ET entubation in cardiac arrest victims

[zmedic]

A medical director who won't terminate efforts or give permission for such on an end stage cancer patient in arrest isn't really doing what is best for the patient. Probably just generating a bill or practicing resuscitation skills.

People are throwing a lot of blanket statements out there, throwing the doc under the bus. Here is my 2 cents.

1: Pronouncing people over the phone is difficult. There are patients who I might stop working in the ER who I would feel less comfortable doing so over the phone. If someone called me and said they had an "end stage cancer patient who does not have a DNR" I immediately have some questions. Why don't they have a DNR? Is that because the family or the patient wanted aggressive treatment up until the end? Why was 911 called? If this was the expected demise of a cancer patient, clearly someone wasn't ready for that or they wouldn't have called 911. How do you know it's end stage? Do you know where in their treatment they were? How they were responding?

Don't be so quick to judge an ER doc for not wanting to terminate the resus of a patient with viable rhythm based on third hand information (the medic telling me what the patient's family member is telling them their doctor said)

Now clearly if someone called in and said that patient was in asystole after 2 rounds of dugs fine, stop. Or if the family was saying stop. But if there is confusion about what is going on with a witnessed arrest I'd rather have them transported and sort it out in person.

The other thing is the DNR. Yeah, people with end stage cancer should have one. But the truth is people tend to have agressive treatment till very very near the end. A lot of patients aren't ready for the discussion while they are still getting treatment that is aimed at cure. It's also a very hard discussion to have. One which we often start by feeling out where the patient is in their thinking. If they make clear they aren't receptive to having a DNR we don't push it.

I'd recommend that those who think the doctor is just a wuss because their patient doesn't have a DNR should try having one of those discussions with a patient undergoing cancer treatment.

 

[Veneficus]

People are throwing a lot of blanket statements out there, throwing the doc under the bus. Here is my 2 cents. .

I don't see it as throwing anyone under a bus.

From the description given, it sounds like nobody even called the ED.

I have seen many times patients who should not have been worked in the ED get worked. For a variety of reasons over the years. Many of which came down to not understanding pathology or emotion.

1: Pronouncing people over the phone is difficult. There are patients who I might stop working in the ER who I would feel less comfortable doing so over the phone. If someone called me and said they had an "end stage cancer patient who does not have a DNR" I immediately have some questions. Why don't they have a DNR? Is that because the family or the patient wanted aggressive treatment up until the end? Why was 911 called? If this was the expected demise of a cancer patient, clearly someone wasn't ready for that or they wouldn't have called 911 .

All very reasonable questions I think any doc would ask if called, but as I said, in this case, I do not see anywhere where a doc was called.

. How do you know it's end stage? Do you know where in their treatment they were? How they were responding?.

I focused in on the extremely emaciated state mentioned twice. In cancer, once a catabolic state is reached, it is terminal. Treatment is usually discontinued at that point for palliative measures. I think most oncologists will tell you though, once that statge is reached, any therapy is palliative.

Don't be so quick to judge an ER doc for not wanting to terminate the resus of a patient with viable rhythm based on third hand information (the medic telling me what the patient's family member is telling them their doctor said)

I am judging a decision on a call that doesn't seem made. I think you are right, if a field provider did call, a plethora of questions need to be answered to a satisfactory level.

But having said that, once the doc laid eyes on the pt. a rhthym is not the only deciding factor in a resuscitative effort. I have seen my fair share of pts in a unit who were basically Frankenstein's monster on a vent with multiple pressors, an IABP, paraenteral nutrition, and hemofiltration who were never going home. (including end stage cancer patients)

Now clearly if someone called in and said that patient was in asystole after 2 rounds of dugs fine, stop. Or if the family was saying stop. But if there is confusion about what is going on with a witnessed arrest I'd rather have them transported and sort it out in person.

Seems very reasonable.

The other thing is the DNR. Yeah, people with end stage cancer should have one. But the truth is people tend to have agressive treatment till very very near the end. A lot of patients aren't ready for the discussion while they are still getting treatment that is aimed at cure..

Just because a patient is getting treatment does not excuse the discussion of prognosis. Some patients refuse to have that conversation, I understand, but intentially not talking about likely outcome or even offering, seems a bit like avoidance to me.

If a patient wants to avoid that's one thing, but a doctor? C'mon.

It's also a very hard discussion to have. One which we often start by feeling out where the patient is in their thinking. If they make clear they aren't receptive to having a DNR we don't push it.

I have no sympathy for doctors who are too emotional for the medicine they practice. If discussions or decisions are too difficult, find another job.

As for pushing DNRs, I am not suggesting pushing them, but I have found how you approach the subject plays a large role in how receptive patients are. I would wager that many patients aren't ready to talk about thier end. But initiating an attempt at that discussion is still the responsibility of the doctor.

I'd recommend that those who think the doctor is just a wuss because their patient doesn't have a DNR should try having one of those discussions with a patient undergoing cancer treatment.

I never suggested the doctor was a wuss because the pt doesn't have a DNR. The patient may have refused one.

Based on the comment about the doctor not discussing one, I question whether or not it was because of how the patient felt or if the doctor was shielding himself.

try having one of those discussions with a patient undergoing cancer treatment.

