My day at work

[Tex]

Originally Posted by ERCougar

I'm not assuming anything...I'm just asking. I take it from your question that you belong to the Miracle Max school of thought?

I'm not sure what you mean by that. I only think there are other possible options as far as God's concerned, other than him continually changing his mind.

[MikeWaters]

Originally Posted by ERCougar

I posted this to a medical blog I occasionally contribute to...

Man in his late 70's is rushed back to the trauma room complaining of chest pain. History of MI and CABG (open heart surgery). He's diaphoretic, pale, and does not look good. Blood pressure's in the 70's with a HR in the 30's. Complete A-V block on the monitor. EKG shows inferior wall MI. We start pacing him, get him aspirin, and await the chest x-ray. With the pacer, BP's improved to 130/80 range. His chest x-ray looks good, we don't have a cath lab at this hospital, so we call the transferring facility and helicopter, start lytics and heparin. He's in a paced rhythm, stable blood pressure, tolerating the pacer well at about 20 mA with good capture.

Gradually, his pressure starts to drop. 110's....90's...80's...70's....nothing. Electrical activity on the monitor, no pulse. We start CPR, open up the fluids. I turn around to talk to the wife, as the patient had requested "no life support" (whatever that means). I get the sense that what he had really wanted was to not be on a ventilator for the rest of his life, so I explain to her that this may reversible if we can get him to the cath lab, and that this is probably worth a round of CPR. She agrees, so we continue. After a couple of minutes, recheck the pulse...still nothing. Push epi and continue CPR. We intubate him. Couple of more minutes and we get a pressure. A good pressure. Funky wide-complex rhythm bordering on V-tach, which is either epi effect (for non-medical folks still reading--you can pump epinephrine into a dead heart and make it beat for a few minutes until the drug wears off...bad) or reperfusion rhythm (a rhythm frequently induced by lytics that resolves on its own...good). But still...it's a good blood pressure. A few more minutes and more narrow complexes...things are looking good.

In the meantime, the helicopter has arrived. They're getting him ready for transport when his pressure starts to drop again. He arrests again. We start CPR and I again turn to the wife. At this point, she's not as enthusiastic about things and we decide to stop efforts. The code is called.

What exactly did she say?

"No life support" does not mean "No CPR". There was no DNR, no legal documents.

If a 35 year old man came in with the same situation would you turn to the wife on whether you should do CPR, and if she said no, you wouldn't?

Odd.

The spouse was in the room during the code? Odd.

[ERCougar]

Originally Posted by MikeWaters

What exactly did she say?

"No life support" does not mean "No CPR". There was no DNR, no legal documents.

If a 35 year old man came in with the same situation would you turn to the wife on whether you should do CPR, and if she said no, you wouldn't?

Odd.

The spouse was in the room during the code? Odd.

There's plenty that's odd about this case, but not the points you're mentioning.

No, he had no legal documents on him or filed, as is often the case. She said he had filled out directives at home that said he wanted "no life support", which is why I had to further clarify things, and why I started CPR. In discussing this with her, she said he didn't want to be "on the breathing machine" or "be shocked", both of which are part of ACLS protocol. I knew we would likely be putting him on the ventilator, so I talked her out of this part, as her understanding of the ventilator was that he would be on it for the rest of his life. When she witnessed the round of CPR and saw his heart stop the second time, she felt like that was more than he would want. Remember, the only reason I talked her into the first round is that this was a witnessed cardiac event in the hospital--the best kind of outcome.

There's a huge difference between a 35 yo and an 80 yo, the biggest being the likelihood of a functional outcome. Lacking any advance directive, I have to make a guess at what the patient would want and go with that. If the wife says no, but I suspect he would want it, I'm legally bound to proceed with the resuscitation; the wife's opinion is just another datapoint in the decision.

I rarely kick out family members during a code anymore. There's research that suggests this is a bad idea (to kick them out). I've found that family members handle things much better when they observe the resuscitative efforts than when they're herded off into a room, only to be told 30 minutes later that "we did all we could".

[MikeWaters]

Originally Posted by ERCougar

There's plenty that's odd about this case, but not the points you're mentioning.

