Here’s the punchline to start: You intubate a patient who is a DNR, but not a DNI while they still have a pressure and are breathing. Then they lose pulses and BP, and they cease breathing on their own, but instead of going to asystole, they maintain a PEA in the 40’s along with a capnography of 14-18. This is a patient that you would do compressions on if they weren’t a DNR, so you obviously don’t start compressions, but what about the ventilations you are already doing? Do you stop or continue? Now if they were asystole, I would stop. But a ?PEA regular rhythm...
Here’s how it went down.
We’re dispatched to a nursing home for a woman in respiratory distress. The nurse meets us at the door and says the patient's pulse SAT is dropping. "She was in the 70's, then we put her on a nonrebreather at 4 lpm, and she is now down to the 30's."
We try to explain that unless you have the 02 up to 12 or so, she is just going to be rebreathing her own carbon dioxide. You might as well put a plastic bag over her head. But she needed a mask, the nurse says, her SATs were dropping. We try to explain, but she doesn't get it.
I look at the patient and ask what her code status is. She is taking shallow gasping respirations.
“She’s a stage 2 DNR.”
“And what does that mean? Is she a Do Not Intubate.”
“It means do everything except rescusitate her if she is cold and stiff. The family is very involved. They want aggressive care.”
“So I can intubate her?”
“Absolutely. The family will meet you at the hospital.”
Out in the ambulance while she is still breathing I intubate her. Inside they had a BP of 50/20. We can't hear an BP or feel a pulse. She is now in full respiratory arrest. On the monitor she is in a bradycardia in the 40's.
Her capnography is 20, then slowly goes down to 14. We should be doing compressions, but she is a DNR.
I find myself in a little bit of a dilemma. I intubated her when she still technically intubatable, but now that she needs resuscitation do I stop bagging her? I decide to call medical control for permission to cease, which they give me. I detach the ambu-bag. "I guess that's it," I say. Her rhythm is still in the 40's. She has no pulse or detectable BP. I stare at her. My partner throws a sheet over her. But then it suddenly looks like she is moving imperceptibly or is it just the shaking of the idling ambulance? I pull the sheet back. This is very confusing to me. She is a pulseless, apneic DNR. Her pupils are fixed and dilated. But her rhythm holds steady and her capnography actually rises. Maybe if I had a Doppler it would show she had a BP, and maybe even though I can't see it she may be breathing imperceptibly. I doubt she is -- I don't see any signs of it, but how can she be generating a capnography of 14. I would think anyone with a capnography of 14 has to have some kind of perfusion going on. Admittedly I could use a course in capnography because I am still new to it and have a lot of questions. But what should I do right now? I am uncomfortable putting a sheet over the head of someone who may not be completely dead. I don't know whether to start bagging again or what. If she wasn't a DNR, I'd be doing CPR. I look at the monitor hoping for the patient to brady down, but she stays strong and steady at 40.I am tempted to tell my partner, “Drive really really slowly.” I call the hospital back and say, "About that presumption..." I tell them I am uncomfortable putting a sheet over her just yet, and will continue to bag her, but withhold compressions. Just then she starts to brady down, and by the time I am at the hospital, about twenty minutes after I intubated her, she is almost completely flat line.
I have stopped bagging her again. The doctor calls her dead and that's that.
The doctor later tells me that he has just read her recent discharge notes from several days ago. She was supposed to be a DNI/DNR. He says I had to go on what they told me.
You can’t come up with enough scenarios sometimes.