Medical protocol question

This weekend I participated in the care of a 44 year old cop who was diagnosed with pneumonia, but along with that he also complained of severe headaches. In short, symptoms a little more involved than just pure pneumonia. This guy was in excellent physical shape but all of his labs showed he was deteriorating fast. I knew it. The ICU nurses knew it, but we couldn’t get his doc to believe it enough to transfer him to the a bigger facility with the services of a pulmonologist. He finally wound up on a ventilator and we found a room for him at one of the bigger Atlanta hospitals. At the time of transport he was only ventilating about 88% of his capacity and that was with 100% oxygen. No spinal tap was done.

Okay. That is a short encapsulated history. Now for my question: As a respiratory professional I knew this guy was in trouble and I wanted to tell his family to call the physician and demand that this man be moved to a facility and a doctor that could help him, but protocol demanded that I keep my mouth shut. We were in touch with the attending all night, but he refused to transfer, and only relented after the ER doc talkied him into it. What else could I have done but give him the best care possible under the circumstances and if I had talked to the family would I still have a job?

If I left anything out, ask away. I realize that this is a medical question and so I will get a limited number of answers, but I have never been so frustrated and I may have helped delay giving this guy the care he so desperately needed by not speaking up. I also realize that it probably was not up to me to go to the family, but no one else took the responsibility. HELP!

Quasi

Was there a doc on site to evaluate the patient?

Generally when ICU nurses have told me that the patient was too sick for their abilities to care for, I’d transfer or bring in an intensivist. (what am I saying? If I’ve got them in the unit, I’ve already called for intensivist consultation!)

Qadgop, MD

Well, sounds to me like you found yourself stuck between a rock and a hard place. I would have discreetly approached the family with “You know, I can lose my job over this, but…” You can always find a job at a facility that has more respect for your expertise and won’t hold it against you for fulfilling your professional and ethical obligations to your patients. You’ll sleep better. Respiratory Therapists tend to know what they’re talking about in situations like this, and I find it unfortunate that the attending was too bothered in the middle of the night to fulfill his obligations. I hope he gets sued for negligence.

I’m interested in knowing if there was a chance to do any other diagnostic tests. You mentioned there was no spinal tap, but were you guys able to do anything else before transfer? I’m assuming we’re talking ARDS here, and if you could provide any more details as to labs, cultures, hemodynamics, vent settings, etc., that would be interesting. I’ve seen a few cases just like you describe, and it turned out they had legionnella. The odds don’t favor that, but something very acute is going on.

Hang in there, RT.

…for your replies. The last set of ABG’s were as follows:
Ph 7.37, Pco2 34 Po2 79, Hco3 19, BE -6 on these vent settings: Vt 750, RR 16 , PSv 5 , PeeP 15 and an Fio2 of 100%. With the exception of LLL, he was “whited out” and we were unable to suction anything at all before he left us.
I remember a little of his lab values to be able to tell you that none of them were particularly critical except that his BUN went from 14 to 29 and that the lab returned a micro-organism report of gram neg cocci in chains and his WBC was 13.8. Other stuff that I did not include in the original post was the fact that he had been hallucinating prior to the ICU adnmission and that his mother died 2 months previously also diagnosed with atypical pneumonia, although she had been chronically ill for ten years and was on a morph pump.
In short he needed some very esoteric treatment that he wasn’t getting from our hospital and I just hope he makes it, but I am afraid that even if he does he will have kidney damage and COPD for the rest of his life.
I really do appreciate y’all letting me “vent” , pun very much intended, and I appreciate your answers and support.

Quasi

Talk to your boss?

Well, I don’t know anything about medicine, but my response to the situation would’ve been to anonymously contact the family and tell them. I’m not a big believer in doing things anonymously (take my handle for example), but the family needed to get that input, and if your job was at risk by telling them, there was really no alternative.

You say cultures showed gram negative cocci, but you were unable to suction any secretions. What was the source of the specimen? Did he suddenly spike a high temp? Legionella are gram negative bacillus, but it takes a well equiped lab to make a good differential diagnosis. I still strongly suspect legionella and I think he should be treated accordingly until it is ruled out. The patient’s age, bilateral infiltrates on CXR, ARDS, increased WBC, confusion, headache, and questionable cultures make me more suspicious. Thanks Quasimodem and keep us posted.

… the lab result was from sputum sample obtained on admission before white-out. His chart read like a detective novel, so many inconsistencies. We heard this morning that the hospital which took him was able to wean him down to 90% FiO2, but his new doc is unwilling to give a prognosis at this point.

Bill H: I have since found out that one of the nurses close to the family did speak to them prior to his “crashing” about moving him elsewhere.

Major: My “Boss” in this instance would have been the doc in question.

Thanks very much!

Q