Ever watched old cartoons?

[CraigBSN02]

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. :-)

[Ivanna_Nurse, BSN, RN]

Thank you for sharing! What a night! ~Ivanna

[angelique777]

I enjoyed reading your story. Have to ask. Did They really let Senior go home after an episode like this. Would this not be considered a Syncope episode warranting a Syncope work up CT of Head etc etc.........just curious or did you know right of the bat that father fainted or had seizure secondary to seeing son arm being worked on ...............Have to ask......stuff like this always gets to me in Clinic

Women comes in today stating I have chest pain

So I ask her where its located....she points to right side of chest and states you know over my heart.......and states the pain starts there and radiates to right shoulder. Pain is reproducible to touch Then on further inquiry she has had the discomfort x 1year. Denies SOB of breath r/t to the episodes of CP or palpitation , no NVD no diaphoresis, etc. When ask if she gets SOB she says yes going up steps. ( Well so do I ....but she says after I push the questioning that not related to CP.)

Well I put her as regular visit intead of acute .......since she was next to be seen any way.

What bother me about her was Hx of DM, Renal insufficiency, HTN, slightly obese, high cholesterol. She is having SOB on exertion and on walking three blocks but unrelated to the chest pain.

How would you rate her complaint while I still thinking she should be worked up for cardiac issues echo stress test but that is primary physcian call. Since patient has all the risk factors for cardiac problems. If a lot of people where ahead of her I would put her first if every one else c/o benign

I rated it low non acute b/c she said x 1year and pain reproducible however what your take

BP =147/67 HR=70, RR=16, Sat =1005 Temp 97

Iam new to triage and this triage is in clinical setting not the ED

Would like your decision making process on this lady

[nightmare, RN]

Could be Gall bladder trouble.Pain radiating to right shoulder is classic sign as is"chest pain"

[ukstudent]

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!!

:chuckle ROFLAO

[scattycarrot, BSN, RN]

Thanks for sharing, Craig! I hate it when relatives do that. Worse 'passout' scenerio I was a partcipant in, was a father of a young girl who hit the deck hard, knocking his head on some piece of equipment and was LOC. Bought into my resus bay as GCS was 8 at a push. Large temporal gash and boggy area over that region. Comes round slowly. Gets a CT and had a lovely SAH (small luckily...no intervention needed). Turns out he isn't very good at the site of blood....really? Never would have guessed and he could have told someone! He was fine in the end, so no long term problems. Anyway, that taught me to always ask the relative/friend if they can handle blood, etc.. and to get them to sit just in case.

And, I HATE that grey color. It does make them look totally dead. Though I remember as a student trying to assertively 'bring round' a elderly patient (DNR) in the day room of a LTC facility who had that grey color, and who actually was dead and had been dead for a little while and all I was doing was bringing lots of attention to the situation.I may as well have been shouting..."found another one dead and hey, your next" to all the other residents! An experienced nurse came over and gently guided me away and handled the situation in a nice calm manner. Hey, at least I knew he didnt look very well.......

[Lunah, MSN, RN]

I may as well have been shouting..."found another one dead and hey, your next" to all the other residents!

Bwa ha ha ha!!!

I was at a DNR patient's bedside about 2 months after I started in the ED in 2005 ... about 30 seconds after his wife walked away, he's got the positive o-sign, flatline on the monitor, no pulse, no respers, the whole nine yards. It's not easy to NOT do anything. I had to MAKE myself calmly get his nurse.

Craig, I learned the hard way to ALWAYS put a chair behind mommy/daddy when their kid is getting sutured, if they insist on being present. We had one lady go down HARD into the door then the floor with her head, even after she kept saying she was fine ... heh. Not pretty. Good for you for handling Mr. Pasty Face so well!

[angelique777]

YES ROFL was very funny thanks again for the post and for the import tips

PS Thanks nightmare good to know........

[rph3664]

Newer cartoons do that too.

Ever seen the "Spongebob Squarepants" episode where Planton hijacked Spongebob's brain, and Spongebob breaks into Squidward's house and walks through his bedroom? Squidward turned totally white before collapsing to the floor in a dead faint.

[zamboni]

OMG! That was a fun read!

I remember waaaay back when I was a paramedic student, and was helping suture a little girl with her Dad in the room. Big tough cop. His baby was getting a whopping 4 sutures. First one in, she whimpers a little, and he drops. Being the hero that I thought I was, I figured that the best course of action as he's heading for the floor is to fling my 100# self between him and the linoleum. Yeah, brilliant. From that day forward, if I can't keep them out of the room, they have to be seated on a chair. I've gone so far as to say that it's a rule (it is...it's MY rule!) Now, I find out that that may not be enough. Thanks a lot.

Oh, and on my next shift...I'm going to incorporate "What the fiddle is wrong?" into my conversation as much as possible.

[CraigBSN02]

I enjoyed reading your story. Have to ask. Did They really let Senior go home after an episode like this. Would this not be considered a Syncope episode warranting a Syncope work up CT of Head etc etc.........just curious or did you know right of the bat that father fainted or had seizure secondary to seeing son arm being worked on ...............Have to ask......stuff like this always gets to me in Clinic

Women comes in today stating I have chest pain

So I ask her where its located....she points to right side of chest and states you know over my heart.......and states the pain starts there and radiates to right shoulder. Pain is reproducible to touch Then on further inquiry she has had the discomfort x 1year. Denies SOB of breath r/t to the episodes of CP or palpitation , no NVD no diaphoresis, etc. When ask if she gets SOB she says yes going up steps. ( Well so do I ....but she says after I push the questioning that not related to CP.)

Well I put her as regular visit intead of acute .......since she was next to be seen any way.

What bother me about her was Hx of DM, Renal insufficiency, HTN, slightly obese, high cholesterol. She is having SOB on exertion and on walking three blocks but unrelated to the chest pain.

How would you rate her complaint while I still thinking she should be worked up for cardiac issues echo stress test but that is primary physcian call. Since patient has all the risk factors for cardiac problems. If a lot of people where ahead of her I would put her first if every one else c/o benign

I rated it low non acute b/c she said x 1year and pain reproducible however what your take

BP =147/67 HR=70, RR=16, Sat =1005 Temp 97

Iam new to triage and this triage is in clinical setting not the ED

Would like your decision making process on this lady

I agree with your decision. The fact that this lady had risk factors out the wazoo is a side point. However, this doesn't sound like new onset cardiac pain. The salient points are: reproduceable RIGHT side chest pain x 1 year and dyspnea on its own that sounds fairly stable. Call it what you like: costochondritis, etc.

As far as Junior and Senior go... I initially thought Senior was gonna pass out, since it's logical sequelae of events. However, the depth of his symptoms caused me to second guess.

-Craig

RN, BSN, and others.

PS - Yes they let Senior go home. My facility isn't the most aggressive in drumming up business, as they already have enough of their own. Plus, I doubt Senior would have stuck around for a full 23-hour syncope workup.