Every month I spend one day covering the psychiatric ER. Last month, I came onto my shift with an elderly patient who had not yet been evaluated. He had allegedly overdosed on Vicodin. Let's call him Jimmy Vikes. His drug screen was positive for tricyclics, acetaminophen, and opiates. He got Narcan in the ER then they punted him to psych. He was sound asleep when I came in, so I figured I would let him sleep while I discharged all the drunks on a Saturday morning.
While I was interviewing a 50-year old manic guy who assaulted his 80-year old parents, the psych tech came over and said "Jimmy Vikes stopped snoring." So I excused myself from interviewing the rambling, abusive jobless manic dude. Jimmy Vics had a thready pulse, about once every 10 seconds. No respirations. I felt my sphincter tighten. I haven't done a code since I was an intern 2 years ago. I told the nurse to call the stat team and I started BLS. They showed up after what seemed like an eternity (our ICU/ER is literally across the street from the psych ER). They intubated Mr. Vikes and took him to ICU. I expected the worst.
A week later, I found out that Jimmy V was discharged from ICU to home. He was alert and at his baseline. A google search indicates that the survival rate of in-hospital CPR is 18%. It's gotta be less than that on a psych unit. My good friend ER doc often references the book "The House of God." Its author describes patients who will not die, no matter what happens. They are called GOMERs. They will not die, despite insane degrees of illness and heroic interventions.
I tell this story not to brag about my life-saving prowess. I am the last doctor that you want doing BLS on you or your loved ones. I am telling you this so that you're aware that another Gomer lives and walks among you. That Gomer better be happy for psych techs with good hearing.
-Psych Doc
10 comments:
Well, at least he didn't go to ground before he coded.
Hold on...how long did they continue to observe him after the narcan was administered?
As an ER Doc, I have to throw the ER under the bus on this one. First of all....if you give a patient narcan...they at least need to be admitted for obs. It was too soon to punt to psych. 2nd....tricyclics and opiods are a nasty combination for respiratory depression. Even more of a reason to admit for obs.
As Psych Doc mentioned, the book The House of God is almost biblical. I had my first "yellow man" case that I caused. He died possibly because of me and it haunts me. If he was a GOMER, he would have lived. But he died bc he was a good person. Maybe I will have the strength to write about it someday. But ironically, it had to also do with Opiods and narcan
-ER Doc
I shoulda made a couple of things more clear. First, the guy hit the ER doors at midinight. Was in psych by 0400. Stopped snoring at 0930. ER doc is right, he shoulda been admitted.
Second, the thing about monitoring his snoring is funny cuz we don't have people hooked up to EKGs, tele packs, pulse ox, etc, because people will try to strangle themselves. Vitals are taken at 0600 (Jimmy V was normal) and that's pretty much it.
-Psych Doc
Sound proof room would have been the best solution. What a waste of money.
U saved him mentally and phsyically. Few can claim that congrats
Wow. It i s like "House of God" come to life. Amazing. Like You All" say (and i must mention, how envious i am of you all!) "Good Save!
Have you all (especially Psych Doc) read "Mount Misery"? A must, epecially for us crazies...delightful!
Also, I dont think elderly people belong on a general psych ward. I hate when "new onset psychosis in a 70 year old" goes to psych. It is always something else. Psychosis doesn't present that late in life...I think. And most people with true psych disorders like schizophrenia have a shorter lifespan...so dont live that long. Long story short...work them up for something other than a psych disorder. If everything else is negative...then consider a geropsych unit
-ER Doc
Gotta diasgree with ER doc on that one, I used to have several elderly folks with true psych dx's, who had been in the same facility for most of their lives. They were well taken care of, saw the facility as their family, and lasted well into their 80's. These were not run of the mill geropsych, they were forensic cases that were deemed better off in a LTC.
So, what was the cause of the code? Just narcotic OD or others stuff? If it was just the vicodin, a blast of narcan and he probably woulda perked up quickly. Still, I agree, I would have admitted him to medicine, not psych.
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