So here is my situation and wanted to get people's opinion on a situation I encountered. I ran a call with a patient with respiratory distress and a valid DNR. In route to the ER I had the pt on oxygen @ 6 LPM via nasal cannula and on top of that I was switching back and forth between giving A&A treatments with a misty Nebulizer and a NRB @ 15 LPM. This way the pt was never with out oxygen. My QA/QI department told me that I should have used a BVM to get a better seal and higher oxygen saturation, and I told them I do not feel comfortable using a BVM on a patient with a DNR due to the "NO Artificial Ventilations". Even if I do not squeeze that bag and ventilate the pt does not mean that everyone else would question if I did ventilate the patient! So I guess my question for the masses is what is your thoughts on this, do you feel comfortable putting your self in question, am I wrong about not using a BVM, am I not understanding the DNR correctly? Even legal views on what to and not to do as of CYA type of thing, remember I work in Texas if that changes any legal standings...
DNR - NO Artificial Ventilation and the use of a BVM?
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unleashedfury
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So they wanted you to place the mask on their face, but do not ventilate them?
If your that far down the hill.. why not CPAP?
If your that far down the hill.. why not CPAP?
Wheel
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I would have considered CPAP as well in this situation I think.
unleashedfury
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I grasp your concept. but if your giving meds to open the airway up some, assuming your giving albuterol, and the first treatment was unsuccessuful patient saturations are still in the toilet, and you moved up to the NRB, keep going to improve saturations. CPAP in line albuterol is your friend.
Solumedrol and Decadron can be your friends but they take forever to work.
Solumedrol and Decadron can be your friends but they take forever to work.
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Wheel
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I actually gave an inline neb tonight. Worked wonders.
unleashedfury
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I did a code, a Lethargy call which i think was a accidental beta blocker OD since her heart rate was in the low 40's. and she said she screws up her meds all the time. And some dudes varicose vein decided to rupture and squirt like ol faitful. Not a bad night. But the SNF hates when I get a release on Codes.
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That's a situation where CPAP (if available) with in-line nebs should work well. Using the mask part of the BVM would work, but I see issues with maintaining a seal while also allowing for the neb to work OR the oxygen to continue flowing and allowing YOU the ability to continue assessing the patient's status.
If you don't have access to CPAP, you then should do what you did: Non-rebreather mask with nebs. The DNR does limit the interventions that you can use unless the patient rescinds the DNR.
That's my 2 bits!
mycrofft
Still crazy but elsewhere
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If a DNR precluding artificial ventilation is in force, any measure creating positive pressure of viable gasses (O2, room air) would be precluded.
A passive mask or cannula dependent upon the pt having independent respirations would not.
A passive mask or cannula dependent upon the pt having independent respirations would not.
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Well, NOT using the BVM that still got your actions questioned, didn't it? People will ALWAYS be able to question why you did or didn't do something. In that regard, you are damned if you do and damned if you don't. So you might as well just do what is right and worry about the explanations later.
As long as you do what is right for the patient and document your actions and the rationale for your actions, you are good to go. That doesn't mean you'll never be questioned, it means you will have done the best you can do to both care for your patient and defend your actions later, if need be.
FWIW, I seriously question whether any clinically significant benefit is offered by a BVM vs. a NRB anyway. I know a BVM with a good seal can theoretically deliver 90% 02 vs. the 70% (maybe 80% on a good day) you might get with a NRB, but that 90% is best case scenario, meaning you consistently maintain a great seal and have no room air entrainment. Realistically I don't see anyone maintaining a perfect seal consistently throughout transport - especially when you are giving nebs, etc. So a NRB makes much more sense to me. Now if you are preoxygenating prior to an intubation attempt it makes sense to use a BVM, because you are motionless and you need to have the BVM out anyway. But during transport I don't think you are likely to be able to maintain the kind of seal you need to reap the added Fi02 available from the BVM.
jefftherealmccoy
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From the sounds of the DNR I would think a BVM would be opposing the pt's wishes. In any case, sounds like a situation where I'd call my medical control doc and put the liability on him.
