What would you have done for this patient?

[Mike123]

I just wanted some feedback as to what you would have done for this patient I had. I had a regular dialysis transport patient yesterday. Pt. is a 85 y/o F that we transport to and from dialysis a few times a week. She fell a few days ago and went to the hospital overnight. She had bruising all over her face and around eyes, four stitches on her nose, and a swollen right hand. She got two CAT scans with no abnormalities while at the hospital. When we were transporting her back to her house, I noticed that her left pupil was dilated (about 4mm) and deformed. Right pupil was PERL at 2mm. This was concerning considering that she fell on her face a couple days before. She was acting completely normal... AOx3 Pulse: 68 Resp: 16 BP: 94/60 O2 sat not reading because of cold fingers. Skins pink warm dry. Cap refill 3 seconds. Again, she was acting totally normal. No SOB or chest pain. I palpated her head and there was no signs of trauma. She denies any head pain or headaches. No battle signs behind ears... nothing other than the bruising from the fall. The pt. just kept saying that she wants to go home. When we got to her house we told the family, and they said she has a doctor appointment in a couple days. they agree, she was completely normal. They were not concerned at all. So we told them to call us or 911 there is any loss of consciousness, change in mental status, head pain, etc. what would you have done?

 

[STXmedic]

I'd have done exactly what you did- take her home and tell the family to keep an eye on her. Are you 100% sure that her pupils aren't always unequal? There are a myriad of conditions that could cause what you saw. She's asymptomatic aside from the pupils, so I'd feel fine leaving her at home with family.

 

[Gurby]

Maybe a lesson to be learned here is to do a more thorough and focused assessment before you leave the hospital when doing discharges like this. You know she fell and has bruising on her face, so do a quick check before you even get her on the stretcher. You can even grab a set of vitals using the hospital's equipment while you're at it. If you had noticed the pupils in the hospital you could have asked someone and they'd be able to tell you whether they were like that when she came in.

Otherwise, +1 to leaving her with family and telling them to keep an eye on her. And any time you're in doubt about something like this, document document document.

 

[DesertMedic66]

I'd have done exactly what you did- take her home and tell the family to keep an eye on her. Are you 100% sure that her pupils aren't always unequal? There are a myriad of conditions that could cause what you saw. She's asymptomatic aside from the pupils, so I'd feel fine leaving her at home with family.

This. Patient is alert and orientated and can make her own medical choices. She doesn't want to go to the hospital so you can't force her. Give her all the information you find and let her make up her mind.

Suggest that she still gets checked and advise family to watch for changes. I'm assuming you are a BLS IFT company so I would suggest to tell them to call 911 if she has a LOC or AMS (I hope a BLS IFT company isn't responding to those kind of calls).

Also make sure you do a full assessment before transport. That is something you might want to know before transport.

 

[Akulahawk]

I would have done an assessment before leaving the facility. Doing this every time has saved some people's bacon a few times... (mine and the patient's). I would have noticed the irregular pupil, the bruising, stitches, checked mental status, and much more as part of the initial assessment done in the room. I would have also gotten report about the patient from the nurse so that I know what the patient's course has been in-hospital. I would also want to know the patient's history, meds, allergies, last dialysis treatment, and lab work. That's all usually available in the discharge packet or can be made available to you from the chart. Any idea if the patient has had cataract surgery?

If all looks good in the room, I'll be happy to take the patient home and remind the patient and family about 911 and reasons to call. This is all stuff I've done a thousand times, or more. Sometimes just taking a couple "extra" minutes on the floor can make a big difference.