If a patient has unexplained hypoxemia, and nothing makes sense, always make sure you check the oxygen oximeter
probe attached to the finger to make sure it is not broken.
probe attached to the finger to make sure it is not broken. One of the most important lessons to learn from data that doesn't make sense, is that it probably doesn't make sense because it's wrong. Most of science can be explained. There is a rational basis for making most medical decisions. Whether that rational basis is followed or not leads to the large variations in practice style.
With that said, I want to give you an example of an ICU patient of mine years ago. A critically ill gentleman in the ICU. I was less than a year into my now six year gig as a hospitalist. I got called by the ICU nurse, frantic that the patients O2 sats were critically low, despite all attempts to make them better.
- Ventilator was working. We checked. We adjusted PEEP. We increased volumes. We suctioned. We did everything we could. Nothing worked
- We checked the CXR. No different than the day before. Unchanged pneumonia with a touch of COPD.
- We checked the rest of the vitals. Stable as a rock. No signs of extremis.
I read through the chart. I went through everything with a fine tooth comb trying to figure out what else could be wrong with this patient. Just before the patient was going down for a CT scan of the chest to look for blood clots, I asked the nurse to change out the oxygen oximeter probe attached to the patients finger.
Viola. Problem solved. Unexplained hypoxemia now explained. It didn't exist in the first place. The oxygen oximeter was bad. Oxygen saturation levels were now 100%. The problem with this patient was that there wasn't a problem. I spent 45 minutes trying everything to get this patients O2 sats up. I almost forgot about one cardinal rule of medicine. If it doesn't make sense, it's probably because of bad data.
Always keep in mind that the data may simply be wrong. And things like
- Making sure the O2 tubing is hooked to the wall
- Making sure things plugged in.
happen far more often than you think it will.
and with Cyanide Poisoning it'll beep happily along at %100 right up to the end...
ReplyDeleteOne note of occurrence from a very frequent flyer:
ReplyDelete"We had a little excitement the night I was admitted as well...my O2 tubing came off the wall, and I remember laying there gasping for breath, and thinking "If I call for help, they'll put me on a vent, and I won't get off" (crazy thoughts when you're hypoxic, no?). My aide had decided not to do his vitals at 4 a.m. (we were all sleeping) but something nudged him to check on me, and he saw the distress I was in, yelled for help, and the 'team' came into my room and put me back on high-flow oxygen (I had 15 liters at admission, given my pulseox was in the lower 80's at arrival). I was told that I was seconds from coding...my pulseox was below 50%."
Technology!!! Yes, it does indeed happen more often than folks like to believe.
ReplyDeleteThat's kinda pathetic the nurse didn't check that herself. No wonder you have such a low opinion of nurses.
ReplyDeleteAlways keep in mind that a "viola" is a stringed instrument slightly larger than a violin and "voilà" is an interjection, used to call attention to, or express satisfaction with, something.
ReplyDeleteMaybe you ought to consider using Archimedes' favorite, "eureka".
I remember being very suspicious that a patient on the psychiatry unit was cheeking his lithium because the level was zero. The lithium order didn't get transcribed to the new week's medex and he wasn't receiving his lithium as ordered the previous week.
ReplyDeleteFrench teachers, harrumph. A dime a dozen these days...
ReplyDeleteI once spent a night covered w[th a cooling blanket that wasn't plugged in. [DUMC, no less.]
On the television? Reefer Madness.
In the dawn's early light, a grad student friend in engineering dropped by to say "hello" and see how I was doing.
He plugged it in...
Oh, I forgot to mention that, while unable to "fix" the cooling blanket, the staff quite ably checked my temp every 2 hours.
ReplyDelete