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Deadly bleed and the ethical decision


mobey

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I'm probably jumping into waters that are WAAYYY over my head, but DNR means 'Do Not Resuscitate', not 'Do Not Stabilize'.

The patient is pretty well through a closing door, but you still owe it to your patient to get them to the best definitive care available. Obviously, he's not going to get what he needs at the current hospital (hence you wouldn't have been called if he could).

When (I'm thinking this patient is far beyond the 'IF' stage) he codes, you have to honor the DNR and not attempt resuscitation measures.

It's my understanding that even if the patient has a signed DNR on file and in his possession (now your possession), all he has to say is "Don't let me die!" or "I don't want to die!", and that is enough to rescind the DNR on the spot. Since nothing in the original post even comes close to those statements, the DNR is still in full force and effect.

Currently, I don't know if pushing blood products is within the scope of practice for a medic in GA (only because I haven't learned the medic's scope of practice and protocols yet), I would imagine that if they are, I would keep the blood products flowing for as long as possible during the transport.

As long as he's still at the original hospital, they can continue to monitor and attempt to stabilize while you, the receiving physician and Med Command are on the phone, (isn't that what they're there for?).

This is a REALLY tough spot to be in, and I'm not prepared at this point to just 'write the patient off', and refuse transport.

Sounds like a plan, What treatment would you like.

So far we have 2 units being pressure infused, a ET tube, and NaCl @ 125.

The BP (blood almost done) is now 80/44 MAP around 50

HR 126

RR 22 deep (assist own resps with Bag only)

SPo2 99%

Pt now moans (or gags since there is a tube there) too deep painful stimuli.

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Hello,

HR 126 with modest BP. So, give some more fluid once the blood is done. Make the Panto an infusion, if possible, as well.

Also, his INR is still elevated (3.2). Some, FFP if possible could be helpful here as well. Now, I am sure that this wouldn't be availabe in this situation: Octaplex (Prothrobin Complex Concentration <PCP>) can be used to fix his INR as well.

Also, prepare a little sedation if needed if the patient perks up some more.

What is his temp? If possible, I would like warmed fluids. I just don't want him to get too cold. Hypothermia is a sure fire way to worsen shock and coagulation issues as well. My new soap box if you will.

I think, I would get Phenylephine ready just in case he needs it after properly resuscitated with fluids.

As for the DNR. I think we need to keep in mind that we don't know the etiology of his lower GI bleed. Could be malignancy. Or, a reptued diverticulum. So, take some time to maximize the odds of a sucessful transfer.

I have seen some train wrecks live to leave the ICU.

Cheers

Edited by DartmouthDave
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Personally, there are few situations where I'll intubate without sedation first. Even if they're unresponsive you can never be sure what's going on in their head. The thought of a silent scream from the patient's perspective terrifies me. A concern with sedation is choosing something that won't bottom out his pressure even more than it is.

You have to balance the fear of anesthesia awareness with the need for sympathetic stimulation. See the next thought below.

The only thing I'll disagree with USALSFYRE on is the paralytics. My concern is with his pressure being so low. Adding a paralytic could, potentially, remove what little sympathetic compensation he has going for him. Not that the paralytics are wrong. I just have visions in my head of pushing them and watching him code right in front of me as a result. (I don't have time to look up the references at the moment but this has happened to coworkers... I know, I know. Anecdote vs evidence based medicine... I'll find references when I have some time to look.)

So the thing to remember is that paralytics actually have VERY little effect on sympathetic drive. The sedatives however, do. Reduce pain and anxiety, you remove a portion of sympathetic stimulation. There's a couple of likely possibilities as to what happened in cases like you mentioned, one is they weren't watching K+ when pushing sux (which is why I don't miss the stuff at all), another is that they removed the respiratory compensation of a severe acidosis leading to cardiovascular collapse. The final likely possibility is that the sedation reduced the sympathetic stimulation enough that converting over to positive pressure in the chest knocked out all venous return. This is one of the reasons to hold/severely reduce the dose of the sedatives.

Of course, that would answer the transport decision right there.

Agreed.

This is a REALLY tough spot to be in, and I'm not prepared at this point to just 'write the patient off', and refuse transport.

Yes and no. We don't like to "write patients off" because we're supposed to "save" people, but sometimes you've got to realize futility and not waste the resources on it. I recently had a discussion over a very similar case with former paramedic/med student. He reminded me that blood is a very finite resource, especially in this type of setting, and dumping it into a patient that's not likely to live is a misuse of it. You can't focus completely on the patient that "might be", but it's just as irresponsible to not at least consider it in a case like this.

Edited by usalsfyre
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Hello,

HR 126 with modest BP. So, give some more fluid once the blood is done. Make the Panto an infusion, if possible, as well.

Also, his INR is still elevated (3.2). Some, FFP if possible could be helpful here as well. Now, I am sure that this wouldn't be availabe in this situation: Octaplex (Prothrobin Complex Concentration <PCP>) can be used to fix his INR as well.

Also, prepare a little sedation if needed if the patient perks up some more.

What is his temp? If possible, I would like warmed fluids. I just don't want him to get too cold. Hypothermia is a sure fire way to worsen shock and coagulation issues as well. My new soap box if you will.

I think, I would get Phenylephine ready just in case he needs it after properly resuscitated with fluids.

As for the DNR. I think we need to keep in mind that we don't know the etiology of his lower GI bleed. Could be malignancy. Or, a reptued diverticulum. So, take some time to maximize the odds of a sucessful transfer.

