Leaderboard

Wow, that sucks! Did your state suddenly drastically increase the CE requirements without any notice?

My gut told me there was no foul play, and I thought it unlikely that both the husband and her father were conspiring to off her, although the husband was clearly driving the bus when it came to her care. There was no durable POA; we were just going by the usual OH rules regarding who makes those decisions, i.e., spouse, then parents, then grown children, then siblings, etc. Ethics committee is a good thought, but I'm not sure how we make that happen at 11pm on a weekend. Ohio currently has two levels of DNR. A DNR-Comfort Care Arrest (DNR-CCA) simply states that no resuscitation will be undertaken in the case of a cardiac arrest. It is frequently interpreted to allow everything else, though we may modify treatment based on discussion with family. A DNR-Comfort Care (DNR-CC) means that no aggressive lifesaving measures will be taken. This is usually taken to exclude intubation, pressors, central lines, defibrillation, but not necessarily IV hydration, artificial nutrition, or antibiotics. There is legislation afoot in Ohio for the MOLST (Medical Orders for Life Sustaining Treatment), but at present the only way to express your wishes regarding specific treatments is in a written advance directive. As you can see, even here, there is room for debate, as some will say that brief life saving interventions would be permissible if the disease process is thought to be easily reversible. Most patients I encounter do not have clear advance directives on what care they would or would not want, which complicates things for those of us in critical care and emergency environments. We often rely on family members to tell us what they know of their loved one to help us guide what we do. If they have no useful information, then we treat under the doctrine that most people would want to survive under any circumstances. Most of the time EMS is, frankly, not permitted to think beyond the written page. Only honoring a recent, signed, very explicit DNR order is perhaps medicolegally the safest way to go. This also fails to address the majority of futile resuscitation that we will perform. Of course, if the patient never said anything, we'll never know that they wouldn't want to suffer a lingering convalescence. Making this call on limited information, from sources other than the patient, is tough. There is that critical time, the immediate resuscitation, that makes all the difference. If you can get someone through that initial issue in the ER, it is very likely the patient will survive. It could be that come patients see that respiratory arrest as an easy way out, and in fact, they are often correct, since the one intervention, intubation, at the critical time, is enough to get them over the hump, to a prolonged convalescence, which is what the patient may want to avoid if they have expressed their wishes not to be intubated. Does this change what we do if the causative issue is one that is potentially easily correctable, or iatrogenic, or self inflicted? In the end, it was all academic. She maintained her own airway and did not require intubation in the ER. The patient was not terribly well educated on her insulin pump, and was also on a long-acting insulin, so it was thought that this, combined with a UTI, caused the hypoglycemia. She was admitted by PCC to the ICU. He made her a full code, and his documentation stated that he "was not satisfied with the documentation of her wishes regarding code status". The husband was apparently pretty unhappy about it, according to the chart. The patient fully recovered, and met with Integrative Care Management. In a well-documented conversation, the patient said she would not want to ever be intubated under any circumstances, and it appears the husband was correct. A DNR-CC form was executed, and the patient discharged home. I bring this up because of the difficult position I was in, not just with the patient and family but with staff. The nurses taking care of her were very experienced and pretty headstrong, and they clearly would have put up a fight if something happened and intubation was medically indicated and I refused to do it. I'm not sure how that would have played out, but it likely would have involved the resource nurse, the AO, another physician from the ER, and hard feelings all around. It would have been fairly ugly. We like to think that we run the place, but when the nurses feel an ethical obligation to do something, they can, and will, stand up to us, and refuse to execute orders they feel are not in the patient's best interest. 'zilla

It seems like this pt is having some sort of GI bleed, of which is causing him to be anemic. This would cause his shortness of breath, as well as St segment elevations, even precipitating an MI. He is on coumadin, he is not tachy probably because of his B blockers, an his urine is dark. Would not be inclined to think that the dark urine is myoglobin, (nothing in hx to point to that). His pressure is up, most likely because he is compensating, although, his pulse pressure might be narrowing. This could be because of cardiac disease, or blood loss. One would keep an eye on his pulse pressure enroute. I would placed two lines, and give high flow 02. I would probably hold the ASA on this one, but would confer with med command just to make sure. Hope this helps.

God bless you Kyle, (Despite my religious beliefs) But what I believe is that you are too smart to write like a child and I'm not going to answer any more of your questions until you at least bother to reread them before posting. From your questions I know you're smart, but you choose to just put forth whatever bullshit your fingers happen to land on. Type, run spell check, proof read, then post. If it's not worth your effort to do so? Then it's not worth my effort to reply. Take care man. Dwayne