Ever seen when a character passes out? All the "color" drains out of him so that he's see-thru??
I ask for a reason. Keep reading.
My pt is a young adult, transferred to us for a distal comminuted humerus fracture with radial nerve palsy. We'll call him Junior. Me and the Ortho and the pt's father (we'll call him Senior) are in the room. Me and the Ortho are taking down the Junior's (shoddily applied) posterior long arm splint to better assess the palsy and swelling.
PS - ever want to easily assess radial nerve palsy in a patient who's splinted? Ask him to make a thumbs up sign. The extension of the thumb indicates the radial nerve is doing its job.
(back to story)
Junior, who I think has been less than forthcoming regarding his youthful indiscretions regarding pharmaceuticals, has quite the tolerance to hydromorphone. So, he's yelping, panting and generally letting it be known that what we are doing, HURTS. We finally get the splint off, prop up the arm, and complete the assessment, at which time Senior says...
"I'm feeling a little dizzy."
I tell Senior, "Sit down in that chair right now. Do not get up." Senior takes a seat in a chair, with his back leaning against the wall. He's perpendicular to us. I notice that in the next 15 seconds, Senior looks awfully gray and has quite the faraway look in his eyes. With Junior's arm secure (for the time being) I go assess Senior.
Junior opines, "What the fiddle is wrong, Dad?"
Senior's head slumps forward, and he's guppy-breathing. Senior looks dead. Looks stone warm dead. Like immediately post-code dead. If he were a Monthy Python character, I'd call him a Norwegian Blue parrot, what beautiful plumage! He's pining for the fjords!!
"What the FIDDLE is wrong with my Dad?"
Sidebar: I have witnessed plenty of people suddenly expire in front of me. I have witnessed a visitor to a patient in Urgent Freakin' Care pick that particular moment to allow his previously undiagnosed thoracic aneurysm to rupture. I have watched a man promptly launch himself into ventricular fibrillation upon being told, 'you are having a heart attack' by the attending MD. I have also witnessed plenty of people pass out in front of me. I could not tell what this guy was doing at this particular time.
I take 7.5 seconds to stick my head out the room and holler (in my *best* big adult man voice):
"I NEED SOME HELP IN ROOM SIX NOW! NOW! NOW!
I preface this with the name of the first person I can recognize & who's name I remember. I prop Senior's head up to open the airway (and stop the guppy-breathing to a more quiet agonal/bradypneic pattern) & I check a carotid pulse; I'm not sure if I feel it. I look at his crotch: no visible or olfactory presence of urine. I continually ask Senior if he's ok. I am answered with glassy eyes and more agonal-esque breathing. The calvary arrives. Junior is asking, in no uncertain terms, just what the fiddle is wrong with Senior, repeatedly. Within 15 seconds after the calvary arrives, Senior goes from ash grey to red face (like a newborn taking a poop, still with the walleye look, however). Senior postures a little (flexion abduction in the upper extremities, for those keeping track at home) and has a brief 2 seconds of myoclonic jerking, at which point his color returns to normal. The calvary murmurs:
"Is he seizing?"
"Is he coding?"
"WHAT THE FIDDLE IS WRONG WITH MY DAD?!"
Senior gets lifted out of the chair to the (newly available) stretcher by myself and a few other nurses. I grab around the chest and they grab legs and we plop him down. I now look at Senior's face.
Senior look like he did when I first met him in the waiting room. Normal color, eyes clear, looking maybe a little more sheepish than before. We wheel Senior to an available room to give him the business...
...at which point we're informed by the ED medical director, "don't register him, just give him food and something to drink" and promptly walks away.
(I mean, I was in full on this-dude-is-coding mode)
Senior is awake, obviously not post-ictal, and sweating like a MLB player in front of a congressional hearing.
"I guess I must've passed out.", says Senior. Normal pulse, respirations and color. Affect normal. Eyes clear and bright.
"Yeah, you had us going there for a bit." Radial pulse 67 and strong, regular.
"It's really hot in here.", says Senior.
"Well, you passed out, that's a fairly normal response. Drink some juice and get up SLOWLY when you feel better."
I go back to room six and inform Junior that Senior is alive, well, and consuming the best apple juice (with 10% real juice from a variety of sources!) our facility can provide.
Moral of the story:
-Airway, Breathing, Circulation: always open the airway. A jaw thrust is easy to do to a sitting person facing you.
-Incontinence is the fifth vital sign: a fairly reliable indicator of significant LOC or something worse.
-You're not so tough: If you even THINK family members will not be able to handle what you are about to do to little Junior, ask them to leave and promise to bring them back when you are finished. Senior was a little wound up from Junior's mechanism of injury, a perceived attitude from the front security officer, and lack of sleep and *I* should have trusted my gut. I have scraped more big, tough 'it's okay I'm a firefighter/marine/contract killer' guys off the floor when daddy's little girl is getting her first stitches.
Post script: Senior was driven home ~50 miles by a friend, and Junior went to the OR for a surgical correction (I'll find out which one tonight). Nobody else passed out or otherwise created a stir for the remainder of the evening.
I was reminded that sometimes, people will pass out and try to make it look like they're coding. It's up to me to determine whether that's true and sometimes that'll take 30 seconds, maybe less. Don't get my knickers in a twist and remember the important stuff.
Airway, Breathing, Circulation.
-Craig
RN, BSN, and others. :-)
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~Ivanna
ROFLAO
