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Los Pollos Hermanos
04-23-2016, 03:28 PM
Good whatever time of day it is where you are!

Is there a US-based doctor or nurse in the house?!

If anyone is unfortunate enough to have person experience and is willing to share anything they're comfortable with, I'd also really appreciate it. Please don't feel obliged though, as I really don't want to upset anyone.

The trilogy has gone off for proofreading (a brutal friend who has her own business), although I have warned her I might want to tweak part of a flashback in Book 3. There's a few flashbacks from Mr Good Guy in Book 3 as the net closes on Mr Bad Guy.

Bear with me as I set the scene.

Mr Good Guy ended up in hospital in Book 1 after a Very Nasty Car not-so-Accident. I'm confident on the medical details, having run them past a doctor (he's a consultant anaesthetist) friend of the family. Part of a conversation (slightly paraphrased):

Him: How long do you want him in hospital for?
Me: A month.
Him: These injuries would keep him in about two and a half weeks.
Me: Has to be a month. I don't want to make the injuries worse, as too much melodrama is a big no-no.
Him: Give him hospital acquired pneumonia. With the types of injuries he sustained and his subsequent treatment he'd be a prime candidate. That'll keep him in an extra couple of weeks on IV antibiotics for a week and then oral antibiotics for another week (he then went on the give me lots of useful info about treatment, etc.).

So... I've got the details of what, how, etc. He ends up in a High Dependency Unit (Step Down Unit as I believe they're called in the US) for five days and on non-invasive ventilation for three of those days. I needed a setback, shall we say, to affect his physical and psychological recovery from the not-so-accident.

In Book 1 the pneumonia is only mentioned in passing. The Book 3 flashback centres on him developing symptoms and being admitted to the SDU. The rest is covered in a paragraph. The reason I'm asking on here is because things might be done (slightly) differently in the US and my doctor contact is 100% Limey. I realise every case is different, but a plausible timeline would be marvellous.

Current scenario is that when patient wakes at breakfast time (so say ~8am) he's running a slight fever, feels iffy, bit of a cough and declines anything to eat or drink. Nurse is concerned, gets doctor. Doctor is concerned. (Patient was feeling off colour for most of the day before but deliberately didn't mention it as he's desperate to go home asap). Mrs Good Guy is phoned and arrives an hour or so later after dropping off their daughter with a friend.

In no particular order I'm after how long(ish) it would take to:
* Run tests to establish that he's likely got pneumonia - listening to chest, X-rays, blood tests, anything else?
* Put him on extra oxygen, IV antibiotics, any other new medication.
* How he might be presenting to the medical team**.
* His symptoms to get bad enough to move him from the Medical-Surgical Unit to the SDU.
* Anything else relevant.

** I've used websites like:
http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/pneumonia/symptoms-causes-and-risk.html
for the facts, although we all know it's those authentic little details that can make or break a scene.

Like I said before, I know all cases are different, but a realistic timeline of how the illness progresses to the point of bring transferred (and at what point tests are done and treatment(s) started) would be really helpful. I don't need nitty gritty details - because he'd be out of it for much of the time he wouldn't remember nitty gritty details, even if I wanted him to.

I think/hope that makes vague sense?

Many thanks in anticipation,

LPH.

Lauram6123
04-23-2016, 08:17 PM
Okay. This is coming from an American Radiologist...

Because your guy would originally (before pneumonia) be on a trauma / surgical service, 8am is a little late because surgeons round very early; more like 6am or 7am at the latest. They discover the fever from the vital signs on the nursing report (unless he/she notifies them before rounds - possible if the fever is very high.) That would prompt a physical exam of the lungs during rounds, when abnormal breath sounds would be detected. This would prompt them to order a chest x-ray, and maybe some labs such as white cell count etc. The chest x-ray would be done and reported within a couple of hours. There's probably an intern on the trauma team who is following up from all the morning rounds stuff, and he/she would inform the chief resident or attending doc by about 10am. At the least, they would then order some IV antibiotics. If they decided he was sick enough to go to step down, they would initiate the transfer process. If you want him to go to Step Down, then you might want to make him a little sicker, because often pneumonia alone isn't enough. Maybe make his blood pressure and or urine output low also. The transfer process can take a while, perhaps several hours given the paper work, availability of beds, transport, exchange of nursing reports, etc. I think 4 or 5 in the afternoon is fairly optimistic.

Hope this helps.

Los Pollos Hermanos
04-23-2016, 08:44 PM
Many thanks for the info - it's a massive help. :)

He was actually transferred to a hospital closer to home three days earlier and "Dr Andy" (my UK-based source) suggested this was enough time for microbes in his new environment to start the pulmonary party. He's recovering from a cerebral contusion and fractured skull, fractured ribs and associated collapsed lung, liver contusion, torn spleen (small tear so repaired and left in situ with close monitoring) and a compound fracture of the radius and ulna AND a displaced closed fracture of the ankle (I also needed the poor bloke to have reduced mobility for a few months). Would that be enough for them to think "Ooooh heck, better get him to the SDU sharpish"? (my characters don't talk like that, btw).

Now for a little think...

If the surgeon does their rounds at 6.30am what time-ish would the nurse have done their observations for the report?

Would the x-ray be done by one of those portable machines, or would he be taken to the radiology department (that's what they're called in the UK - is it different in the US?)?

How long would it take for the white cell count results to come back?

How quickly would they give him extra oxygen?

If he's showing noticeable symptoms by 6.30am -- cough, fever, lack of appetite -- would it be realistic that by late morning his fever is comfortably into triple digits, he's coughing a lot more and is finding it more of an effort to breathe?

Erm... that's all I can think of for now.

Again, big huge thanks to you!

Lauram6123
04-23-2016, 09:20 PM
Many thanks for the info - it's a massive help. :)

He was actually transferred to a hospital closer to home three days earlier and "Dr Andy" (my UK-based source) suggested this was enough time for microbes in his new environment to start the pulmonary party. He's recovering from a cerebral contusion and fractured skull, fractured ribs and associated collapsed lung, liver contusion, torn spleen (small tear so repaired and left in situ with close monitoring) (splenic injuries are virtually never repaired....a small laceration that is not actively bleeding will be left to heal primarily, and followed with CT scan....more serious ruptured or bleeding spleens are either embolized through an arterial catheter or simply removed....no one really sews on a spleen) and a compound fracture of the radius and ulna AND a displaced closed fracture of the ankle (I also needed the poor bloke to have reduced mobility for a few months). Would that be enough for them to think "Ooooh heck, better get him to the SDU sharpish"? (my characters don't talk like that, btw).

Now for a little think...

If the surgeon does their rounds at 6.30am what time-ish would the nurse have done their observations for the report?

