mobey Posted February 28, 2011 Author Share Posted February 28, 2011 Hey Mobey, I maybe overthinking again...but what was the patients quality of life prior to this event? He was living in an assisted living housing. He has his own appt, but group eating and games. He regularily leaves to visit daughter/grandchildren. No assistance with walking/bathing etc. Link to comment Share on other sites More sharing options...
fakingpatience Posted February 28, 2011 Share Posted February 28, 2011 Called to a Rural hospital. No physician available. 82 y/o male presented last night after syncopal episode. Found hypotensive, with hx of 2 day coffee goround emesis, and hematochezia. HGB 47 Pt on coumadin, but has not had it in 2 days INR 3.2 Pt was talking GCS 15/15 this morning, but has passed 700ml measured blood per rectum within the last hr, and dramatically decreased in conciousness. It is now 1400 hrs. The pt has a DNR, however asked to be transfered to the city (2hrs away) for surgery. This was at 1300, shortly therafter his vital signs changed, he became lethargic/confused and eventually losing conciousness. Daughter agrees with plan, and wants him transfered. Physician calls you, and washes his hands of the pt. You have the hospital at your disposal. You enter the room to find: Appropriate size for age elderly male, lying supine with loud snoring resps. RN in room for report and monitoring him. He is GCS 3. (the pt, not the nurse) Nasal cannula in place with 2lt 02 running IV in place x2, both 18 G. One Nacl 250ml/hr. One locked. BP via machine: 74/32, HR 132 reg (no radial), Resp 22 deep reg. Temp 36.7, BGL 10.4mmol Pt has had 500ml Nacl Vit K 1000ml Pentaspant All within the last 2 hrs Nurse sts, "Dr. says he would like you to stabalize him and get him to the city ASAP." I am a BLS provider, so most of my questions are out of my scope, but here are my initial thoughts 1st, I thought that definitive care is very different from a DNR order. I don't think there is any conflict with the patient saying that he wants to be transported for definitive care, while still maintaining the DNR. Why does this patient not have bloods running? Does his DNR specify for intubation/ artificial ventilation? With snoring respirations, it seems it is going that way fast. How does the patient look in regards to his respiratory condition? Does he appear cyanotic? Do we have a SP02/ capnography? I would want to talk with the MD in person. Does the MD feel the pt has a chance of surviving a 2 hour transport in his current condition? Does the daughter know the chances of her father dying in the back of the ambulance? Has the admitting hospital been notified of pt's worsened status? What are our provisions for transporting a dead body if/ when he codes in the back? Link to comment Share on other sites More sharing options...
mobey Posted February 28, 2011 Author Share Posted February 28, 2011 Why does this patient not have bloods running? Don't bother with why, you are at a small hospital with a clinic Doctor. He called you because he is in over his head. Do you want blood running? Does his DNR specify for intubation/ artificial ventilation? With snoring respirations, it seems it is going that way fast. I quoted the DNR on P1, you can interpret it just as I had too. How does the patient look in regards to his respiratory condition? Does he appear cyanotic? Do we have a SP02/ capnography? No cyanosis, Very pale. No capnography, Sp02 will not register I would want to talk with the MD in person. Not gonna happen. The MD is back at the clinic seeing pt's. He has done his part in calling EMS to get the pt out of there, the rest is up to you. Let's not get too hung up on trying too get this Doc to make any decisions. This is a REAL call, and your pt's MAP is REALLY 43. Fighting about wether it is fair for a Doc too dump this on you is not gonna help this situation. You must make the decision whether to stabilize & transport or refuse to transport & walk away. The next decision will be, how far are you willing to go on treatments. Link to comment Share on other sites More sharing options...
island emt Posted February 28, 2011 Share Posted February 28, 2011 As was asked above: Does the pt have blood running by rapid infusion & do you have enough to make the 2 hr transport to the big city hospital? Other than that there's not much " care you can provide in the case of an internal bleed. Diesel bolus and hope that he doesn't code while enroute to higher level facility. Sounds like the rural Doc has made the decision that there's nothing more they can do for the Pt , and is passing this off on the EMS crew. Link to comment Share on other sites More sharing options...
paramedicmike Posted March 1, 2011 Share Posted March 1, 2011 You sure you're not missing a decimal in the HGB number? Do you mean 4.7? Or is HGB, like BGL, measured differently in Canada? (Honest question.) Has the receiving facility actually accepted this patient? Are they ready for him to be in surgery within a short time after his arrival? Two hours away? Is this two hours of Sunday driving time? Or is this two hours of "EMS driving" time? What time of year is this? What are the road conditions between here and there? How long will it take for the air medical guys to get there? If available and timely this guy buys a flight out. How much blood does the rural hospital have on hand ready to be used? Manage and secure the airway. Try to avoid paralytics if possible. If blood is available, start it. Be careful, though, about bringing his pressure up too high, too fast. If his bleed has managed to clot the last thing he needs is to have it blown off by increased volume and pressure. Additional treatment and decision making will be determined by knowing the answers to my questions above. Link to comment Share on other sites More sharing options...