No, he had no legal documents on him or filed, as is often the case. She said he had filled out directives at home that said he wanted "no life support", which is why I had to further clarify things, and why I started CPR. In discussing this with her, she said he didn't want to be "on the breathing machine" or "be shocked", both of which are part of ACLS protocol. I knew we would likely be putting him on the ventilator, so I talked her out of this part, as her understanding of the ventilator was that he would be on it for the rest of his life. When she witnessed the round of CPR and saw his heart stop the second time, she felt like that was more than he would want. Remember, the only reason I talked her into the first round is that this was a witnessed cardiac event in the hospital--the best kind of outcome.

There's a huge difference between a 35 yo and an 80 yo, the biggest being the likelihood of a functional outcome. Lacking any advance directive, I have to make a guess at what the patient would want and go with that. If the wife says no, but I suspect he would want it, I'm legally bound to proceed with the resuscitation; the wife's opinion is just another datapoint in the decision.

I rarely kick out family members during a code anymore. There's research that suggests this is a bad idea (to kick them out). I've found that family members handle things much better when they observe the resuscitative efforts than when they're herded off into a room, only to be told 30 minutes later that "we did all we could".

I've never seen a family allowed to observe a code.

What if you cracked a chest. Would you want the family still there?

[ERCougar]

Originally Posted by MikeWaters

I've never seen a family allowed to observe a code.

What if you cracked a chest. Would you want the family still there?

No...but that's why I said "rarely". The family's never been to the ER in time to witness that anyway. And I can't think of another procedure that I would kick them out for.

If you haven't ever seen the family allowed to observe a code, you're hanging around a lot of old school doctors, because it's definitely the emphasis now (at least in EM--I can't speak for the other specialties).

[ewth8tr]

Originally Posted by Colly Wolly

Interesting story, thanks for posting.

I had my first ever medical emergency experience this past January when we were visiting my wife's grandparents in San Diego (El Cajon-Blossom Valley area). It was the evening and we were watching tv with her grandmother and great aunt. All of a sudden, the great aunt starts making these weird snoring, horse-like noises with her eyes closed. Very loud and animated. Then she just stops. We call ner name and no response. I walk over to her chair and see that she had wet herself. No breathing, and no pules. Time to call 911. My wife's grandmother calls 911 while a cousin performs CPR and I administer a blessing. I got my first exposure to "agonal" breaths. Freaky.

The ambulance gets to the house and they giver her some shots and put her on this boogie board thing that had a belt on it that did the CPR compressions. By some miracle they get her heart beating again. We go to the hospital and the ER doctors are saying it's not good, she's in a coma, and it's time to call relatives to get the affairs in order. She was intubated and breathing on her own, but she was twitching like crazy and not responding to physical stimulation or sound. We left the hospital that night thinking we wouldn't see her alive again.

The next morning she was awake and talking. Doctors couldn't believe it. Sorry for rambling. I just think it would be crazy to be an ER doctor and see people go through stuff like this on a regular basis.

Agnonal breathes are certainly freaky. Last year, my Mom died after a return of breast cancer that spread to her brain, skull, ribs, and hip. I was by her side when she died and it's still something that affects me thinking about.

[il Padrino Ute]

Originally Posted by ewth8tr

Agnonal breathes are certainly freaky. Last year, my Mom died after a return of breast cancer that spread to her brain, skull, ribs, and hip. I was by her side when she died and it's still something that affects me thinking about.

As tough as it must have been for you to see her go, I'm guessing she was very happy to have her son by her side when it was time to go.

[MikeWaters]

Originally Posted by il Padrino Ute

As tough as it must have been for you to see her go, I'm guessing she was very happy to have her son by her side when it was time to go.

I briefly volunteered in an AIDS hospice. I was told by the staff that most often the patients "chose" to die alone. I.e. if someone was with them, they would most often die when the family or friend or staff left for a time (i.e. go get a meal).

I don't know if this was their folklore, if there was some truth to it.

[ERCougar]

Originally Posted by MikeWaters

I briefly volunteered in an AIDS hospice. I was told by the staff that most often the patients "chose" to die alone. I.e. if someone was with them, they would most often die when the family or friend or staff left for a time (i.e. go get a meal).

I don't know if this was their folklore, if there was some truth to it.

That's interesting, and probably true. Again, I can't speak for other specialties. Our deaths tend to be in the unexpected category (even in those whose deaths you would think would not be surprising), and watching the resuscitation seems to soften the blow a bit. In a well-planned death such as occurs in a hospice setting, things may be really different.

PS Why are they coding people in hospice?

[MikeWaters]

they are not coding people in hospices.