Nursing generally records vital signs every four hours or so, unless they have orders to space the out more so the patient can sleep. At the least, they will make sure to have it done before the docs come around.

Would the x-ray be done by one of those portable machines, or would he be taken to the radiology department (that's what they're called in the UK - is it different in the US?)

Films done in the department are of far superior quality, and therefore always preferable. Given this guy's extensive injuries, they may opt for a portable which is unfortunately much less sensitive and specific for confidently finding the pneumonia (even more so with all the broken ribs etc.)

How long would it take for the white cell count results to come back

In an efficient hospital, an hour at least, likely a few hours longer in real life

How quickly would they give him extra oxygen?

If he's hypoxic, they could get a nasal cannula on him in minutes

If he's showing noticeable symptoms by 6.30am -- cough, fever, lack of appetite -- would it be realistic that by late morning his fever is comfortably into triple digits, he's coughing a lot more and is finding it more of an effort to breathe?

Sure

Erm... that's all I can think of for now.

Again, big huge thanks to you!

Hope this helps!

Los Pollos Hermanos
04-23-2016, 10:01 PM
It most certainly does! Humungous thanks once again as I'm not very confident writing medical stuff. Murdering someone is fine, but not medical stuff! ;)

The spleen thing wasn't explained very well (by me). I need him to keep his spleen for future "use" (yeah, you're better off not asking!) so Dr Andy said have a fairly minor injury that that the surgeon can sort out and leave it in - so he doesn't have the needing to take antibiotics for life and get immunised against various unpleasant things I can't remember off the top of my head. Dr Andy mentioned the embolisation procedure when I grilled him about medical stuff.

I'll have a nurse do their checks at 6am and say he was ok at midnight. He's been having trouble sleeping (nightmares, flashbacks) so when his condition stabilised they tried to leave him alone as much as possible overnight (I checked this).

I'll just mention he had an x-ray - people can interpret it how they see fit.

With one of those clip-on pulse oximeters, what percentage does the saturation have to dip below for the docs to say "Here's some extra oxygen for you, my good chap!"? My googling is inconclusive.
Quite an interesting bit of kit. I bought one the first time I went to Colorado. I'm usually 98-99% here in England, stayed around 98% in Denver but after 1.5 hours at the top of Mt Evans (14,000+ feet) it went to 96%. I didn't feel any different though, apart from more than a couple of hours at anything over 10,000 feet makes me ravenous.

Big thanks, you absolute legend!

Lauram6123
04-23-2016, 10:10 PM
It most certainly does! Humungous thanks once again as I'm not very confident writing medical stuff. Murdering someone is fine, but not medical stuff! ;)

The spleen thing wasn't explained very well (by me). I need him to keep his spleen for future "use" (yeah, you're better off not asking!) so Dr Andy said have a fairly minor injury that that the surgeon can sort out and leave it in - so he doesn't have the needing to take antibiotics for life and get immunised against various unpleasant things I can't remember off the top of my head. Dr Andy mentioned the embolisation procedure when I grilled him about medical stuff.

I'll have a nurse do their checks at 6am and say he was ok at midnight. He's been having trouble sleeping (nightmares, flashbacks) so when his condition stabilised they tried to leave him alone as much as possible overnight (I checked this).

I'll just mention he had an x-ray - people can interpret it how they see fit.

With one of those clip-on pulse oximeters, what percentage does the saturation have to dip below for the docs to say "Here's some extra oxygen for you, my good chap!"? My googling is inconclusive. This varies from patient to patient, but certainly when it gets below 90 then it's probably time for extra oxygen. (This is out of my area of expertise, though)
Quite an interesting bit of kit. I bought one the first time I went to Colorado. I'm usually 98-99% here in England, stayed around 98% in Denver but after 1.5 hours at the top of Mt Evans (14,000+ feet) it went to 96%. I didn't feel any different though, apart from more than a couple of hours at anything over 10,000 feet makes me ravenous.

Big thanks, you absolute legend!

You are most welcome. Disclaimer. All doctor stuff was written by Mr. Lauram6123. (He's the radiologist, not me.)

Los Pollos Hermanos
04-23-2016, 10:11 PM
I shall call you Mr & Mrs Absolute-Legend then! ;)

ColoradoGuy
04-23-2016, 11:12 PM
I'm an ICU physician and I generally agree with the above. I have a couple of thoughts to add.

Hospital acquired (aka nosocomial) pneumonia covers a very broad category of clinical syndromes. Sometimes it rapidly progresses over hours, sometimes more indolently. In that it is like other kinds of pneumonia. It depends on the microorganism and other things. So you have latitude really to do whatever your story needs. Fever, cough, increasing shortness of breath, increased respiratory rate, and increasing need for oxygen, all coupled with a new infiltrate on chest x-ray are typical.

As pointed out, we usually start oxygen when the saturation by pulse oximeter gets below 90%. We start with nasal cannula oxygen and move on from there as needed (oxygen mask, noninvasive ventilator, invasive mechanical ventilator).

At least in the US we would never leave a patient to sleep all night without vital signs being measured. Routine is every 4 hours, more often as needed.

These days we can get a chest x-ray very quickly. The portable machines we use have the capability to look at the image immediately. It is also instantly sent to the patient's electronic medical record and we can see it on our computers. I never wait for a radiologist to tell me what's there. ICU docs are so used to reading chest x-rays we proceed once we look at it.

Los Pollos Hermanos
04-23-2016, 11:43 PM
Ooooh! Bonus for two reasons:

1. Proves my point that things are sometimes done a little differently across the Pond.

This is about two weeks after the not-so-accident. Would they be waking him around 2am to do observations, or could they take their readings from the monitor if he's asleep? I assume he'd still be hooked up some sort of monitor, even in a medical-surgical unit?

2. This part of the story is based in Denver! Nothing like a bit of help from a CO-based medical guru. ;)

As a flatlander (I live at 500 feet) one thing I had wondered about was whether the altitude would affect his oxygen saturation under these circumstances? He's not from Colorado originally, but has lived in Golden for the past ten years and can cycle up Lookout Mountain so I'd assume he's acclimatised?
(I was fine walking on the flat in Denver, but when I had to walk up about fifty steps I felt like I'd jogged up them. I also turned into a one margarita lightweight - haha!)

I need him to go from a bit unwell to being transferred within 6-8 hours. Would a SDU or ICU doc visit the medical-surgical unit if there was a chance they might be getting a new patient? The x-ray would be taken whilst he's still there, so would it be the radiologist doing the interpreting?

ALSO:

Something I've wondered, which I might well need for a future story I'm pondering as we cyber-speak:

Blood loss at altitude. If someone got injured - say in Denver - and lost ~30% of their blood volume, would the effects be more noticeable than if they'd lost the same amount at/near sea level? And, would there be a difference between a resident and a visiting flatlander?

