We had a "respiratory distress" transfer to the unit some days ago. The woman, significantly obese, is wheeled down in the a large armchair. In her clothes. That's committing at least two cardinal sins against ICU staff right there—the rules for unstable patients (i.e. if you can't breathe) are, no clothes, and in the bed! So the nurses, suitably, had a cow. The woman and her floor nurse tried to explain that she has such difficulty breathing that she sleeps in a chair, even at home. So I suggested leaving her in the chair. I mean, really, she looked fine except for not being able to breathe. I'm not being facetious. She was gasping like a fish, and only able to spit out 3-4 words at a time, but she could walk! Obviously she was a long-term COPDer or something, so she was compensating for this. But her blood CO2 was over 100 (which I didn't even know is compatible with life), so, not wanting to have to code or intubate her in a chair, we compromised by putting the bed into a chair position.
Within an hour we put her back in the chair.
Orthopnea is not a cool thing. When some obese people lay flat, their entire abdomen pushes up against their diaphragm, and they literally can't breathe. I've seen obese people start to black out because they're being forced or coerced or strongly encouraged to lay down. Do you want to code a 400 pound man? I don't.
I once heard a local story—this is purely hearsay, so don't subpoena me—about an obese man with a host of the usual end-stage problems (diabetes, heart attacks, dialysis, lives in a nursing home) who presented to the ER for whatever reason, and was allowed to sit in a chair so he could breathe...until the night shift nurse, who was new, made him lay on the cart, argued with him about it, and eventually got orders to put him in restraints to keep him in the cart...where he coded and died.
Is the moral of the story that we need more obesity/orthopnea education, or that if your patient says "I can't breathe" we should listen to them?
This is not a funny subject, but part of me almost wants to see the Charles-Dickens-derived term Pickwickian syndrome come back.
I've seen this many, many times, where a patient is just too big to lie down or have their feet up level with their hips. A big consideration for us as paramedics is that we *have* to fasten a seat belt around every patient, and if someone has to dangle their legs, the seat belt is impossible.
ReplyDeleteFrankly, I'd rather risk a crash/lawsuit/losing my job/being crushed by a flying 500 lb patient in the back of my ambulance than resuscitate said 500 lber. :D
It's risk vs. benefit :D
Kudos for thinking outside the box.