Need to vent a little

[JoelEMT]

So, While I was working last week, one of our neighboring areas gets a call for an unresponsive, non- breathing pt after being hit in the head. On arrival they find that the pt is in full cardiac arrest. After intubation/ first round meds, a spontaneous pulse returns. (no shockable rhythms) so all the way in to the rural hospital they are bagging this pt. shortly after arrival, pt condition improves to the point of spontaneous resps. (`8-10/min) Now, This pt NEEDS to go into the city for further testing/observation. But the rural hospital decides that they don't want to "waste" a bed in the city with this pt, that they are going to pull the tube and let them die. As EMS we (involved and those who heard the story) were choked that they had decided that this was going to be their course of action. My question is WHY was that their decision? The pt had been down for less than 8 min and had bystander CPR I believe. Not to mention the leaps and bounds in improvement from a full out cardiac arrest. The pt was however still unresponsive at the time that the decision had been made. (less than 1 hour ofter collapse)

Now I don't want to jump to any conclusions here but the ONLY thing that I and the others can think of that may have resulted in this course of action was that the pt was a Downs' syndrome pt. I may be wrong, Maybe there is something I don't know about or what. But my question still remains as to why this pt did not go to the city and the decision to pull the tube and let them die was made?

Any thoughts? comments?

[shorthairedpunk]

You never mentioned what the families request was in this matter?

It is beyond EMS when the family is at the hospital, If the power of attorney for healthcare requested that course of action then what EMS wants is irrelevant.

If the patient had spontaneous respirations and had become pulsatile then extubation may have been warranted.

To what extent were this patients head injuries and what tests were performed to asses brain function within the facility prior to the decision not to transport?

Was CT available at that facility?

[JoelEMT]

As far as I know, The family wanted the pt to survive via whatever means necessary. The nearest CT was 1.5 hrs away. And it is my understanding that even though the pt had spontaneous resps the pt was still hypoventilating (~8-10/ min) I agree that extubation may have been warranted, but usually not in the face of hypoventilation, also given that the pt was still unresponsive. (therefore, not fighting the tube) As to the extent of the injuries, I don't know specifically. I do know that the attending ALS crew were extremely upset with the decision not to transport to the city. (suggestive to me that the pts' injuries may have been potentially serious but not so serious as to warrant "pulling the plug") I don't really know the specifics. If transport time was an issue the pt could have been flown out by helo in about 60 min round trip. (out there and back)

[Ridryder 911]

How old was the patient ? Also neuro eval.. any deep brain function, lower limbic & mid brain function? The larger hospital may have consulted & informed them to check certain things, then make a decision. I know Down's syndrome have several congenital defects, which may leads them into a DNR category.

Does sound a little harsh though..if I was attending I send & let them decide to pull after CT, etc. Unless you didn't think he make the trip.

Be safe,

Ridryder 911

[THE_DITCH_DOCTOR]

I don't see anything out of line with the decision that was made. The patient had an incurable disease with neurological complications. Personally I think the best thing they could have done was to limit the resuscitative efforts- yes, it would have been nice to have a "save" but you have to stop and think about what the patient's long term prognosis would have been- even a neurologically normal person has a low chance of survival without gross complications even with short down times, doubly so with head trauma, let alone who started out with the mental capacity of probably no more than a 5 or 6 year old. Sad but true, the best thing that could have probably been done for this patient is for them to be allowed to die.

[Great_Llama]

Sad but true, the best thing that could have probably been done for this patient is for them to be allowed to die.

In whose opinion? If the patient wanted to go fine. If the family wanted to let them go, again, that is their decision. If they had a will or something stating DNR, or no living on tubes or whatever then their choice again. If this was just something that was going to happen again and shortly and they got a DNR from the right people, then again okay. Or the person would go through too much pain and suffering, as in as soon as they brought them back they'd just arrest again or they were brain dead or whatever else might mean they'd never respond again, then certainly this might be mercy and I hope that was the docs decision.

If this person had a chance to live, no matter the downs syndrome, and they wanted to, even if the docs didn't know how long this person might live, and they didn't do anything then shame on them. Just because someone has an incurable disease doesn't mean they deserve to die. They deserve to live every moment of life that is allotted to them. For a doctor to make a moral call and decide that someone may as well be allowed to die because they have downs syndrome is horrible. It's not the doctors call in my opinion, unless the patient has no guardian or will and the doctor is the only one that can make a decision. It's especially wrong to decide that because someone has an incurable disease that they shouldn't be allowed a chance to live. If the ER rooms had decided that with my mom, she'd have lived a few years less than she did. She had cancer that spread all over basically. Chemo wasn't working, bone marrow worked for a year and then relapse and when she was bad the docs worked hard to get her going again. In fact she was told six months when it first got diagnosed and she lived 13 more years, though some of them were tough for her. She had a will to live and fought to the end....but it was clear the fight was going the wrong way and she'd eventually lose, but I can tell you that even though the last few years were tough, she'd have never given them up for nothing.

We may not want to live a certain way and may rather be dead than to live that way, but not everyone thinks the same as we do. Some people want to fight to hold on to life until there is no other choice and those people should be given that chance, downs syndrome or no.

[craig]

forgive me for asking

buy when did getting a medical degree entitle a person to takes gods place?

i agree that the prognosis may not have been good for this patient, and they may have passed away after extubation, but surly they have to be given that chance?

i seem to remember that doctors in Australia agree to the Hippocratic oath, don't they do this any more in the US?

if there was no will or DNR requests from the patient or family, what right has the doctor at a regional hosp[ital have to discontinue treatment with out doing ALL diagnostic tests (the CT scan)? even if it is a a further hospital.

if that happened here in Australia, there would be a commission inquiry and the doctor would be asked to explain his actions and the consequences could be dire for the doctor that made the decision.

just don't seem right to me, and as the attending ambo i would be pissed off as well

stay safe

[THE_DITCH_DOCTOR]

Yeah, they require the Hippocratic Oath, but most forget- PRIMUM, NON NOCERE (the first tenet of the Oath in Latin- First, do no harm). I'm sorry but the life expectancy of a Down's patient is about 40-50 years and the quality of life just isn't there. Apparently the family didn't have a problem with withdrawing care in this case and therefore I don't have a problem with it.

I'm sorry but I don't look at this as a save. There are just times where the quality of the life you are "saving" is more important than the fact you did.

[Ridryder 911]

Sorry wake up & smell the coffee... It happens everyday.. every ER, ICU, CCU, floor units etc.. physicians or even extenders.. make the call. Unless the family is really wanting the patient to be resuscitated with a hx. of long term illness (COPD/ Extensive Cardiac) with a terminal or pro-long hx. most resuscitation's efforts are little to none. I do not believe in them, but some hospitals have ... slow codes, or pharmacological efforts only where no compression & ventilation's, just meds pushed.

I know, now when patients have been attempted in the field, very little to no effort is made in ER if there has been no prior response. Also, after the second round of ACLS medications the arrest is called.

Decreasing prolong efforts & death with dignity has became more aware in emergency medicine.

Be safe,

Ridryder 911

[THE_DITCH_DOCTOR]

I retract my earlier statement about the best possible course of action: The best thing that could have happened in this call to start with would have been for the ambulance to have been delayed by a train or traffic.