Big, big, massive thanks!

ColoradoGuy
04-24-2016, 12:01 AM
Blood loss at altitude. If someone got injured - say in Denver - and lost ~30% of their blood volume, would the effects be more noticeable than if they'd lost the same amount at/near sea level?
I don't think so.


And, would there be a difference between a resident and a visiting flatlander?

Again, I don't think so. I say that because Denver isn't really that high. For example, I live at 7,200 feet. It makes my relatives short of breath with exercise when they visit, but I don't see it affecting your story. Oxygen saturation of hemoglobin (what the thing on your finger measures) is an exponential function. You don't see much clinically significant effect at Denver level (5,000 feet) but the effects increase sharply if you get higher than 10,000 feet or so. This has been shown in multiple studies.

Those of us who live at altitude generally have higher concentrations of hemoglobin. For example, mine is about 7-8% higher than the usual normal. This has been studied also, particularly in really high places where people live like Peru.

Los Pollos Hermanos
04-24-2016, 12:24 AM
Thanks for clearing that up. It doesn't make any difference to the outcomes for the victims (evil cackle), but if it had done I'd have wanted to incorporate it.

I remember learning (in GCSE biology, so aged ~15) about how people who live in the Andes, Himalayas, etc. have more haemoglobin and more red blood cells - we related it to athletes training at high altitudes as a legal way of enhancing their performance.

I really noticed it in Golden (when I did some reccie-ing for the parts of the story set there) when I walked from town (~5,600 feet) to where the patient lives when he's not being ill (~6,100 feet) and I was puffing like a billy goat! A 500 feet brisk climb wouldn't even make me break sweat here.

If I moved to the Denver area (hypothetically, although I wouldn't grumble if I had to!), how long would it take for my haemoglobin to fatten itself up?!

Cheers...

Roxxsmom
04-24-2016, 12:33 AM
When I first moved to Boulder, I noticed that I got a bit out of breath trotting up stairs for the first couple weeks, but I adjusted quickly. As Coloraodguy said, Denver isn't that high. I was young and fit at the time, which also helped, and I didn't have asthma or another lung disease. I am older, in cruddy shape, and have developed exercise-induced asthma, so I suspect it would take me longer to adapt if I were to move back to Boulder today.

There are short (changes in 2,3-DPG (https://en.wikipedia.org/wiki/2,3-Bisphosphoglyceric_acid)), and longer-term (increases in RBC count and hematocrit) that happen over a few months. There are also different evolutionary adaptations (http://news.nationalgeographic.com/news/2004/02/0224_040225_evolution.html) that exist in human populations that have lived at extremely high elevations for many generations. You or I could live in Nepal all our lives, but we still wouldn't be as adapted to the elevation as most Sherpa people are, for instance.

Los Pollos Hermanos
04-24-2016, 01:04 AM
Thanks for that article. I read somewhere they're trying to find the genes responsible for these adaptations, but can't remember the source. I find stuff like that really interesting.

The first time I went to Colorado I made the pilgrimage to Fairplay (blame my university days South Park obsession!) and got chatting to one of the shopkeepers. She was telling me about how babies up there usually need to be on supplementary oxygen for the first few weeks, although her youngest had needed it for six months. She also said the little kids don't have much stamina for sports until they're closer to their teens. You learn some interesting stuff talking to the locals!

Cheers...

Los Pollos Hermanos
04-24-2016, 01:12 AM
One thing I've just remembered is bumping into an ex-colleague and her family at Las Vegas airport four summers ago. Her eldest son has CF and she was saying that he really struggled at some of the places they visited in California due to the altitude - I think she said Yosemite NP was the worst. Out of interest, would that be an issue in Denver, or do CF sufferers adapt (to an extent)?

Roxxsmom
04-24-2016, 01:21 AM
I've read that women who live in towns like Leadville have babies with lower birth weights (and in fact, CO has the highest percentage of low birth weight babies in the country (http://www.thebump.com/a/babies-born-at-high-altitudes-weigh-less)). Anecdotally, my own grandmother lived in Silverton when she had my mom and my uncle, and she had a terrible time with her pregnancies (was very sick with hyperemesis gravidarum) and had some miscarriages between the two. I don't know if the elevation was a factor in this or not (or maybe something in the water) or if it was just her genetics. My mom had a lot of nausea when she was pregnant at sea level too, though it wasn't as bad as it had been for my grandma (the family stories about all that throwing up probably influenced my decision to never have kids).

I don't know specifically how well and quickly people with severe respiratory ailments like CF might adapt when they move to a lower-high elevation places like Denver. I'm guessing it might take longer, since they're already struggling with reduced lung function. It might depend on how well their condition is being managed too. But people with CF do live and receive treatment (http://www.childrenscolorado.org/departments/breathing-institute/programs/cystic-fibrosis) in Colorado, obviously.

ColoradoGuy
04-24-2016, 03:02 AM
If I moved to the Denver area (hypothetically, although I wouldn't grumble if I had to!), how long would it take for my haemoglobin to fatten itself up?!

Cheers...

Probably 6 months or so, maybe a month or two less. A normal red blood cell lives for about 3 months so it would take about that long for your red blood cell population to increase significantly. Red blood cell synthesis is driven by a hormone made by your kidneys called erythropoietin. It takes a while for that to kick in.

ColoradoGuy
04-24-2016, 03:47 AM
I've read that women who live in towns like Leadville have babies with lower birth weights (and in fact, CO has the highest percentage of low birth weight babies in the country (http://www.thebump.com/a/babies-born-at-high-altitudes-weigh-less)). Anecdotally, my own grandmother lived in Silverton when she had my mom and my uncle, and she had a terrible time with her pregnancies (was very sick with hyperemesis gravidarum) and had some miscarriages between the two. I don't know if the elevation was a factor in this or not (or maybe something in the water) or if it was just her genetics. My mom had a lot of nausea when she was pregnant at sea level too, though it wasn't as bad as it had been for my grandma (the family stories about all that throwing up probably influenced my decision to never have kids).

I don't know specifically how well and quickly people with severe respiratory ailments like CF might adapt when they move to a lower-high elevation places like Denver. I'm guessing it might take longer, since they're already struggling with reduced lung function. It might depend on how well their condition is being managed too. But people with CF do live and receive treatment (http://www.childrenscolorado.org/departments/breathing-institute/programs/cystic-fibrosis) in Colorado, obviously.

