Thursday, March 18, 2010

It always happens at shift change, right?

So after a busy but not-too-hectic evening, I finally sat down around 2245 to finish up my charting.

I had a lot to catch up on, because of a new admission to 63. He showed up on the unit around 1800, but was immediately whisked off to dialysis before I had a chance to do any assessment beyond "He's alive, A&Ox3, and doesn't look like he should be in the hospital." He came back to the unit around 2130. I did my admission sheet, got him dinner, and brought him his (late b/c of dialysis) meds in record time, done around 2230. He was doing just fine all through it.

So at 2250 his wife comes up to the desk with a worried look and says, "My husband is not acting normal at all. I need you to come take a look right now." She said it with such calm and straightforwardness that I was immediately terrified. When people come at you with histrionics it's usually something stupid like needing a repositioning. When there's an eerie calm, you know there's trouble.

I popped my head into the room, and he's staring off to his left, with a right-sided facial droop that I didn't recall seeing 20 min earlier when I was last in the room. We asked him to say his name, and his speech was slurred and unintelligible. He was able to lift his left arm on command, and give my hand a good squeeze, but we couldn't get any response from the right hand side. Couldn't even get him to turn his head that direction.

"Well, shit" I thought.

So I called the on-call doc and asked her to get up to us to check him out. Resource came in to check his vitals, which were fine. We decided to call RRT to get a little extra help.

Doc showed up a little before 2300, we called a Stroke Alert about a minute later. This involved doing an assessment on pronator drift, and getting a bunch of blood samples.

The lab had been in not too long before and said he had "slippery" veins. They weren't lying. Luckily, he had an 18g in his forearm with brilliant blood return that we were able to get samples from. Thank god.

He was off the floor and down for a head CT by 2313, which isn't too bad, timing-wise. Things seemed to move much more quickly, and I was always surprised when I looked at my watch.

His poor wife was rather shocked, because this wasn't what she expected at all. Hell, they were going to send him home from ED earlier that day. Got him dressed, took out his IVs, everything. Then they changed their minds and sent him up to us.

So after the CT they sent him to ICU, and I had to wait awhile to give report to the nurse who would take him. Hooray for overtime!

I was told by Pappa that they did find a couple blockages on the CT and he was eligible for tPA.

I'm curious to see how it all ends up when I go back to work today.

Addendum: So apparently they didn't do the tPA after all, owing to the severity of the stroke and how many areas it involved, as well as the fact that the pt was a Jehovah's Witness. If there were bleeding side effects from the tPA, it would be very problematic if he didn't accept transfusions. He is stable now, transferred to our neuro unit, already able to swallow safely and working on his communication skills. Apparently they called an erroneous code blue on him yesterday when he had a seizure post-dialysis. Luckily he's still okay.

Well, okay as can be expected....

No comments:

Post a Comment