Scenes From the 21-st Century Doctor's Office
A patient's death prompts a doctor to assess 'Do Not Resuscitate' orders
Tuesday, March 9, 2010
The emergency department is always noisy, but sudden screams from a staffer still get attention. The triage nurse is yelling, "Not breathing, had vitals at triage and just croaked," as she runs toward us pushing a wheelchair. In it, a pale, thin man is slumped over and looking gray. I'm the attending physician in charge. Amid the usual strokes, heart attacks and bleeding ulcers, my day just became interesting.
"Anyone know of a DNR on him?" I ask. If there's a Do Not Resuscitate order, we won't prevent his impending death, which means no chest compressions or electric shock for a dangerous heart rhythm. If there's also a DNI (Do Not Intubate) order, we won't insert a tube to help him breathe.
Blank stares all around. "His daughter dropped him off with a chief complaint of weakness and went to park the car. I think he has cancer and is on chemo," the triage nurse says. Without concrete proof of a DNR or DNI, there's no hesitation. We resuscitate; we intubate. Click, klang, the laryngoscope snaps open and the patient has a tube down his throat within seconds. On the monitor, he is flat-lining -- no heartbeat -- and he has no pulse. I ask the nurse to start cardiopulmonary resuscitation, or CPR. The nurse has good technique, but even harder chest compressions would be better.
"Allow me," I say as I take over the chest compressions. This is unusual for an attending physician to do because it's hard to think during manual labor. But correct CPR, faster and more forceful than most people think, is of paramount importance for this patient. I'm moving his blood and feeding his brain with glucose and oxygen, keeping the neurons from dying. I synchronize my words with compressions and call out for a pacemaker. It's not here; someone's going to get it. Okay, hurry up. Pumping . . . thinking . . . .
"You want epi? Atropine"? the nurse asks. Yes, everyone knows the standard protocol: If there's pulseless flat-lining, it means asystole -- the heart's ventricles aren't contracting -- so start CPR and inject the drugs epinephrine and atropine to stimulate the heart. I decline the usual drugs, expecting they'll do more harm than good. This resuscitation isn't by the book. The nurse looks confused, "Asystole, epi, atropine. It's what we always do."
"Unless the asystole is from too much potassium," I reply. That would explain it. "Get two amps of bicarbonate. Take over compressions," I say to the intern. "Central line kit, please." The jugular line takes seconds, and I flush it with sodium bicarbonate. This probably will correct the blood's extreme acidity, which I suspect is driving up the potassium. The external pacemaker finally arrives. Technicians attach the pads to the patient's right shoulder and left ribs. But I want them on front and back for "better capture." By this I mean that the electrical stimulus will be transferred more effectively and will better induce the heart to contract. While the pads are being adjusted, I glance at the monitor.
"He's got a rhythm!" Slow wide blips on the monitor with a barely palpable pulse. "Dial up the pacer," I order. Potent electric shocks at 80 beats per minute begin to stimulate his heart, causing the muscles of his chest and neck to spasm as well. The pacer is working. Now there is a strong pulse, great blood pressure of 150/80, and his pupils are beginning to constrict, suggesting decent blood flow to the brain. The EKG's normal. He has a heart that works. He gags, coughs and starts to reach for the breathing tube in his throat. He has a brain that works. I order narcotics and sedatives.
"Good job, everyone," I say, knowing the pride they have in their skills. I'd customized the therapy on the basis of intuition and experience. And the interventions were optimized and performed without delay by skilled hands. But we're not done.
"Where's the family?" I ask. "I need some history." They're waiting outside. I wipe the smile of success off my face and walk out slowly. I introduce myself, and before I can go further, a woman interrupts and hands me papers. "He has DNR and DNI orders," she says.
It's a bit of a shock, and I take a deep breath. The papers clearly show that both CPR and intubation should have been off-limits. I didn't know this, and I erroneously saved my patient's life.
I carefully explain that everything happened fast. We weren't aware of the DNR and the DNI. Now, he's stabilizing. Then I get the story: several failed rounds of chemo; several weeks of weakness, decreased appetite and depression; many days of feeling unwell. I hear that his meds don't include appetite stimulants, antidepressants or narcotics; why not? The family wants me to "make him comfortable."
"Right now he's comfortable," I respond, and they appear surprised. They thought comfortable was going to be complicated, exclusive of everything else. I explain about the euphoric pain relief of the fentanyl infusion and the deep sleep and amnesia induced by the propofol drip that accompany his life support. He feels no pain; he's sleeping. I also tell them that his heart appears to be working and, on the basis of his purposeful hand movements, his mind might still be intact. I ask the questions still unanswered. "Is the DNR in effect now? In case of heart arrhythmia, can I give him a shock or more chest compressions? Given the sedation, it won't hurt." Confusion overcomes the family, and I step back to let them think it over.