Leadville has been studied a lot by the pediatric cardiologists at Denver Children's Hospital. They don't deliver babies there any more -- Aspen is now the highest hospital that does. After delivery the pressure in a baby's pulmonary artery, the vessel that goes to the lung, drops as part of the transition to extra-uterine life, bringing more blood to the lungs. It takes a few days to a couple of weeks normally. The Leadville babies had considerable delay in this reflex, which is driven by ambient oxygen. And yes, home oxygen companies are a big business in the Rockies. People with severe lung disease have more problems. As I noted above, oxygen saturation is not a linear function, so once you get above 10,000 feet or so the problems increase quickly. Lots of people with lung disease can tolerate Denver but have trouble in places like Cripple Creek or Leadville. I've had more than a few patients who develop altitude sickness at 10,000 feet and then recover quickly when they come down to 5-6,000 feet.

Los Pollos Hermanos
04-24-2016, 02:00 PM
It's interesting stuff. So, if a baby was born in Denver, its pulmonary artery pressure would drop, etc, etc at a rate comparable to sea level-ish and so no extra oxygen would be needed? Does that mean it would then be okay to go above 10,000 feet for a day out in RMNP say? Or would you leave it until the baby was a bit older? I know what I'm trying to say - haha!

The altitude didn't bother me, I have to say. I did notice above about 11,000 feet, even if I was driving, every so often I'd do this massive sigh for apparently no reason - which I assume was a way of getting more oxygen into me? I was definitely breathing more quickly when I was out and about in RMNP, Breckenridge, etc. but made sure I was swigging the water because I read you lose more water vapour because you're breathing faster, and this can exacerbate altitude sickness.

Actually, a quick couple of questions about patient monitoring (my googling has again been inconclusive):

In a Medical-Surgical Unit, would the patient have heart/BP/oximeter monitoring constantly with the readings displayed, or would it all be recorded as and when needed, along with temperature? Would his previous injuries dictate a particular combination of constant/intermittent monitoring? He's now around two weeks post-accident.

What method/location would they use to measure temperature? Ear? Under tongue? Armpit? Where my cat really doesn't appreciate (he growled Very Loudly at the vet!) having his taken?!? He has no facial injuries (the patient, not the cat).

Cheers...

ColoradoGuy
04-24-2016, 08:25 PM
It's interesting stuff. So, if a baby was born in Denver, its pulmonary artery pressure would drop, etc, etc at a rate comparable to sea level-ish and so no extra oxygen would be needed? Does that mean it would then be okay to go above 10,000 feet for a day out in RMNP say? Or would you leave it until the baby was a bit older? I know what I'm trying to say - haha!

A baby born in Denver does have a slower drop in pulmonary artery pressure than at sea level. You can measure that but it doesn't make much clinical difference in most of them.


Actually, a quick couple of questions about patient monitoring (my googling has again been inconclusive):

In a Medical-Surgical Unit, would the patient have heart/BP/oximeter monitoring constantly with the readings displayed, or would it all be recorded as and when needed, along with temperature? Would his previous injuries dictate a particular combination of constant/intermittent monitoring? He's now around two weeks post-accident.

What method/location would they use to measure temperature? Ear? Under tongue? Armpit? Where my cat really doesn't appreciate (he growled Very Loudly at the vet!) having his taken?!? He has no facial injuries (the patient, not the cat).

Cheers...

In the US at least there are 3 kinds of hospital beds: ICU, regular floor beds, and something in between, often called step-down or intermediate care. Patients in ICUs always have monitoring leads on, patients in step-down/intermediate often do, and patients on regular floors rarely do. Assuming your character is well enough 2 weeks post injury to be out on a regular floor bed, he would have vital signs (temp, pulse, respiratory rate, blood pressure) taken intermittently without a monitor. Where I work temperature is these days most often taken on the forehead with an automated device called a temporal thermometer.

Los Pollos Hermanos
04-25-2016, 01:49 AM
Good stuff and many thanks!

Were those temporal thermometers (just had a little visit to google images) around in 2008, which is when the flashback takes place? If not, what was the thermometer of choice back then?

If the patient was asleep at 6am, would the nurse do some of her observations before waking the patient? Ideally, I'd like her to suspect something's not quite right before he tries to unsuccessfully pretend that he's feeling fine (he's in complete denial about what happened to him and is desperate to go home).

Cheers...

ColoradoGuy
04-25-2016, 06:11 AM
Good stuff and many thanks!

Were those temporal thermometers (just had a little visit to google images) around in 2008, which is when the flashback takes place? If not, what was the thermometer of choice back then?

Yes, they were around


If the patient was asleep at 6am, would the nurse do some of her observations before waking the patient? Ideally, I'd like her to suspect something's not quite right before he tries to unsuccessfully pretend that he's feeling fine (he's in complete denial about what happened to him and is desperate to go home).

Well, the nurse needs to hold his wrist for a manual pulse and wrap a cuff around his arm for a blood pressure. Respirations can be counted on an asleep person.

GeorgeK
04-25-2016, 01:29 PM
Okay. This is coming from an American Radiologist...

Because your guy would originally (before pneumonia) be on a trauma / surgical service, 8am is a little late because surgeons round very early; more like 6am or 7am at the latest. They discover the fever from the vital signs on the nursing report (unless he/she notifies them before rounds - possible if the fever is very high.) That would prompt a physical exam of the lungs during rounds, when abnormal breath sounds would be detected. This would prompt them to order a chest x-ray, and maybe some labs such as white cell count etc. The chest x-ray would be done and reported within a couple of hours. There's probably an intern on the trauma team who is following up from all the morning rounds stuff, and he/she would inform the chief resident or attending doc by about 10am. At the least, they would then order some IV antibiotics. If they decided he was sick enough to go to step down, they would initiate the transfer process. If you want him to go to Step Down, then you might want to make him a little sicker, because often pneumonia alone isn't enough. Maybe make his blood pressure and or urine output low also. The transfer process can take a while, perhaps several hours given the paper work, availability of beds, transport, exchange of nursing reports, etc. I think 4 or 5 in the afternoon is fairly optimistic.

Hope this helps.As a surgeon I say the surgeons you work with are sleepyheads. I usually started rounding at 04:30 :), otherwise, yes.

To the OP, An anesthetist is a nurse, an anesthesiologist is a doctor. Also although there are Med-Surg units here and there, the preference is to have separate medical and surgical units because combined units greatly increase the risk of wound infections. Generally flowers as gifts are ok on med units and hopefully banned from surgical units, again due to wound infection risk. Flowers grow in the dirt and dirt often has some pretty nasty bacteria and so flowers typically will have some on them.

Pneumonia in a trauma patient is a risk partly from being in a hospital (statistically 20% chance per day of contracting some sort of nosocomial infection while in the hospital) and the main risk is atelectasis (not breathing deeply enough to clear the stuff that's basically always trying to grow in the lungs).

I remember a staff meeting where the administration presented data on expenses. Another surgeon complained about me having respiratory therapy see patients post op to educate them on proper use and technique of incentive spirometry. He announced, "George is wasting resources!" To which I replied, "That depends on how you look at it. How many of my patients have post op pneumonia and how many of yours do?" The administration nurse sheepishly nodded. He didn't say another word.

