulance ramp and run down the hall to see what's up. Lots of yelling and chaos. A young woman is in the back of a private auto surrounded by a small group of onlookers. Is she delivering a baby perhaps? Unfortunately not. She's been shot in the chest and dies despite our aggressive efforts to save her.
3) A woman is brought in for altered mental status, and that assessment seems to be on the money. A quick chart review shows a recent admission for cocaine overdose. While we are trying to verbally calm her down and assess her, she says she needs to pee. Good, we need a urine sample anyway. As the nurse is walking her to the bathroom, she breaks away and runs right out of the ER, across the parking lot, and faceplants into the bushes. A tech and I drag her back inside.
4) A psychotic suicidal young man is being transferred to a psychiatric facility. The EMS team arrives to transport him, but they seem uncomfortable and clueless. The patient has been calm the entire time he has been with us, but you can tell he is boiling inside and ready to blow. The ambulance crew mess around for quite a while, asking too many questions and stalling with paperwork and phone calls. When they are finally ready to transfer the patient to the EMS stretcher, he instead runs out of the ER and climbs up on the roof of a nearby parking garage, his elderly father following him. The police finally subdue him, red lasers illuminating his chest. He is transported by the police to the psych facility.
5) Shift change, 7:15 am. One of our ER nurses is walking out the door of the ER after a busy nightshift and is run over by an intoxicated driver who is backing up way too fast, in a hurry to be triaged for his low back pain. Our nurse thought she was done for the night, but she ended up staying in the hospital far longer than she had planned. A**hole patient-wannabe was triaged to jail.
Labels: crossing the line, drunks, ER, nurses, paramedics, patients
posted by scalpel at 12:11 AM
5 Comments:
If I'm sick I wanna got to ER, the one on television. They meet every ambulance at the dock and start shouting orders too. I especially like how it's always the same orders: lytes, CBC, type and cross 4 units and a cross-table cervical spine x-ray, stat! They must have some pretty thick nurses if they haven't got that down by now.
We pull people out of cars all the time but we usually don't meet the rigs outside unless it's multiple traumas or somebody is already out there smoking. My favorite one was when they opened the side door on a truck and the patient tumbled out, cervical collar still intact, and started rolling around on the pavement while the medic just sat there looking at him with a bored expression on his face and our security officer threw him back in the rig and said he had to go to the other trauma center because he was handcuffed. Good times.
So - with the agitated delirium is it the adrenaline that ultimately kills the patient? Never heard of it - interesting though.
Glad the nurse ended up alright.
What it is (I think), is low ATP in the brain (and other organs too). ATP concentration is exquisitly well regulated and is commonly (but erroniously) thought to be "contstant" due to "homeostasis" (a completely non-physiological concept). Actually, ATP concentration is a control parameter that is used to "turn off" non-essential pathways to concerve ATP for immediate consumption as during "fight or flight" to provide ATP for "running from a bear".
Being caught by a bear is certain death, so our physiology has evolved the ability to divert all resources to escape, which greatly increases ATP supplies by turning off systems that are non-essential in the long term.
As ATP supplies get depleted, and more pathways are turned off, physiology turns off the ones with shorter and shorter time horizons. When the time horizon reaches the present is when you drop dead from exhaustion.
I think this is a generic mechanism for acute psychosis, particularly that associated with hyperpyrexia. I think the hyperpyrexia is from mitochondrial uncoupling, which lowers ATP concentration, which shuts off long term pathways (and induces endorphins that make you feel good). Normally pain from exertion and exhaustion is your body telling you that your ATP consumption has exceeded your ATP production capacity and your body is shutting doen long term pathways. Your body lets you continue, and muscle can be worked to death.
Stimulents don't actually increase ATP production, what they do is increase ATP availablity by reducing ATP consumption by non-volitional pathways. In the long term, there are no non-essential pathways.
That is why when they code, they are very hard to bring back. There is no reserve ATP to sustain cells for even brief times. In the limit of perfect ATP regulation, every organ would fail simultaneously.
Nitric oxide is one of the signaling molecules that regulates this. The state of acute stress is a low NO state. You would have to raise NO levels stat. Which is difficult if not impossible. Maybe IV sodium nitroprusside to calm him down. I have no real idea if that would work or not. There is lots of hysteresis in a low NO state. There may be no way to recover if it gets this low.
That's an ER nurses worst nightmare, mowed down in the hospital parking lot by a drunk
That happened to one of our ER's unit clerks. I think she may be off the crutches now.
I give her at least partial blame for not getting out of the way, though.
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