Friday, January 27, 2012

Sissyphus MD

2 am.

It's always 2 am when the potentially bad arrives unheralded.  In this case it was a middle aged woman having an allergic reaction.

These come in varying degrees of severity.  At the mild end you have a few hives and an anxious patient.  This is not all bad, as adrenaline is the first line drug for allergic reactions.

But this was at least potentially a bit worse.  Wheezing and swelling of the lips, of rapid onset.

Well, the lip swelling was not quite this severe

We started out OK, with decent vital signs.  There is a standard litany...IV access, antihistamines, steroids, adrenaline.  Maybe a fluid challenge if the blood pressure was trending low.

But in the ER you always have to be prepared for the best and worst case scenarios.  So we moved the patient to the trauma bay, the place where we have all the tools.

There is a sort of checklist in these situations.  Plan A is that the medications work and everything returns to normal.  Plan B involves intubation in case the airway threatens to swell shut.  Various later letters of the alphabet involve ever more invasive measures, ultimately ending up with things I have not actually done on humans, but have demonstrated a fair degree of proficiency in with sheep and dogs in a lab setting.

But tonight at least fortune smiles upon us.  Quick administration of drugs holds things stable.  Oh, at one point the wheezing got a bit worse and I glanced over to where the intubation equipment stood ready, but a breathing treatment of bronchodilators relieved matters considerably.

In a rural ER there is little middle ground.  The folks who do great get fixed and go home.  The folks who do lousy get shipped out with dispatch.  But this lady lingered a bit.  Sometimes the only thing to do is wait, and the only place to do it is the one location where we would have a fighting chance if things went bad fast.

That means a patient sleeping soundly in the ER at 5 am, waiting for the medications to finish their work.

And they did.

All went well.  In a small clinical setting patients are often very appreciative.  She expressed her thanks.  I shook her hand and said it had been my pleasure.

As the sun rose at 6am I called her friends, the ones who had dropped her off and subsequently been sent home.

It took them a while to turn up I guess, and at 8 am when I pulled out of the parking lot I looked in my rear view mirror.

There was my patient.  Standing on the curb waiting for her ride.  Snowflakes swirled down around her.  Her lips were now back to normal size and were pursed around a cigarette as she took a deep, and apparently satisfying drag.


ScottH said...

I've got that problem, too. Flushing out your lips, mouth and throat with cold water and applying ice to your lips and mouth drastically cut down the itching and swelling if you do it immediately.

Tacitus2 said...

Scott, if folks ever started acting sensibly the ER would be a much less busy place.....