GeorgeK
04-25-2016, 01:48 PM
A few things to add

Splenectomy does not mean lifelong antibiotics. All that would do is breed out resistant organisms which we around here like to call Godzillabacter which may or may not respond to Gorillacillin. Splenectomy does necessitate a few vaccines like Pneumococcal and Meningococcal vaccines and one other which escapes me right now. Those above are correct in that the preference is to watch and allow the spleen to heal and if that's not working you don't repair it, you remove it. Embolizing large organs was a thing a couple decades ago but is frought with significant morbidity and so other than a few specific indications has fallen by the wayside.

I actually just got out of the CCU today and not once did anyone check my blood pressure or pulse manually. They relied on the monitors. The nurses did not observe me while I was sleeping as their habit was always to slam the door open when they entered and then typically failed to close the door. The last place that you want to be if you need sleep is a hospital.

Although in my internist's office they use a forehead temperature probe, in the hospital they used an oral thermometer connected to the same monitor that reads the blood pressure. I think that it may automatically chart things that way so the nurse doesn't have to write things down and maybe get numbers transposed. Obviously different places can and will do things differently

Albedo
04-25-2016, 02:11 PM
To the OP, An anesthetist is a nurse, an anesthesiologist is a doctor.

Not in Commonwealth countries (maybe Canada). We make a distinction between anaesthetists (doctors) and anaesthetic nurses.

GeorgeK
04-25-2016, 03:07 PM
Not in Commonwealth countries (maybe Canada). We make a distinction between anaesthetists (doctors) and anaesthetic nurses.
The OP said the setting is US, but yeah, ok.

Albedo
04-25-2016, 03:23 PM
:) Not correcting anyone, just pointing out an interesting difference. (My understanding also is that an anaesthetist in the USA has a much broader role than an anaesthetic nurse in Australia. Is it true they are often the main person doing the anaesthetics for a procedure? That would rarely happen here except for very minor procedures.)

ColoradoGuy
04-25-2016, 04:59 PM
I actually just got out of the CCU today and not once did anyone check my blood pressure or pulse manually.

How are you George? Doing OK?

GeorgeK
04-25-2016, 07:00 PM
How are you George? Doing OK?Mostly exhausted now. NTG really packs a whopping headache and being allergic to narcotics and kidney issues such that I have to minimize NSAIDs...not fun at all. No new MI, just severe HTN induced syncope or rather near syncope and chest pain. I collapsed in the pharmacy waiting for BP meds. Main complaints, Radiologist said he'd come in on the weekend to do a nuclear stress test then never showed. Cardiologist wasn't on call. I have an outpatient appointment with someone out of town who treats the patient rather than the billing slip. Dietitian didn't understand what celiac disease meant or what food allergies were, so my wife ended up bringing me food. The one time I trusted the cafeteria after thoroughly explaining things I had to spend the next several hours in the bathroom.

Discharge with Rx for NTG and to quadruple dose of one of the meds I was on, went to the pharmacy and insurance won't cover it because, "It's too soon to refill." Even though it's a new prescription for a much higher dose. I freaking hate Humana health insurance

ColoradoGuy
04-25-2016, 07:42 PM
Mostly exhausted now. NTG really packs a whopping headache and being allergic to narcotics and kidney issues such that I have to minimize NSAIDs...not fun at all. No new MI, just severe HTN induced syncope or rather near syncope and chest pain. I collapsed in the pharmacy waiting for BP meds. Main complaints, Radiologist said he'd come in on the weekend to do a nuclear stress test then never showed. Cardiologist wasn't on call. I have an outpatient appointment with someone out of town who treats the patient rather than the billing slip. Dietitian didn't understand what celiac disease meant or what food allergies were, so my wife ended up bringing me food. The one time I trusted the cafeteria after thoroughly explaining things I had to spend the next several hours in the bathroom.

Discharge with Rx for NTG and to quadruple dose of one of the meds I was on, went to the pharmacy and insurance won't cover it because, "It's too soon to refill." Even though it's a new prescription for a much higher dose. I freaking hate Humana health insurance

Sorry to hear of your travails with Humana (not surprised about that, actually) but glad to hear it's a blood pressure thing. That's a lot better than a new MI. And yeah, the vasodilation of NTG type meds really whacks you with a headache, especially if you're a migraine person like me.

Los Pollos Hermanos
04-25-2016, 10:44 PM
Cheers for the extras. My UK medical source, whom I refer to as Dr Andy (his name's Andrew and he's a doctor - I'm a clever devil, me ;) ) is what we call a Consultant Anaesthetist over here. He gives me the medical facts, but can only advise on how patients are treated in the UK (specifically England). That's why I was asking for American input as I know lots of things are done/said slightly differently on t'other side of the Pond.

This part of the story is set in the US and there's actually no medical action in the UK-based chunks. There's not a huge amount of medical stuff in the US-based chunks, it's just that I feel so out of my comfort zone writing medical scenes.

As for the medical staff, with the focus not being on them I refer to them as doctor/surgeon/nurse/paramedic. That's sufficient for the story. Much as I love reading a good medical thriller* you'll never see me write one. I'd rather write a soppy romance (not that anyone would want to read it - I don't do soppy).

* I loved Robin Cook in my teens (e.g. Coma) but alas, my love for him has died over the past decade. :cry:

Shame my patient can't be on a monitor, but accuracy prevails...

GeorgeK
04-25-2016, 11:12 PM
Shame my patient can't be on a monitor, but accuracy prevails...They could be on a monitor. It depends on what's going on. Nowadays heart monitors don't need a wall connection. They can be wireless and if the suspicion is low but the Dr just wants to keep an eye on things, they could have a heart monitor out on the regular floor. The other doctors might rib the doctor who ordered it but it would not be unheard of. Also if the doctor wanted a heart monitor, and again the risk was low but the hospital needed the beds for sicker patients in the usual monitored wards, they might be out on the floor. A pulse oximeter can be out on the floor without any difficulty. It would not be unusual to put a pulse ox on a patient if say a nurse got two patients confused or drew up too much narcotic for pain and the doctor wanted an extra measure of security while the patient slept it off. If the circumstances are right it would be reasonable.

Los Pollos Hermanos
04-25-2016, 11:23 PM
A pulse oximeter would be fine. Just enough for her to suspect all is not rosy in... well, not paradise, but you know what I mean. Pulse rate up slightly, oxygen % dropped by one... She could observe his breathing rate whilst he's asleep. What does early pneumonia do to blood pressure, if anything?

Cheers...

