I found out at work recently how important establishing a baseline mental status for a patient is, and as well as how much of our assessment of a patient's status relies on nothing that can be said or measured, and when at times, maybe those things should be said, just to make sure.
We received a call to a patients home for a severe headache, and for some reason, my partner had first contact with the patient and pt. family. When I had entered the primary caregiver was giving a report to my partner, and the patient was on a hospital bed in the living room. The patient was completely unresponsive, eyes shut, and appeared to be breathing only after prolonged observation for chest rise.
This patient appeared dead.
The rest of the family was quite unconcerned with the situation, and after ascertaining that this patient was, in fact, breathing, we continued to listen to the patient's daughter describe the situation.
The Patient was a 82 year old female on Hospice care, I thought that my partner had asked what for.
She hadn't. I didn't want to trouble the patient's family with asking questions that had already been asked, I should have, I need to get over that. I was going to be teching the call.
My partner asked the patient's daughter if this was the patient's baseline.
"Oh, yes"
Maybe I didn't want to ask more questions, because the whole situation seemed very casual to the family in the room, it was just a simple issue that the doctor said should get checked out, and they didn't want to wait until Monday, so I knew THEY weren't too worried. but if I'm not asking questions when its casual, will I ask them when things get a little more on edge?
As we began to move the patient, she opened her eyes, and starting making vocalizations that were unintelligible, as well as strange kissy noises. The family seemed unconcerned with this, so we just went with it, but right away I wasn't sure how I was going to present this to the emergency department at the hospital.
But just to make sure, when we finally got in the ambulance, and I asked her:
"Hey, My name is Devin, what is your name?"
....and she answered the question completely appropriate.
"Is this her baseline?"
"This"....what exactly does "this" mean? The patient could have been yabbering up a storm and answering all on Alex Trebek's questions correctly minutes before we walked in the door.
Internal observations and judgements don't translate well as "this", especially when talking to a cargiver, who may or may not know exactly what you are asking.
The patient's daughter spoke with us, right in front of the patient, for a few minutes at least and the patient didn't let out so much as a stir, murmur, or blink.
I know now that when I am ascertaining history from a family member/bystander/layperson, I better be specific.
The situation resolved itself uneventfully, but not without me looking like a moron to the Emergency Department, as well as learning a thing or two, which is always good.
The patient ended up having shingles...
No stoke, no vascular issues, nothing.
Good learning experience if you ask me.
On a side note, this family wasn't really ready for this woman to be DNR, it was easy to see, and maybe a discussion for a later time.
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