Case study - what would you do?

[Lev]

Mr. Jones is a 42 year old male who arrived via EMS to your hospital's ER with complaints of sudden shortness of breath and sharp 10/10 chest pain radiating to his left shoulder and back. Vital signs on arrival to the room are BP 138/65, HR 127 BPM, RR 36, and SpO2 is 99% on 15L of oxygen via a non rebreather mask. Mr. Jones has no underlying health conditions. He has a slim build and smokes 3/4 pack of cigarettes per day. The MD arrives to the room as the patient rolls in and respiratory therapy is called to the bedside. Mr. Jones in is visible respiratory distress and is using accessory muscles to breath. Mr. Jones is very agitated and states in full sentences that all he needs is some oxygen and insists that he will be fine without having labs drawn or an IV inserted. His family is very surprised at how he is acting. As this patient's nurse, what are your next steps?

[mbtsab]

this was very fun to depict, and I am just pre-nursing! exciting stuff

[No Stars In My Eyes, LPN]

When I read OP, my very first instinct was to be like Cher in MOONSTRUCK and give the patient (standing in as Nic Cage) a hearty slap in the face and yell, "GET OVER IT!"

But then I kept reading through the posts and realized y'all were being quite serious.

Which I appreciate.

A lot!

It's been umpty-ump years since I have worked in any hospitals, let alone handle critical situations. I'd be more than happy to hand over the responsibilities to more experienced +/or recently educated folks.

If you have a grandparent, though,with dementia, I'm your girl.

Good thing it takes all kinds to make the world go round!

[That Guy, BSN, RN, EMT-B]

This makes me think of the post from the guy who said he was an ED nurse and didn't think it was necessary to carry a stethoscope or use one for assessment. I digress...

I was thinking of this too! Because the unequal breath sounds should have been the huge red flag to chase that path. But hey the CXR would show it anyways right.

[gunny48]

Resistant to treatment? Simple. He just found out what the ACA deductible was....

[MunoRN, RN]

Based on the fact that he appears to be hypoxic and probably not in his right state of mind. They're obviously not going to let this man walk out of the hospital, which seems impossible for him at this point anyways.

He clearly needs an EKG, chest xray/CT, labs - cardiac markers, etc. Obviously a PE or MI will potentially kill him so I would be in there doing everything in my power so get the appropriate tests ordered for this man. Get his family involved if need be.

"Hypoxia" is not an accepted basis for declaring a patient incompetent to make medical decisions. There are number of medical conditions that are likely to cause the patient to fail the criteria necessary for refusing care, but the legal basis is always the criteria, not the underlying cause. A patient has to be able to express that they understand what is or might be wrong with them, what treatments or tests are being proposed, and what the risks are of refusing. So long as they can do those things, what some doctors call the "magic words", they can refuse. You can't tell a patient that they know longer get to have decision making power over their own care because their O2 sat is 85%.

This particular situation shouldn't be difficult to obtain consent, since he's in denial about what treatment he needs, not refusing care that he is aware he needs. Usually a blunt discussion of reality will do the trick, but it's still necessary, otherwise it could end up delaying care.

[MunoRN, RN]

I think age definitely played a role here. This was a scary event in an otherwise young healthy individual.

It seems almost predictable in a 'young' male, particularly one who claims "no medical history", which more accurately means "I've never been to doctor".

Many men have peculiar ways rationalizing their health needs. One is the "if a tree falls in the forest" method: If you never give anyone the opportunity to diagnose you with high blood pressure, then do you really have high blood pressure?" Another is the reverse logic method: If doctors says I need to take a medication because I have high blood pressure, then if I don't take the medication I don't have high blood pressure.

This guy's response is pretty typical; if I'm going to be fine with minimal treatment then I'm not really that sick, which is what I want to believe so I'll just use overcome what's wrong with me by believing something else.

This is usually pretty easily fixed by clearly explaining what is wrong and how we know that and what they can expect by following their plan. If that fails, find the wife, girlfriend, mom, sister, etc.

[NursesRmofun, ASN, RN]

Oops...late...deleted