GeorgeK
04-25-2016, 11:41 PM
A pulse oximeter would be fine. Just enough for her to suspect all is not rosy in... well, not paradise, but you know what I mean. Pulse rate up slightly, oxygen % dropped by one... She could observe his breathing rate whilst he's asleep. What does early pneumonia do to blood pressure, if anything?

Cheers...With a few exceptions the earliest sign of infection is a slight rise in heart rate. In the early phase of infection the BP might be stable or rise a bit due to the faster heart rate. In late stages of pneumonia when bacteria are releasing more toxins or the white cells are killing large amounts of bacteria, hence releasing more toxins, the BP will drop. That is when people, if they are going to tend to have strokes, heart attacks and other vascular phenomena, of which one of the most dreaded is DIC, Disseminated Intravascular Coagulation.

Also one of the more common reasons to see a pulse ox out on the floor is the doctor forgot to write an order to discontinue it. It also would be even more reasonable if rather than a continuous pulse ox, there was an order to just do a spot check along with the vitals.

Another thing about pulse oximeters is that their accuracy drops rapidly the lower the O2 saturation. In my book, anything under 90% means you should consider an arterial blood gas to see just how inaccurate the pulse ox is. A pulse ox of 85 might mean an arterial blood gas O2 saturation of 85 or it might mean 60

MDSchafer
04-26-2016, 01:39 AM
I'm an American RN.


In no particular order I'm after how long(ish) it would take to:
* Run tests to establish that he's likely got pneumonia - listening to chest, X-rays, blood tests, anything else?
* Put him on extra oxygen, IV antibiotics, any other new medication.
* How he might be presenting to the medical team**.
* His symptoms to get bad enough to move him from the Medical-Surgical Unit to the SDU.
* Anything else relevant.

Most American hospitals run their shifts 7a to 7p, and most nurses do their head-to-toe assessment at the beginning of the shift. If I discover a patient with some signs of increased work of breathing I'm going listen to their chest, listen to their breathing, and ideally consult a respiratory therapist if they're on the floor. After that I'm going to page the doc, or his NP, and ask for a pneumonia workup. So that means you, or your phlebotomist draws the lab and either X-Ray comes to you, or you send your patient to imaging. Once the X-Ray is read, you look at it, and decide to call the doc or his NP or PA. Typically then the provider looks over and orders a pair of antibiotics, at my facility its normally Vanco and Cipro. A lot of time all of this happens before the doc rounds, particularly if he's a surgeon. It's happened a few times where the surgeon was informed of this during his afternoon rounds. This isn't a reflection on the MDs, but typically they spend ten minutes a day with their patients because that's all the time they have.

It would take several days, typically, for pneumonia to get bad enough to warrant a move back to the ICU. Some people get really sick,and some people don't. As far as oxygen, it depends on what their stats are. If an otherwise healthy individual with no respiratory comorbidities stating below 92 percent with any increased work in breathing I'm going to put 2 liters of oxygen on him. If it doesn't come up above 80 you can increase it beyond 2 liters, which technically you need an order for but no hospital actually requires.

Other tidbits: We wouldn't say "Medical Surgical Unit" or even "Med-Surg" Floor. In America we'd call it by the floor names, like Six-West Yellow, if it's in the Yellow Tower, for example. Med Surg is really an industry term we wouldn't use with patients or family.


It would not be unusual to put a pulse ox on a patient if say a nurse got two patients confused or drew up too much narcotic for pain and the doctor wanted an extra measure of security while the patient slept it off. If the circumstances are right it would be reasonable.

So, if a nurse made a med error... Seriously? The nurses in your facility must love working with you if that's the public image you present of their profession.

The most common reason a patient would be on pulse ox on the floor is because the nurse or a respiratory therapist is concerned about someone's work of breathing. If it the breathing looks labored, or the pulse ox drops, protocol is to put the patient on O2 and monitor the patient. Most of the time we put patients on continual pulse ox the MDs weren't made aware and never knew because you don't need an order for it.


:) Not correcting anyone, just pointing out an interesting difference. (My understanding also is that an anaesthetist in the USA has a much broader role than an anaesthetic nurse in Australia. Is it true they are often the main person doing the anaesthetics for a procedure? That would rarely happen here except for very minor procedures.)

Yep, nurse anesthetists are the often the only anesthetists in the room for procedures. They're highly trained and make about $150,000 to $200,000 a year depending on the state and facility.

ColoradoGuy
04-26-2016, 01:54 AM
The most common reason a patient would be on pulse ox on the floor is because the nurse or a respiratory therapist is concerned about someone's work of breathing. If it the breathing looks labored, or the pulse ox drops, protocol is to put the patient on O2 and monitor the patient. Most of the time we put patients on continual pulse ox the MDs weren't made aware and never knew because you don't need an order for it.


Yes. Most of the standing order sets that we use have a prechecked order box for a nurse or respiratory therapist to place a patient on a pulse oximeter if they think it's indicated. If a patient does have one, you can read heart rate off it as well as oxygen saturation.

Los Pollos Hermanos
04-26-2016, 04:46 AM
Big thanks for the replies! Hmmm... So he could have had a pulse oximeter after he was transferred just to monitor him to ensure he coped with the transfer (it involved a flight) and it was left in place as a bit of an oversight? That would be convenient! He did have a punctured lung in the not-so-accident if that carries any weight.

The floor terminology is only for the narrative. There's not a huge amount of doctor, etc speak in the story as I don't feel confident writing it. I've got round this by either having someone relay the information to someone else, or for me to summarise what's been said in the narrative.

MDSchafer
04-26-2016, 06:11 AM
Big thanks for the replies! Hmmm... So he could have had a pulse oximeter after he was transferred just to monitor him to ensure he coped with the transfer (it involved a flight) and it was left in place as a bit of an oversight? That would be convenient! He did have a punctured lung in the not-so-accident if that carries any weight.

I don't think that would work. ICU pulse ox devices are basically disposable sensors with a built in tape that goes around the finger and a wire that connects to the monitor. ICU nurses routinely leave them on when they transfer the patient, but since they're not connected they don't transmit data anywhere. The ones we use are the floor are basically boxes you can put on someone's figure and they'll trigger an alarm if it falls below a limit you set.

Albedo
04-26-2016, 06:15 AM
Yep, nurse anesthetists are the often the only anesthetists in the room for procedures. They're highly trained and make about $150,000 to $200,000 a year depending on the state and facility.

Thanks! Yeah, that's very different to our system. Anything more than light sedation here would always be done by a doctor. We also don't really have anything equivalent to a 'physician assistant'. At least, I don't think so. I'm still not sure what physician assistants actually do in your health system.

vsrenard
04-26-2016, 06:21 AM
I asked my sister about this. She is an internal medicine hospitalist:


In no particular order I'm after how long(ish) it would take to:
* Run tests to establish that he's likely got pneumonia - listening to chest, X-rays, blood tests, anything else?