I have seen some train wrecks live to leave the ICU.

Cheers

I've seen trainwrecks leave too, but I think it's important to recognize the difference between a 40 year old who is a 30 minute flight from a tertiary facility and a 70+ year old who is two hours from a surgical solution. And a hemoglobin <5 tells me he's been bleeding a while, and it doesn't appear to be stopping.

An INR of 3.2 doesn't really shock me as he's on coumadin (in fact, I'm suprised it's not much, much higher. With this level of blood loss I'm expecting to have coagulopathy) but I agree we should take measures to reduce it if we can

I'm curious as to the reason as to for phenylephrine over say, norepi as the pressor. I've got VERY limited experience with neo (I've transported only twice) but my understanding is you have to have sufficient levels of endogenous catecholamines to be effective. This patient would seem to be at high risk for depleting his own stores. Am I missing something? Again, I really don't have any experience of note with this med so any info you have is appreciated. Thanks.

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Good thoughts & discussion.

I'll wrap this up as a review, and discussion can continue.

I did not intubate. I saw a ventilator as artificial resuscitation, and opted not too.

OPA & NRB was applied.

Prior to the blood, I put in 250ml of Pentaspan, then 2 units of blood.

The BP came up too 92/48.

The pt's GCS came up to a 10, and he was answering yes or no questions however A&O could not be determined so I did not ask further resus directed questions.

At this point we moved him to our cot, and my EMT became very pale, and started dry heaving. When I asked what the issue was he replied "I think he just expelled some more blood".

On visual assesment there was approx 3-400ml fresh blood on our cot from his rectum.

We put him back on the hospital bed to clean him up, and he dropped his pressure again. After another 500ml saline pressure infused, it came back up, and he regained Conciousness again.

It was then I made the decision not too transport. The daughter could not be contacted, so I had the RN call the Doc to discuss my decision. He concurred.

The daughter was able to come in a short time later, and say goodbye to her dad as she had not seen him since he lost Conciousness the first time.

I am pretty sure he would not have made the trip, even if he had, I believe he was not a surgical candidate.

I could be very wrong.

The pt had a foley in, and had no urine output in 1.5hrs.

I truly believe the decision I made was in the best interest of the pt, and family.

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Mobey, after reading some additional details, I don't disagree with your plan of action. I was under the impression that daughter, doctor and patient were all there in person making the decisions. That would put a huge kink in my plan to "move faster bubba" and changes my thought process.

Knowing she isn't there and believing he will expire does change the dynamics.

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I'm really disturbed by this whole deal.

You were told by a doctor who was not there and only talked to you on the phone to stabilize the patient and transport?

Then when the patient crumped the final time the doctor did not even come in to see the patient?

Did the doctor ever come in to see the patient? Had he been there at least once?

I'm just trying to get a handle on the lack of physician involvement.

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I'm really disturbed by this whole deal.

Then when the patient crumped the final time the doctor did not even come in to see the patient?

Did the doctor ever come in to see the patient? Had he been there at least once?

No, No, and No.

The physician saw the pt when he first dropped his pressure. He started Pentaspan, and called EMS. He then left the hospital, to return to the clinic for appts.

For the next hour, I managed the pt and made my decisions.

I realize this sounds really negligent to you, but this is actually quite common here. Paramedics in Canada (especially Ab) are recognized by rural physicians for thier expertise in this area. It is very common to get called to smalltown hospital to manage a code, or to perform an RSI, or manage a critical sepsis, or anaphylaxis.

It seems as though this Doc should be reported, but I can tell you right now: You would NOT want him managing this patient!

Remember these are clinic Dr's that do not handle critical pt's very often.... like maybe 10 per year.

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Actually it did sound negligent but you are correct in saying I don't know much about paramedics in canada. I trust you that you managed the patient as well as or better than most doctors out there. So the only thing I was surprised as why did the doc not return when the patient crashed for the final time. But I trust your treatment of the patient as I know you from this forum.

I used to work in a small town a long time ago where the ER docs were the clinic docs. We had standing ER orders for everything and even standing orders for the scenario when we don't have a freaking clue, and once the standing orders were done we called the doc and he may or may not have come in to see the patient.

There were times when the doc would say discharge the patient, I'll be in later to sign the chart. (lawsuit waiting to happen if you ask me)

I know that you are placed in much higher honor than our paramedic counterparts inthe US. I for one would not want many medics I know to manage a patient in the hospital setting without a doctor present. That would be bad.

I know you did the right thing, the right treatments and in the end the right thing happened to the patient.

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I'm curious as to the reason as to for phenylephrine over say, norepi as the pressor. I've got VERY limited experience with neo (I've transported only twice) but my understanding is you have to have sufficient levels of endogenous catecholamines to be effective. This patient would seem to be at high risk for depleting his own stores. Am I missing something? Again, I really don't have any experience of note with this med so any info you have is appreciated. Thanks

Hello,

No central line in situ. Phenylephrine dose not cause damage as much tissue necrosis if infiltration of the IV occurs (according to our IV therapy manual). Also, it can be given IV push PRN (100-400 mcg IV as needed) as opposed to an infusion. Running an infusion could be an issue if blood is going, Panto, ect.

We usually put 10mg in 100cc minibag of NS for a concentration of 100mcg/cc.

You are 100% correct about the catecholamine stores. But, their depleation effects all pressors. I don't think Neo is more prone to issues. I will have to look this up.

Thank you

Edited by DartmouthDave
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