File under: Something New Every Day
The group home patient with a history of mental retardation was found unresponsive in his wheel chair. The small frail man has significant kifofis. His body is flaccid and he cannot even hold his head up. The quick story is he was found that way this morning. Normally he is alert. He seems to be having periods of apnea, but his color is good and he has a decent radial pulse. I'm guessing CVA. "He's a no compression," the aide says.
"A DNR?"
"No, he's no compressions only. He doesn't have a bracelet."
"But he's a DNR?"
"You can breathe for him."
"But I can't do compressions?"
"Right."
"So he's a DNR?"
"No, he's a full code, just no compressions. He has osteoporosis and compressions won't work. They'll break his ribs. We have a doctor's order."
"I'll need to see that."
They produce it:
"Notice of "No Chest Compressions" for "Patient name"
In the event "Name" goes into cardiac arrest, immediately call 911 and start rescue breathing. When emergency personal arrive, inform them of no chest compressions and give them a copy of the Dr's order for no chest compressions along with this notice.
This has been agreed upon by "state agency responsible for patient" and ordered by his PCP.
I shake my head. I don't argue with the aide, but I am thinking to myself -- this isn't going to fly. Our state is pretty rigid on its DNR/resusitation order forms and this one -- while being agreed upon by a doctor and a state agency -- is most certainly not valid. Additionally it is over two years old. Our DNR orders must be updated every six months.
I think it is a way around what I am told is a rule that no patient in the care of the state can have a DNR order, so this is not a DNR order, per se, but a half-assed resucitation order. I suppose it would be okay if I took a scapel out and sliced the patient open and reached in an did open cardiac massage just so long as I wasn't doing compressions.
Fortunately, the patient doesn't code on me or get much worse than an occasional apniec pause that responds to stimulation. At the ED, I relay the info to the hospital staff who all admit they have never seen such an order. I later talk to a hospital staffer who tells me of a lengthy conversation he has with the case worker. The case worker tells him he can defibrillate the patient repeatedly, but can't do compressions because they will break the patient's ribs. He doesn't seem to understand that you need to do something to circulate the blood. You can intubate and defibrillate, the case worker says again.
***
My preceptee, who wasn't with me that day, asked what I would have done had the patient coded. I would have called medical control, I said. I would have said, "Doc, this what I got, Whaddya think?"
That's why they get the big money.