We deal with DNR's and living wills a lot and honestly, most of the time I'm on the phone with the doc and then documenting the crap out of what they tell me to do.
We deal with DNR's and living wills a lot and honestly, most of the time I'm on the phone with the doc and then documenting the crap out of what they tell me to do.
Epi-do
I see dead people
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I am not going to comment about treatment of this patient, since everyone else has pretty much covered that angle.
The point that I want to make is that you stated this is a DNR and the patient is in respiratory distress. Therefore, I am going to assume they still have a respiratory drive and a pulse. Since a DNR only covers what is to be done in the event of a resuscitation, it isn't even in play at this point. I know it gets said all the time, but Do Not Resuscitate does not mean Do Not Treat. Do what is best for this patient to assist in improving his/her respiratory status.
The point that I want to make is that you stated this is a DNR and the patient is in respiratory distress. Therefore, I am going to assume they still have a respiratory drive and a pulse. Since a DNR only covers what is to be done in the event of a resuscitation, it isn't even in play at this point. I know it gets said all the time, but Do Not Resuscitate does not mean Do Not Treat. Do what is best for this patient to assist in improving his/her respiratory status.
jefftherealmccoy
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I don't know if there are other states that are the same, but there are different levels of DNR where I work. It's also called a POST form (physicians orders for scope of treatment). It can call for IV fluids, antibiotics, intubation, o2, or specific treatments OR complete lack thereof. normally we go by what the POST says unless family requests something different. In which case we'll either do what family asks or contact OMC.
If a DNR states no artificial respirations I think it is safe to assume that means before the patient codes
Because if it meant no artificial respirations after the patients codes then...well...wouldn't that be a moot point.
If a patient NEEDS a BvM they are in respiratory failure and not just distress. If they are in respiratory failure then we consider that a condition needing resuscitation. And thus...the DNR is valid and no positive pressure ventilation will occur.
mycrofft
Still crazy but elsewhere
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If a DNR states no artificial respirations I think it is safe to assume that means before the patient codes
Because if it meant no artificial respirations after the patients codes then...well...wouldn't that be a moot point.
If a patient NEEDS a BvM they are in respiratory failure and not just distress. If they are in respiratory failure then we consider that a condition needing resuscitation. And thus...the DNR is valid and no positive pressure ventilation will occur.
Don't we resuscitate after the pt codes? And we stop after declaration?
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Right, but the OP wasn't talking about delivering positive pressure ventilation; he was referring to using the BVM as an oxygen delivery device. Or at least that's how I understood what he wrote.
Respiratory "distress" vs. "failure" is semantics in these situations. Either the patient wants mechanical ventilation or not. Ideally, that would be spelled out in the advanced directive, of course, but it isn't always clear.
If the advanced directive is a simple "DNR", then traditionally that means do everything up until they arrest, but once they stop breathing or lose a pulse then do nothing at all. If they don't want mechanical ventilation or intubation BEFORE arresting, then that needs to be spelled out separately from the DNR.
Ah, well in that case I wouldn't bother using a BvM. The amount of oxygen you are going to deliver (while higher in theory) will make no practical difference in a patient that needs more O2 than a NRB can supply. It's kind of like saying a 12 gauge needle would deliver more fluid faster in a trauma patient then a 14.....
Depends on your hospital and EMS system setup. Yes we declare after the patient is dead...most of the time....but our hospital also calls "code blues" and our EMS crews do as well (we use triage colors for general impression on the radio) for patients in respiratory arrest with a high probability of imminent arrest. We consider this resuscitation of a patient from near death I guess.
TheLocalMedic
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You stole my response! DNR comes into play once they are in cardiac or respiratory arrest. Until they reach that point, it's treatment as you would for anyone else. Yes, even patients in resp failure get a BVM. Once they completely stop breathing, then you can follow the DNR wishes.
This is why the DNR is many areas is being replaced by different forms. Here it's the POLST; Physician's Orders for Life Sustaining Treatment) which goes into much more detail about what a patient does or does not want done.