Trainwreck #4

[systemet]

What got me writing was that I didn't hear any of the responding posters suggest that the stability that was present was likely the best you were going to get. No one stepped back to question if furthering/continuing/initiating aggresive treatment was necessary.

I don't think we get to make the decision as to whether we continue aggressive care. I think that's up to the patient, who has a choice to determine what's done in this situation by writing a DNR / personal directive.

I think we have a moral and ethical responsibility to help here, to the best of our ability, and do whatever we can to increase any small chance of her recovering.

I accept fully that the "stability" here might be tenuous. I agree that altering the dopamine and vent settings might undo this "stability". Perhaps, in the best of all possible worlds, they're better made via consultation with an intensivist / EM guy at the receiving facility.

But if that's not available, then we have to make a judgment as what's in the best medical interest here. It does sound like the dopamine is being ran too aggressively, and should be backed up, and that the ventilation strategy is overaggressive. There's a sound argument not to give her a push if she's teeter-tottering on the brink of stability, as we don't not which direction she's going to move in.

But I think the aggressive pressor usage is going to do terrible things to her afterload and cardiac oxygen demand, and may be worsening the situation. As with the hyperventilation and potential pH issues.

No one came to the conclusion that things were likely to get worse REGARDLESS of what was done.

I'm not sure that's true. Several people identified that this patient was a "train wreck", which was actually the title of the thread.

To me, all that was obvious. That led me to my conclusion that the woman was stable ENOUGH for immediate transport. What I heard you relate was that AFTER you started adjusting the whatnots the woman began a fatal spiral. But honestly, it wouldn't have mattered if you did everything or nothing.

And of course you can't know whether it would matter if you did nothing, or if you intervened, because you have to do one or the other. Doing nothing, and saying, "This is the best stability we're going to get", is also a choice that has consequences for the patient.

So it's not so much an ethical question as it is a moral dilemma. In a case like this, which is clearly end-of-life syndrome, when do you admit to yourself that it's a lost ship and all that's left to do is to make its passage as gentle as possible without neglecting your duties?

Has the passage been made more rough here? The patient is anesthetised, and if we go by the logic that she's not going to recover whatever we do, then she's not regaining consciousness regardless. She's sedated and has had analgesia.

We can make the argument that it might be easier for the family if she codes at the receiving facility instead (in this situation, partially hypothetical, she did). Did our intervention really hasten the death? And if it did, did it do it for minutes, hours, or days?

This kind of stuff usually doesn't get considered in scenarios and it should be. We're the ones that have to live with the actions (or inactions!) we take and the choices we make. In the end we don't agonize about the fact that we lost them, what haunts us is how.

I'll agree there's an element of ego in here. And if you're suggesting that the medical field dehumanises the patient to enable them to cope psychologically, I'll happily agree with that. But what's your alternate plan of action?

Would you leave the dopamine as it is? Leave the ventilator settings as they are? Will these actions result in the patient dying quicker, but with less sweat for the paramedics in the back?

Would you let the tension pneumothorax kill the patient? Do you think it would be less likely to occur if she's being hyperventilated with a short I time? Because I'm thinking that might increase the risk.

Would you refrain from cardioverting the VT? Would you refrain from working the pulseless VT, or VF that resulted?

How would you justify this to the receiving facility, or to the patient's family?

It's easy to say that she's not going to recover from this, and that she's beyond the help of modern medicine -- and I think it's likely that she is. But how do you explain these decisions to the family or other medical staff?

I hate anecdotes with a passion, but I'll share one anyway. I once saw an 80 year old woman pre-arrest in the CCU. She was in the lowest priority monitored beds, waiting for the system to find somewhere for her to go, after having a relatively uneventful NTSEMI. They found her right before shift change, as tends to happen in big hospitals.

Acute renal failure, K+ of 9. Infarcted in the middle of the night. I got to see them run the hyperkalemia protocol like you wouldn't believe. Even the ventolin and kayexylate -- strangely they even pushed the furosemide. Intubated her, stat angio, bunch of stents, and a balloon pump. I remember thinking how terrible it was. They could have just let her die, spared her all this indignity.

A week later I talked to her, and we had a conversation about the weather outside, after she'd been extubated and taken off the pump.

I agree that a lot of what we see is hopeless. But every now and again there's something that's not. How do you avoid losing that person in a cloud of cynicism?

All respect to you, I know you're a thinking guy. I'm not trying to insult you. I'm just trying to understand your thought process. If you have something to teach, I'm happy to hear it.

 

[BrushBunny91]

Oxygen, vitals, and transport...

 

[Handsome Robb]

Oxygen, vitals, and transport...

Not trying to call you out just pointing something out, this patient is intubated, has an NG tube placed, and is on a dopamine infusion. As a BLS provider you should refuse transport and request ALS. The interventions in place are out of your scope of practice, therefore putting you out of your scope of practice by accepting responsibility of the patient and transporting.

Keep posting, you'll learn a lot around here, much more than your EMT class. However, testing for your class and NREMT cannot be based on answers or explanations you read here.

 

[BrushBunny91]

Thanks NVROB. I do understand my level of care and I would call for ALS.
I appreciate what this forum does to start up those critical thinking questions I might never be asked in class.