Just how sick are you?

We have had our fair share of super sick patients recently. And this is not necessarily a good thing. In all of the cases, each patient waited too long to seek medical attention.

Patient 1; late 20s: presents to the ER with difficulty breathing, fever, chills. Pt is sent to ICU with RR in the 40s and with an insulin drip. Pt is alert, able to talk, but is very uncomfortable. Throughout the night, I keep a close eye on this patient because I had a really bad feeling in my gut. Sats say upper 90s but I tell the other nurse with me that I just don't believe it. White count is over 40. While working through the admission, I ask the other nurse to please see if she can get me a couple more IV sites. BP stable, but HR increasingly tachycardic, in the 120s. As the night progresses, RR goes up to the 50s, HR goes up to sustained 180s. Sats and BP bottom out in a flash. Pt is in respiratory arrest, and is subsequently intubated. This happens at shift change. Later that same evening, the patient goes asystole and is coded, but is brought back. And what is brought back is not the same person that I admitted. This newer version of the patient has gross neurological deficits. This patient, who was able to talk at admission, is now pretty much a vegetable. We were sure that they wouldn't make it. Now, a month and a half later, the patient remains in the hospital with a peg tube and will need long term care for the rest of their life.

Culprit? Strep pneumonia.
Patient waited 2 weeks before seeking medical care.
Did you realize that 30% of pneumococcal patients become septic and then 30% of those die?

Patient 2: Patient in their 80s, presents to the ER with fatigue, weakness, and cough for 1 wk. Pt is transferred to the ICU due to hypotension and tachycardia, but was admitted to the hospital with pneumonia. Upon arrival to my shift, I listen to lung sounds and all I hear is water. Everywhere. Pt is alert, but a little nauseous. Nailbeds are dusky. O2 @ 6L per nc. White count 1.0. History of CA, but not currently. + Blood cultures. No urine output. As the night progresses, pt is unable to sleep,but is alert and talking. I teach the patient how to use the yankauer to suction the secretions out so that they would not have to use tissues, which in turn, dry out the mouth. It almost seems that the patient is getting better? Which I know is not necessarily a good sign. The next night, the patient expires. I heard it on the radio.

Culprit? Strep pneumonia.
I recently read that when white counts are low, it is not necessarily speculative of cancer, but in fact can be due to an infectious process so widespread that the body isn't able to produce enough white cells to counter those being used to fight the infection.

Patient 3: Late 30s, presents to the ER with abdominal pain for 3 days. Yeah, a regular presentation, but after testing, the patient is rushed to surgery as this patient has a perforated ulcer. Comes to the ICU post op and on the vent. I didn't personally have this patient, but I assisted with the care for 3 nights of hell. BP won't stay up, has to be on dopamine and then an epi drip. Pt is in renal failure. Continues to be on 100% FiO2 on the vent because this patient cannot tolerate any type of weaning before the sats bottom out. Pt is now in multi-system organ failure and expires 2 nights after my last shift that week. Died of pulmonary edema.

Culprit? Septic from a perforated ulcer.
Sad case, really.

Patient 4: mid 70s, presents to the ER with abdominal pain for at least a week. Admitted to the floor and to see the GI doctor, who subsequently schedules surgery for the next morning. Arrives to the ICU on the vent, but doing well. Surgeon tells the family that this patient waited too long to seek care, that it was possible that this patient would not survive this. Pt has so much ischemic small bowel, that there is nothing left at this time to take out and put together. 2 days later, the surgeon goes back in for another ex lap, and finds pink bowel. Only has to remove 6 feet and is able to reconnect the remaining so that this patient does not even need an ileostomy. A week later, patient is able to move the floor, completely stable, and completely aware of how close they came to dying. This was truly some type of miracle. This patient attributed it to the praying done at church.

No culprit this time. This patient was lucky.