I have just had an email from Matt tonight, who describes a job he was at recently and asks my opinion on what happened. It was one of those jobs that left him wondering if the decisions made were the correct ones. I will reproduce the email below (with his permission) and open it up to you guys for your opinions too. It should provide an interesting discussion for those of us in the profession, and for those readers who aren’t medically orientated, hopefully it will give you an insight into some of the tough decisions we have to make.
Over to Matt:
First off I like to say it was not my patient but my partners as we alternate each call. We responded to a local Nursing home for reports of an elderly male who had aspirated some vomitus. We arrive on scene its about 11PM. We are met by the patients nurse in the hallway who states that he has been admitted short term for a bout of pneumonia. He has been feeling a little unwell and just prior to our arrival he vomited at the same time taking a deep breath and he had aspirated a significant amount of vomit. The nurse had informed us that she had tried to suction using a yankhauer as best she could but that he was still in significant distress. As we enter the room we find an elderly male in bed with the head of the bed upright. You could hear from the end of the hallway that his lungs were full of fluid. He was in pretty bad shape. He was cool and pale. His O2 saturations were in the mid to high 60s on a nasal cannula which improved to about 69-70% with a non rebreather, he is breathing about 24 times a minute and his mental status is pretty much in the toilet from hypoxia i’ll give him about a GCS 5. This poor gentlemen needs some agressive treatment and here we are to help. Now here comes the dilemma. He has a Do Not Resucitate order for an unrelated medical condition and as soon as it is produced everyone seems reluctant for aggressive treatment. Now my train of thought is a DNR is strictly in place for when a patient is in cardiac or respiratory arrest. Now some may think that intubating is a resusatative measure which it is when in an arrest type situation but for this particular case my thought was to prevent further aspiration and a means to try and suction some of the vomit that was in there. However my partner disagreed on the intubation route and did not want to perform that intervention. Now however he did mention using CPAP which I was unsure about due to the fact that it was not edema in the lungs it was vomit and our main goal was to get the vomit out not try to push it back into the circulatory system. Now I was just the driver in that situation so I left it in my partners hands to do the right thing. I then proceded to drive rather quickly to the hospital which was about 8 mins away. Unfortunately all my partner decided on was vascular access and continuation of his non-rebreather along with the standard ECG etc. At the hospital I thought the doctor would then do the right thing and maybe intubate but again the DNR surfaced and he said ” Well I wont be intubating him” and I believe he ordered BiPAP and NG suctioning and at that point we completed our handover and left. I never did follow up with this mans outcome but im sure the outcome was not good. Does anybody else think that the intubation/suctioning route was the way to go. We do have RSI capabilities and I feel that this would have been in the best interests of the patient. Would there be anything you would have done differently I would love some feedback.
I suppose I should put my oar in the water first…
In all honesty, I think I would have done the same as Matts partner (possibly even without the IV). In my eyes a DNR is a DNR, and it is applicable in ‘pre-terminal’ events. As I understand it, the patient does not have to be in full cardiac arrest for the DNR to stand. We were not present when the discussions and decisions were made and therefore we were not to know the ins and outs of a potential living will, which may have been made before the formal DNR.
Matt states that the cause of the call was separate from the condition causing the DNR, however, the patient in all likeliness had a life shortening illness which was coming to its natural conclusion, and any ‘extraoridnary’ interventions may well have still been against the wishes of the patient.
It can be really,really hard to stand back and do nothing, but in my humble opinion, I think it was the right (and safest) decision. That doesn’t make it any easier to sleep at night though!
I hope that helps Matt, and I hope my wonderful friends out in the great blogosphere can offer their opinions too. Over to you guys!!