Not long--an Emergency Department visit (five or six hours) where the physician listens to the chest, then checks labs (complete blood count, chemistry panel) and a chest xray. Findings would be: vitals with oxygen requirement (i.e. the patient would need nasal cannula oxygen), possibly tachycardia (high heart rate), "crackles" on lung exam on the side of the pneumonia, and elevated white blood cell count.


* Put him on extra oxygen, IV antibiotics, any other new medication.


As above, this would take maybe five or six hours from the time the patient arrives at the ED to the time they are admitted. They would be given doses of IV antibiotics, IV fluids, and supplemental oxygen. If oxygen levels are low enough, non-invasive ventilation (Bipap) would be used.

* How he might be presenting to the medical team**.


He would initially have pleuritic chest pain (chest pain on inspiration), fevers, cough productive of sputum, malaise, generalized weakness.


* His symptoms to get bad enough to move him from the Medical-Surgical Unit to the SDU.


This might be either due to two things--his oxygen requirement could increase (i.e. he is initially put on nasal cannula oxygen and then requires Bipap or even invasive ventilation--intubation) OR he could be developing sepsis, which would mean worsening tachycardia and hypotension (sepsis is a more generalized infection and would imply that the pneumonia is spreading to the blood or becoming more systemic). Depending on the hospital, patients with sepsis could be transferred to an ICU or the SDU. Patients on bipap could be potentially managed at an SDU or ICU as well (at my institution they would only be put in an ICU but this may vary depending on the hospital). Patients who are intubated would have to be in an ICU.

cmhbob
04-26-2016, 06:50 AM
For a patient-eye view....

I developed pneumonia summer two years ago. No clue where I picked it up. I presented to my primary care provider with a cough and heavy mucus, tinged with red. They sent me to radiology, who took the pics, then sent me back to my PCP (this is all in the VA - veterans - hospital here). By the time I has walked back to the PCP, the nurse was waiting with a wheelchair to take me to the ER.

I stayed there for about 2 hours. My O2 sats dropped to about 85%, and I got short of breath - noticeably lightheaded briefly - before them putting a nasal canula on my with O2 at 3 liters.

I was sent up to the ICU (in an isolation room, due to fears of TB because of the bloody mucus) for about 36 hours. Once the O2 was running, I felt fine, and was weaned off oxygen just after I left ICU. I got hit with heavy doses of IV antibiotics for those two days, although I can't recall which ones. Also got a couple of albuterol breathing treatments until they decided that was a bad thing for me. That's where you have to inhale the medication via a special breathing machine.

I had some other issues that popped up while I was in there that necessitated some other treatments, but that's the relevant stuff for you.

Los Pollos Hermanos
04-26-2016, 10:15 AM
Many thanks for the extra info, you lovely people! I've got to leave for work in a few minutes, so apologies if this is rather rushed.

* I've read about double pneumonia, which as I understand is the involvement of both lungs? I don't want him so ill he needs artificial ventilation in ICU, so would you recommend I stick to just one lung being affected?

* If so, would the lung that got punctured be more likely to be affected, or is there no correlation?

* Would it be feasible that the nurse arrives to do the (currently sleeping) patient's observations, notices he's breathing a little faster than before and puts an oximeter on his finger whilst he's still asleep? Or would the nurse only do that when the patient is awake?

@ Cmhbob: Thanks for the patient perspective. Sounds scary?! I'm glad you've recovered and thanks for sharing your experience. :)

GeorgeK
04-26-2016, 06:14 PM
I'm an American RN.


So, if a nurse made a med error... Seriously? The nurses in your facility must love working with you if that's the public image you present of their profession.
... the MDs weren't made aware and never knew because you don't need an order for it.


.So you think that nurses are infallible and you make a habit of not informing the physician of changes in the patients' status. I'm glad we've never had to work together and everywhere I've ever worked you need a physician's order to start oxygen except during an emergency in large part because supplemental oxygen isn't exactly safe for every patient. There are types of emphysema where the only thing keeping the patient breathing is the respiratory drive induced by their relative hypoxia

One of the scariest nurse mistakes I've seen... I got a call from the nurse, "Dr K the pharmacy says that Zantac doesn't come in the dose that you ordered for Mr X.

"I didn't order any Zantac for him."

"Sure you did. It's right here in easy to read block letters."

"Spell the drug that I wrote."

"AZTREONAM."

"That's not zantac. That's aztreonam. It's an antibiotic."

"Well they both have a Z in them!"




* I've read about double pneumonia, which as I understand is the involvement of both lungs? I don't want him so ill he needs artificial ventilation in ICU, so would you recommend I stick to just one lung being affected? There's probably no reason for you to specify



* If so, would the lung that got punctured be more likely to be affected, or is there no correlation?With penetrating trauma I'd be more concerned with the possibility of an empyema but pneumonia is certainly possible. Most hospital acquired pneumonia has to do with atelectasis and then aspiration. Atelectasis can be either side. Aspiration can as well but usually is on the right



* Would it be feasible that the nurse arrives to do the (currently sleeping) patient's observations, notices he's breathing a little faster than before and puts an oximeter on his finger whilst he's still asleep? Or would the nurse only do that when the patient is awake?Depends on a whole bunch of variables, mostly revolving around how sick the nurse's other patients are, but there is no reason they couldn't do a pulse ox while asleep



@ Cmhbob: Thanks for the patient perspective. Sounds scary?! I'm glad you've recovered and thanks for sharing your experience. :)

Los Pollos Hermanos
04-27-2016, 12:34 AM
Thanks for the extras!

MDSchafer
04-27-2016, 04:44 AM
So you think that nurses are infallible and you make a habit of not informing the physician of changes in the patients' status.

Nurses are completely fallible, but you seem to enjoy throwing my profession under the bus in your answers. I don't go around posting about the numerous, and potentially fatal, MD errors I've caught over the course of my career because we're a team. There's no value in me trying to run down the reputation of MDs because I'm only as good as the docs I work with. I work with some great doctors and I don't see the value in anonymously posting their mistakes in a public forum. Good teammates, in my opinion, manage up other members of their team, both in the workplace, and in internet forums.

You apparently find value in running down the reputation of nursing as a profession, and that's fine. Not all of us are team players, and not all of us watch each other's back, you don't and that's you're choice. I'd ask that you give the women and men you worked with that professional courtesy of not publicly bashing the people you relied upon to give great patient care -- especially now that HCAHPS scores are seen as the measure of hospital quality and nursing has a huge impact on those scores -- but I don't expect you to. After all, you're a surgeon, who rounds at 0430, and routinely saves your patients from incompetent nurses.

