What would you do?

[ERDoc]

Labs are fine. Sats are now in the mid to upper 90s. No pneumothorax was seen on a poor chest xray prior to central line. The ptx is a small ptx in the right upper lung area.

[scubanurse]

I'd be inclined to monitor it. If sat's start dropping or condition change, change the course of treatment. I'm just thinking leave her be for a bit since her body has been through a lot. Will admitting service take her now?

[Just Plain Ruff]

Yes I'd be inclined to monitor the pneumo as well, now if the pneumo was further down in the lung then yes I'm sure she'd get a chest tube due to the location but since the location is high in the lung, there's not a big possibility that the air will migrate downward but only upwards. I've seen many pneumos in our little ER that were in the uppper lobes managed via "just watching them" rather than chest tubes.

So have the docs called the hospital attorneys yet for this one?

Has the doctor spoken to the paramedics supervisor yet? The proximal cause of this ladies problems all stem from the medics actions in my opinion.

[ERDoc]

Not sure about the lawyers but the medical director happens to be a close friend of the treating physician so it has been passed along. Ruff, what is different with this pt than the ones that you have see "watch and wait"?

[Just Plain Ruff]

i don't think she's much different than many patients other than she was given 2 mgs of narcan (which she should not have been) which set off a cascade of adverse events which has caused her much pain and suffering. (all caused in the beginning by this idiot medic). She required sedation, then intubation, then a subclavian because the admitting team wouldn't take her without a CT of somesort with contrast, then she get's a pneumo(small one that doesn't need a chest tube or needle decomp) and she's still intubated. She needs constant monitoring in an ICU and multiple chest x-rays because we nicked the subclavian when inserting the line.

She may very well develop a hemo pneumo if we aren't careful. (does she take blood thinners?????? - we might want to address that for the short time since we did pneumo her while trying for a subclavian). She is still intubated requiring medications to keep her sedated in order to keep the tube in without her pulling the tube.

Have we addressed her nutrition needs as well since she cannot eat with a tube in place?

And one more thing, Is the family here and are they pissed yet? The damn well better be!!! I would be if I were them, I would not be pissed at you but I'd be pissed at the EMS Crew who started this entire fiasco. All because some dumb ass medic thought it was cool to slam 2 mg's of narcan to grandma when .4mg would have done the trick.

So we have grandma who will probably end up with some nosocromial infection (think ET TUbe acquired if we aren't careful and diligent in keeping the infections at bay) and if we are lucky we won't have a sentinal event and hope the hospital is up to par with it's medical monitoring which If ERDoc or his cohorts are involved I have every bit of faith that a they are.

But I don't see anything more to look at other than a train wreck that could have been prevented. I still say we watch and wait with Grandma and see how she fares, but if we notice the pneumo extending downward due to the ventillator mechanics causing the extension or the patients lung anatomy not being what it used to be in her prime, then we would need to think about a chest tube.

But yeah, let's just watch and wait.

Might want to think about looking forward and talking about a DNR. If she does indeed pass away, then the family has a pretty good case of negligence in my opinion against the medic. Or at least malpractice (if you can charge a medic with malpractice)

[chbare]

I don't want to get too involved and incur the wrath of ERDoc, but the fact that we have initiated positive pressure ventilation in the setting of a pneumothorax may be more concerning than a spontaneously breathing patient with a small pneumothorax. Also, what about the location of the central line?

[Just Plain Ruff]

I don't want to get too involved and incur the wrath of ERDoc, but the fact that we have initiated positive pressure ventilation in the setting of a pneumothorax may be more concerning than a spontaneously breathing patient with a small pneumothorax. Also, what about the location of the central line?

But I don't see anything more to look at other than a train wreck that could have been prevented. I still say we watch and wait with Grandma and see how she fares, but if we notice the pneumo extending downward due to the ventillator mechanics causing the extension or the patients lung anatomy not being what it used to be in her prime, then we would need to think about a chest tube.

I thought thats what I was meaning to say, maybe I didn't say it right.

[mobey]

If the pneumo is tension, then yes: Needle or Finger thoracotomy, followed by chest tube.

If it is a small pneumo then it may resolve on its own and we are better off to let it be.

When making the decision we should peek at her INR if she is anticoagulated.

To make the decision can we get a current set of vitals?

Do we know what meds she's on?

We have her on Narcs & Benzo's for sedation right?

[ERDoc]

She's on a propofol drip with normal coags. As chbare said, this lady is on positive pressure ventilation so a tension pneumo is almost a guarantee. This lady requires a chest tube. A pigtail would be acceptable if your facility had them. So, the ICU accepts the pt and off she goes.

As others have said, the moral of the story is to be gentle with the narcan, especially in people on chronic narcs. It may be funny to slam them just before they get to the ER to watch them puke all over the staff (I'm not saying that is what happened in this case) but you can also cause some real problems. There is no guarantee that this case would have turned out differently but something as simple as pushing a huge dose of narcan caused this poor woman to require intubation, a central line and a chest tube as well as a hugely expensive visit to the ICU billed to the generous taxpayers of the state.

[Just Plain Ruff]

That's true doc, pushing the narcan didn't guarantee the cascading of these events but it sure didn't help matters.