Wednesday, January 31, 2007

The Man Who Wouldn't Die (Part 2)

Here's Part 1:

The Man Who Wouldn't Die

Now Part 2:

So I'm just sitting around thinking I've been doing nothing but routine EMS calls -- lots of elderly flu, dehydration, falls, psychiatric, TIA type calls with nothing much to write about despite being so busy when the tones go off and we are sent to respiratory distress -- SEVERE, according to the dispatcher. En route we are updated Respiratory Arrest. I'm sitting in the back so I start setting up. The med radio dispatcher says it is a male patient so I take out a number 8.0 tube, attach the capnography filter, insert a thin stylet, attach a 10 cc syringe, and then set up a saline lock with flush, a Venaguard, a #20 catheter, an alcohol wipe and put them in my pocket.

On entering the house I hear, as many times in the past, "No shock advised, continue CPR." I follow a long 02 cannula into the den where a man lies on his back, his mouth open, attached to a defibrillator, looking quite dead. It has been ten minutes since we were dispatched.

"I felt a pulse when we got here," a first responder says. "But I can't now."

"Start CPR," I say.

Since he is already on a defibrillator, I have my partner attach him to our monitor with just the basic leads. He is in for all intents and purposes asystole with only a rare occasional complex. The tube goes in easy, and the monitor shows the cardiac oscillations of CPR against the lungs causing a small tidal volume without bagging.

(Since I have started attaching the CO2 line to the ET tube before actually intubating I have been fascinated by this initial phenomenon that goes away as soon as I give my first ventilation. To me it is proof that CPR by itself does produce a small amount of ventilation on its own.) My initial ETCO2 is 32, but it quickly declines.

The first responder is doing okay CPR, but I tell him to push faster. We are going to do the new CPR, I say.

While I am going for the IV, the apnea alarm goes off, and the number has dropped to 6 with a very small wave form. The alarm is very annoying. I stopped what I am doing and reconfirm my tube. The lung sounds on both sides are decreased, but there is nothing over the belly. There is good compliance. I undo the ET holder and go back in and visualize. I'm in, the tube is sitting through the chords. The new commercial tube holder we are using snaps when I try to retie it, so I have to get out tape to fasten it. The number stays low. Pound harder on the CPR, I stay. I tell the responder bagging to just squeeze the bag a little. I go back and get the IV, and for the first time remember I carry Vassopressin, and so instead using epi I push in Vassopressin and follow it with an atropine. Still nothing on the monitor. The ETCO2 is only about 5. It seems to me it should be higher. I shut the monitor off and turn it on again to see if it needs a reset. Same reading. I put on a new capnography filter. Same deal.

"Excuse me," a man says coming in from the other room where one of my partners is getting information from the family. "I'm the family pastor, and his wife doesn't want anything done if he can't be helped. He's been very sick."

"Well, I can't stop now. I have protocols to follow, but if we can't get him back soon, I am going to call it."

"She really doesn't want him to be on a machine. It is his wishes as well."

"We're doing the best we can," I say. "We just have to finish out our protocol and if we can't get him back, we won't transport."

He is still, asystole. I push in another round of drugs and then a third.

The responders doing CPR are looking a little tired. I take over, and I really start pounding, and as I pound I am getting for the first time, good complexes on the monitor. "Like this," I say. "You really have to pound it. Fast and deep."

The pastor reappears now with a phone in his hand, saying "It's his doctor, he wishes to speak to you."

I let one of the responders take over CPR and go in the other room to talk to the doctor, who tells me the man has terminal lung cancer and they had spoken about making him a DNR, but thought he had a few more weeks at least before they had to worry about it. I tell him I am sorry for having to work him, but no one said anything to us about his being a possible DNR or having terminal cancer. I explain that I am running through my algorithm and than I don't anticipate transporting. He seems pleased with my explanation.

I go back in the other room and see the first responder is doing CPR to beat the band. I announce that I am going to call the code and I have him stop. I look at the monitor. There is a rhythm.

The ETCO2 is still only about 8. I check for pulses. Nothing. Well, I guess we stick at it a little longer I say.

The cop who is sweating says how about getting a board and getting him on the stretcher. I explain about the terminal cancer and how this is probably just the drugs being circulated by the good CPR, and I am not going to transport unless I get a blood pressure.

He says he understands and goes back to the CPR.

I do another round of drugs. After another five minutes we stop and check the monitor. It looks like he is back to asystole.

Okay, let's stop, I say.

Blip, blip, blip. The rhythm picks up again.

This goes on and on. Every time we stop, the rhythm starts again. His end tidal is up to 10. Nothing to sustain life, but I can't call him with a rhythm, but at the same time I don't want to transport him because after all he has terminal cancer, his pupils are fixed and dilated, and his family doesn't want anything done.

We stop again. I watch the rhythm to see if it will brady down. I am prepared to call him if it does. I am tired and my eyes seem hazy. I think I am seeing things. The man looks a little blurry.

"Is it just me or is he breathing?" the woman at the head doing the ventilations says.

"He's breathing," I say.

His end tidal should be much higher. I can't feel a pulse, but he is moving his chest.

I swear silently. Now what do I tell the family and the doctor. One of my partners has already hinted to them that we are winding down that no survival looks possible.

The man is dead, but he is not dead. We've been working him forty minutes, his pupils are fixed and dilated, he has terminal cancer.

I look at the monitor and he starts to brady down. Start CPR again, I say as it goes flat.

We do two minutes of CPR and I say, if he's flat line, I'm calling it for real.

We stop. He has a rhythm.

I want to just call him, but what if he starts breathing again after we put a sheet over him.

We go back and forth asystole, PEA.

The first responders are drenched and exhausted even with switching CPR every two minutes. They are looking at me for a resolution. Either call him or transport him.

Finally, I do what I probably should have done earlier, I call the hospital and thankfully get a veteran doctor, who I explain the story to. I ask for permission to presume. "Yes, by all means," he says.

When I return, I tell them to stop CPR. I look at the monitor.

At last:

I call the time. Nearly an hour after we started.


Some lessons learned and thoughts.

1. I firmly believe a family ought to have the right to say enough is enough. Screw me and my regulations and protocols. A family's wishes ought to count for more than they do.

2. Okay CPR is bad CPR. As a medic, I need to make certain all CPR is pounding hard, fast and deep, exhausting John Henry versus the steam drill CPR.

3. I think what happened was I loaded the guy up with drugs and only when we started really hammering the CPR did they get circulated well, and then he was getting slammed with mega dose vassopressors.

4. Despite the brief period of respirations, I think most of the monitor activity was just electrical.

5. The LP 12 apnea alarm is a pain. It can't be programmed. It goes off when it can't detect a breath, even though the ETCO2 is reading 3-7 and there is a small wave form.


All told we worked the man for nearly an hour. While it was physically draining for the first responders. It was emotionally draining for me -- trying to do the right thing, trying to decide what the right thing was, and then just when I would think the issue had been settled, he would come back alive or psuedo alive.

The family and the pastor were very gracious and I guess it worked out in the end. The man passed away at home. No trip to the hospital. No living on a machine.