Roxxsmom
04-27-2016, 05:57 AM
Leadville has been studied a lot by the pediatric cardiologists at Denver Children's Hospital. They don't deliver babies there any more -- Aspen is now the highest hospital that does. After delivery the pressure in a baby's pulmonary artery, the vessel that goes to the lung, drops as part of the transition to extra-uterine life, bringing more blood to the lungs. It takes a few days to a couple of weeks normally. The Leadville babies had considerable delay in this reflex, which is driven by ambient oxygen.

Interesting. When I lived in CO, people said that women who lived in leadville had to go to lower elevation cities to deliver their babies, but when I googled this, I didn't find anything, so I figured it was a local rumor.

My mom was born in Silverton, CO, and it turns out she has a teeny hole in her heart (this wasn't discovered until she had a mild stroke a few years back, in spite of her having frequent echocardiograms because of having Marfan's syndrome). Evidently, the hole could put her at increased risk for strokes, though it's sub-clinical in terms of things like blood O2 levels and so on. They're on this now with blood thinners and so on, and she's doing well, though it's one more thing on the list of those nagging worries we all have with aging parents.

Could the heart hole thingy be because of the issues with the air pressure up there? I don't know if it's where the foramen ovale was, or if it's someplace else.


And yes, home oxygen companies are a big business in the Rockies. People with severe lung disease have more problems. Now that you mention it, I do remember seeing more people out in public (at grocery stores and so on) with those little carts that lug O2 canisters than I do in CA where I live. I figured at the time that the altitude made people with emphysema and so on struggle more.


As I noted above, oxygen saturation is not a linear function, so once you get above 10,000 feet or so the problems increase quickly. Lots of people with lung disease can tolerate Denver but have trouble in places like Cripple Creek or Leadville. I've had more than a few patients who develop altitude sickness at 10,000 feet and then recover quickly when they come down to 5-6,000 feet.

Yeah, Hb saturation an S-shaped curve, so once you hit a pressure where you're in the steep "drop off," the effects change quickly. I've had all kinds of stories from friends about altitude sickness on hikes and so on. I was lucky enough never to get it to where I had worse than a headache and mild breathlessness upon exertion, but one friend got really sick (throwing up and so on) on a hike up Long's Peak, to the point where he dropped out of the hike and went down to the trailhead and waited for everyone else. He was mortified, and the odd thing was, he was just as accustomed to altitude as the others on the hike were and was in good shape, not ill or in poor health or anything. He hadn't gotten a lot of sleep the night before, so maybe that influenced it?

Cath
04-27-2016, 02:58 PM
Gently, folks.

GeorgeK
04-27-2016, 07:10 PM
Nurses are completely fallible, but you seem to enjoy throwing my profession under the bus in your answers. I don't go around posting about the numerous, and potentially fatal, MD errors I've caught over the course of my career because we're a team. There's no value in me trying to run down the reputation of MDs because I'm only as good as the docs I work with. I work with some great doctors and I don't see the value in anonymously posting their mistakes in a public forum. Good teammates, in my opinion, manage up other members of their team, both in the workplace, and in internet forums.

You apparently find value in running down the reputation of nursing as a profession, and that's fine. Not all of us are team players, and not all of us watch each other's back, you don't and that's you're choice. I'd ask that you give the women and men you worked with that professional courtesy of not publicly bashing the people you relied upon to give great patient care -- especially now that HCAHPS scores are seen as the measure of hospital quality and nursing has a huge impact on those scores -- but I don't expect you to. After all, you're a surgeon, who rounds at 0430, and routinely saves your patients from incompetent nurses.You are repeatedly seeing insults where there are none. It's a simple fact that most medication errors occur at the hands of the people who actually administer the medications whether you are talking wrong dose, wrong medicine, wrong patient, or failure to give the medicine at all. In the same way that most mistakes in the operating room are at the hands of the surgeon. Most mistakes in the courtroom are the fault of the lawyers. My experience with nurses is the same as physicians and really any occupation that you want to list. About 5% are incompetent. However that's not the issue here. I was explaining possible realistic scenarios to the OP. Furthermore I've grown tired of your hateful accusations and will add you to my ignore list. I suggest you do the same.

Cath
04-28-2016, 04:22 AM
Like I said, gently. Let's focus on answering the OPs question.

Thanks!

Los Pollos Hermanos
04-30-2016, 11:59 PM
Just need the numbers now, pretty please.

* What would/could his oxygen saturation be the day before he starts showing symptoms? (I've got it at 98% at the moment).

* I've had the nurse (who suspects all is not well) clip a pulse oximeter onto his finger before she wakes him for blood pressure (and temperature). What % could it have dipped to that would confirm her suspicions but not really have him showing slight symptoms other than breathing faster than he did the previous day?

* Which leads to -- The normal breathing rate for an adult is apparently 12-20 breaths per minute. Please could you suggest an appropriate to his symptoms "night before number" and a corresponding "morning after number"? So, if it was 17 the night before what number would raise her suspicions that morning?

Cheers...

MDSchafer
05-01-2016, 03:13 AM
Just need the numbers now, pretty please.

* What would/could his oxygen saturation be the day before he starts showing symptoms? (I've got it at 98% at the moment).

* I've had the nurse (who suspects all is not well) clip a pulse oximeter onto his finger before she wakes him for blood pressure (and temperature). What % could it have dipped to that would confirm her suspicions but not really have him showing slight symptoms other than breathing faster than he did the previous day?

* Which leads to -- The normal breathing rate for an adult is apparently 12-20 breaths per minute. Please could you suggest an appropriate to his symptoms "night before number" and a corresponding "morning after number"? So, if it was 17 the night before what number would raise her suspicions that morning?

Cheers...

It depends on how quickly it develops. Typically your 02 doesn't start dropping until you've started having respiratory distress.

Nurses don't take vital signs, techs do, and oxygen saturation are typically part of vitals, which are typically taken every four hours on a med-surg floor.

Don't get caught up on the numbers. What you're concerned about is how much effort are they putting into breathing. Patients can have labored breathing and still be breathing 18 times a minute. What you're looking for breath sounds, do they sound like bubles or like crackles, and are they using the accessory muscles to help them breathe? What's the quality of their breathing, are they taking short, shallow breathes? Don't get caught up on the numbers, if someone has shallow, fast breathing, then that's a cause concern and immediate intervention

Los Pollos Hermanos
05-01-2016, 04:27 AM
Thanks! I'll tweak his breathing description as suggested. If I say he's breathing 22 times per minute, but the breaths are shallower than before and his oxygen % has dropped from 98 to 94 (research tells me 95% and above is considered ok??) does that sound feasible? If this gets published the last thing I want is a medical type to read it and then fling the book across the room/out of the window in disgust!

What would I refer to the "tech" as in the narrative?

For a fairly short flashback it's causing me one heck of a lot of grief - I really loathe writing medical stuff! ;)

Cheers...