I get a page with 7 numbers and nothing else, no name, no patient name, nothing. I call back thinking that it’s a nurse asking can my patient have a one time dose of zofran or dilaudid for breakthrough nausea, or pain, you know, the typical stuff. Instead it’s a frantic nurse, “We called an RRT on room 13.” My response, “Okay, I’ll come as quick as possible. Breifly, what happened?” “I’m not sure Dr. Obsession, but she is not very responsive. She desat’ed and she is only breathing around 8 times a minute” We go back and forth with a little convo as I’m running there with my upper level resident. My final response, “Okay, is there a physician at the bedside?” “No, we are waiting for you!”
Wow… yes, a rapid response was called and they were waiting for me. A rapid response is pretty much 1 step below a code blue. It’s not something that can wait an hour for attention, but it’s not like the patient has stopped breathing or had some cardiac event in a code blue. At my medical school we had a rapid response team. So whenever a rapid response was called, the RR team would go to the bedside, often before the primary team arrived. I was under the impression that we had one too, but I guess not.
Back to the story. We get to the bedside and there are about 5 nurses and nursing assistants at the bedside and a pharmacist. The patient is on oxygen and that is it. What amazed me was that it really took about 15 minutes of questioning to get the full story. The patient had an extensive cardiac history and had been having some intermittent episodes of various arrhythmias throughout the hospitalization. Our first thought was cardiac. After a brief physical, and realizing that she was lethargic, but arousable, we proceeded with further tests. It was a relief to see that her oxygen level was being maintained on 2L oxygen, and right now a full code didn’t seem imminent. We did a host of tests: EKG, ABG, CBC, BMP, cardiac enzymes and coags.
At this point, something in my gut is telling me that it’s a medication she got. Initally the nurse caring for her told me the only medication she got was a tiny dose of narcotics. Considering she had been taking this dose for several days, I wasn’t completely sure that would do it. I ask my upper level whether they thought naloxone was appropriate and I was immediately told no. Naloxone is a medication that basically blocks the actions of narcotics and can be used in overdose situations. Once we got all these tests cooking, I asked the pharmacist to go through the medication record, only to find that another nurse had given the patient a nice sized dose of a sedating anti-nausea medication just 10 minutes after that narcotic. The combination of these medications made her sedated and decreased her respiratory drive. At that point I spoke up again to my upper level indicating that I thought naloxone was necessary. The nurse grabbed the medication and pushed naloxone. It was amazing… just 45 seconds later the patient was completely alert. She told us that she could hear us the whole time, but couldn’t open her eyelids! I learned that naloxone also works for phenergan overdosing as well!
That was a pretty intense moment. It was crazy to be the ones called to the bedside for an acute event. I learned the importance of considering all things in the differential, not just what initially seems obvious. It was important to work as a team. The nurses, respiratory therapy, pharmacist and the doctors worked well together. It was also a learning moment for the nurses because they had 2 nurses giving this patient meds – one in training the other full time. I am so happy that it was just a matter of giving one medication to solve the problem!