mobey Posted March 1, 2011 Author Share Posted March 1, 2011 You sure you're not missing a decimal in the HGB number? Do you mean 4.7? Or is HGB, like BGL, measured differently in Canada? (Honest question.) HGB is in g/l. Not too sure the conversion, but normal is around 150, blood is usually transfused around 80 and our guy is at 47. Has the receiving facility actually accepted this patient? Are they ready for him to be in surgery within a short time after his arrival? No. You are too report to the ER. There is no recieving surgeon, just the regular ER MD. Two hours away? Is this two hours of Sunday driving time? Or is this two hours of "EMS driving" time? What time of year is this? What are the road conditions between here and there? How long will it take for the air medical guys to get there? If available and timely this guy buys a flight out. Road conditions are good, This was last week here in canada (the cold part). 2 hrs is driving STAT. The trip as far as logistics is concerned, is not a problem. Pt survivability though, that was my concern. Air crew via fixed wing can be here in 1hr. Then a trip too the airport to pick them up, then load the pt, then drive back too airport, then 1/2hr flight, then meet recieving ambulance...... you get the idea, not too time saving really. How much blood does the rural hospital have on hand ready to be used? 2 Units unmatched. Manage and secure the airway. Try to avoid paralytics if possible. Not questioning you Tx here bro, just want to point out this is a DNR pt requesting "No artificial resucitive measures" I do realize that is open to interpretation, and would like to hear your view on intubation with/without sedation in this case. If blood is available, start it. Not too get all dramatic on ya, but again, is blood transfusion a "artificial" resucitive measure? Either way, 2 units are hung and being pressure infused. 2nd IV is still NaCl @ 125ml/hr Additional treatment and decision making will be determined by knowing the answers to my questions above. Really appreciate you imput on this one. I could not have felt more green as I did with this case. Link to comment Share on other sites More sharing options...
usalsfyre Posted March 1, 2011 Share Posted March 1, 2011 This guy will die enroute. No doubt about it. I doubt the local ED has enough blood on hand to manage this case. Call the receiving physician and my med control, get a three way conference call going if need be. Explain your concerns. I would do everything in my power to avoid taking this transfer. He doesn't sound like he's going to make it a 30 minutes into this transport, much less two hours. Even IF he makes it to the receiving, he's got to make it to surgery, through surgery, and through a uhhh, "complicated" ICU stay. He's VERY likely to have multi-organ dysfunction NOW from mismanagement (who in the heck thought a LITER of colloid was a good idea?!) not to mention two hours of bleeding later. Sometimes being a patient advocate means making people aware of the facts, probable outcome and that it might be better to die somewhat comfortably with family around rather than in the back of an ambulance or ICU two days later with a $250k bill. Barring making everyone see the reality of the situation, every compatible PRBC the hospital has with an equivalent amount of FFP and platelets for the trip, intubate with VERY little sedation and a heavy dose of paralytics, set your vent to minimize pressure in the chest, and consider that you may need catecholamine infusions to keep this guy alive, as he may run out of his own endogenous supply quickly. Cross your fingers and pray to your deity of choice, it's gonna be a LONG trip. Link to comment Share on other sites More sharing options...
DwayneEMTP Posted March 1, 2011 Share Posted March 1, 2011 Yeah man, you're fucked here. If the hospital has reached the end of the best care that they can provide, then the best chance that he has for survival is to get to another, better, hospital. I'm guessing that flying him is not an option, further care at this facility is not an option, or so it sounds, so it in your lap, right? Do you cover your ass and refuse..let him die at the hospital, or give him the best chance possible and transport? I know God damned good and well that you did play the CYA card. This guy is so ready to code that he's practically dead already. No blood running means, I'm guessing, no acceptable blood products at this hospital. Intubate/vent, get enroute, pour on the Os, open his fluids up a bit and see if you can get his pressure back up around the 80-90s range, light it up, don't let your partner freak out and kill you driving fast, and honor his DNR half way there when he dies. Being kind of a smart ass I know, but I'm willing to bet that I'm not far off. At my last gig we had to make these decisions sometimes and most times they worked out ok. But I'm willing to bet that this is not one of those times. Dwayne Link to comment Share on other sites More sharing options...
paramedicmike Posted March 1, 2011 Share Posted March 1, 2011 (edited) Ok. Based on your follow up you're screwed. I just don't see the guy surviving. Even if, by chance, he makes the trip, he won't make it to, or through, surgery. HGB is in g/l. Not too sure the conversion, but normal is around 150, blood is usually transfused around 80 and our guy is at 47. Here in the States we measure in grams/decilitre. Normal values for an adult male is 14-18 gm/dl... lower as men age. I was unaware of the difference in measurements and thought there was a missing decimal. I should've clarified that before moving to treatment. Air crew via fixed wing can be here in 1hr. Then a trip too the airport to pick them up, then load the pt, then drive back too airport, then 1/2hr flight, then meet recieving ambulance...... you get the idea, not too time saving really. Agreed. Not a viable option. Not questioning you Tx here bro, just want to point out this is a DNR pt requesting "No artificial resucitive measures" I do realize that is open to interpretation, and would like to hear your view on intubation with/without sedation in this case. Not too get all dramatic on ya, but again, is blood transfusion a "artificial" resucitive measure? You're correct that it's open to interpretation. With as simple as the wording in the DNR was presented I would take supportive measures to include anything up to the point of arrest including airway management and blood if indicated. Once he's arrested, however, everything stops and this gentleman is on his own. 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. Also, I'm not going to necessarily retract starting the blood. If he's going to have any chance at survival he'll need it. He's still a living, breathing person. That being said, I think the idea of a phone conversation with a doc at the receiving hospital is definitely in order. 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.) Of course, that would answer the transport decision right there. Really appreciate you imput on this one. I could not have felt more green as I did with this case. This is an interesting case and I'm really interested in hearing how it played out. Thanks for posting! edited once for a capitalization error. Edited March 1, 2011 by paramedicmike Link to comment Share on other sites More sharing options...
Lone Star Posted March 1, 2011 Share Posted March 1, 2011 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. Link to comment Share on other sites More sharing options...
Recommended Posts