I have. On a handful of occasions. Including one patient who is a physician. Perhaps I am just a cold hearted :censored::censored::censored::censored::censored::censored::censored:, but I do not find it any more or less difficult than many other aspects of patient care.

(I suspect though it is a combination of my desensitization and way too much pathophysiology.)

 

[zmedic]

The wuss comment was in response to: "his Dr. was too scared to bring up the subject." I don't know what the situation was in that case. But I think everyone here should realize that they shouldn't be judging someone else as incompetent without having all the information. Sure there are cases when DNR should have been discussed but it wasn't. But lack of DNR + patient with cancer does not =incompetence.

As to it being "too emotional for doctors," I agree, that isn't a reason not to have the conversation. But rather that there are situations where bringing up a DNR comes across as we are giving up on the person. I have seen the opposite approach which is that DNR is discussed with ever single patient. Makes it easier not have to decide who to talk to about it, but I think it creates uneeded problems with those healthy 50 year olds who are like, "I'm here because I have pneumonia, what are you talking about?"

I agree that there should be goals of care discussions. But if the goal is to cure that patient DNR isn't really appropriate. You shouldn't be doing agressive chemo or surgery on someone and discussing DNR. Actually DNRs are automatically invalidated if the person is having surgery. Found that out the other day on anesthesia. If the case being done and the code they are worked. No DNR in the OR. I guess the thinking is if they are comfort care only you wouldn't be doing surgery. Maybe so they don't add to the perioperative mortality stats. Don't know if I agree with that policy but it's interesting.

 

[Veneficus]

But lack of DNR + patient with cancer does not =incompetence.

For certain. Like I said, pt could have refused.

As to it being "too emotional for doctors," I agree, that isn't a reason not to have the conversation. But rather that there are situations where bringing up a DNR comes across as we are giving up on the person. I have seen the opposite approach which is that DNR is discussed with ever single patient. Makes it easier not have to decide who to talk to about it, but I think it creates uneeded problems with those healthy 50 year olds who are like, "I'm here because I have pneumonia, what are you talking about?"

I think that this is probably an over reaction from doctors not discussing DNRs when appropriate. Just like everything else, there are probably 1 or 2 incidents in question and a blanket policy is made to try to correct it after the fact.

Personally, I like more targeted intervention than blanket policy.

I agree that there should be goals of care discussions. But if the goal is to cure that patient DNR isn't really appropriate. You shouldn't be doing agressive chemo or surgery on someone and discussing DNR.

I respectfully disagree with this statement.

In some cases, particularly in stage iv malignancies, the cancer was likely discovered too late for a high probability of curative interventon. It is my opinion that the full course of the disease and prognosis with and without treatment be discussed.

It was 4 years ago almost, but I saw a palliative care study that showed people who fight and people who deny serious illness as psychological protection usually have about the same length of survival. With depressed patients less. So I can see your point.

However, having said that, if you are not looking at a case where the stars are lining up so, I think the DNR discussion needs to come early. Perhaps with the aid of social, family, and relious support if viable.

Actually DNRs are automatically invalidated if the person is having surgery. Found that out the other day on anesthesia. If the case being done and the code they are worked. No DNR in the OR. I guess the thinking is if they are comfort care only you wouldn't be doing surgery. Maybe so they don't add to the perioperative mortality stats. Don't know if I agree with that policy but it's interesting.

I think there is a bit more to this than what is explained here.

If a person is compensating for any disease and is taken to surgery, with the exceptions of massive injury or catastrophic illness (like a ruptured aneurysm, which I argue is an injury but that is a topic for another time) then unless something went wrong, should be perfectly capable of being resuscitated to their pre-surgical state. An arrest in surgery, whether induced or as a complication is likely reversible.

But if I could point out, there are palliative surgeries for cancer. Examples include reduction of a painful mass, or helping to relieve an airway obstructing tumor.(like bronchogenic carcinoma) These patients are told prior to surgery that the surgery will not cure their disease.

I have not yet met a surgeon who would provide paliative surgery when a tumor had infiltrated a great vessle though.

 

[Basermedic159]

As we all know, since the EMT-B's to EMT-P's, the interruption of chest compressions to ventilate the patient (according to the recommendation of 30:2), drastically decreases the coronary perfusion pressure, seriously decreasing the survival probability of the patient.
We also know that the only way to vent without interrupting cardiac compressions is to ensure an advanced airway (encontraqueal tube, laryngeal mask or Combitube). So why ILS or ALS teams, when identify cardiac arrest, the first approach is not to proceed with endotracheal intubation, or placement of the laryngeal mask?
In Portugal, we use the recommendations from the American Heart Association, and we have our protocols with specific actions, as I think which happens in the U.S..

I accepted suggestions, approaches, and everything you find relevant to this discussion.

For a BIAD I like the King Airway. Do you have kings or just combitubes?

 

[Medic Tim]

I am a fan of the king airway.

 

[HMartinho]

For a BIAD I like the King Airway. Do you have kings or just combitubes?

In our ILS units, where I work with my nurse partner, we have ET tubes, LMA's and combitubes.

Kings are not usual here.