Difficulty breathing at the nursing home. The officer who arrives on scene tells us to keep coming lights and sirens.
The room in the nursing home is sparse. The patient, a large man in a hospital johnny, is pale and diaphoretic with a low grade fever and edema in his abdomen and extremities. His eyes follow me slowly as I assess him. His lungs are full of rhonci and probably some rales mixed in. It all sounds crappy. I ask him if he is in any pain and he says his back hurts. He says the bed is uncomfortable, and he is too weak to position himself better. With a nonrebreather on he is only SATing at 90%. His heart rate is in the 130's. The nurse comes in with the W10 and I ask what kind of respiratory history he has. None, she says. He has metastasized cancer into his bones. He just came back from radiation. He's only been here a few days. He just started breathing poorly an hour ago, although he has been edematous since he got here. Also, he hasn't peed for a while. And he's a DNR.
Whenever I hear the DNR status, I admit, I feel a small, if sad relief. I won't have to work as hard on this one as I thought, I think. I check quickly through the paperwork, verify the DNR order, and then slip the papers in my pocket. "We'll get you over to my stretcher now," I say, "and try to get you comfortable." The police officer helps us move the man who is quite heavy. I try to get his head under the pillow comfortably, but as it is, his feet are hanging off one end of the stretcher and his head the other. I sit him up to aid his breathing.
When we put him in the back off the ambulance, I look up at him and think for a moment that he has coded. His head is still and cocked slightly back with his mouth open. I see no chest rise. "Stimulate him," I call to our third partner, who rubs his shoulder and he lifts his head slightly and looks at her.
I tell my other partner to just head to the hospital. He is a DNR, but I don't want him to die on us, so I tell him to go lights and sirens, but easy.
And dying is what this man is doing. His breathing is becoming agonal. The light is leaving his eyes. His lungs are slowly filling with more fluid. I can't hear a blood pressure and he only rouses if we stimulate him. I think for a moment about calling the hospital and requesting permission to use some aggression in my treatment, but I can't figure out quite how to ask, plus I know once I mention he is a DNR, they will likely say no because what he needs is to be intubated. He is too lethargic for CPAP, doesn't have the pressure for nitro. My only option is probably dopamine. I use the electronic cuff and it comes back with a BP of 120/90, which I do not believe. I do it again and it reads 80/40. I try a manual again and hear nothing. After I pop in an IV, I look up at the man and his eyes are completely glazed. His mouth is moving in the classic fish out of water manner. I shake his shoulder and ask how he is. He looks at me and just nods.
When I call the hospital, they ask to verify if the man in indeed a DNR. Yes, I say. Very good, they respond and I can tell they are feeling the same as I did initially. Okay, he's really sick, but we don't have to devote full resources to him.
It's awful watching somebody die like this. Wheeling him down the hall, I see nurses and other EMS people looking at the patient. I can see they are thinking. He's not doing too well. One EMT looks at me and gives an expression as if to say, how come I'm not assisting his breathing. "D-N-R," I mouth and he nods.
They assign us a room and I relay the story to the nurse and show her the paperwork. She goes to get a doctor. My partners and I try to get the man comfortable sitting up on the bed. I rub his shoulder and again he opens his now blank eyes. "You all right?"
He nods, gives a small tired grunt and closes his eyes.
The doctor comes in and I haven't gotten thirty seconds into my report when the man's daughter is led into the room by a registrar. The doctor turns to her and she is crying already. He asks what her wishes are and she says she doesn't know. She wants to know how he is, and the doctor says, he is not doing well. The doctor sees that the DNR is only a week old and tells her it represents her father's wishes and that this is probably what they should honor. I'm standing in the corner watching. It is a heartbreaking scene and an urgent discussion, but at the same time I am aware of something else going on. The man is passing. I don't know if he will be dead in the next minute, but I think his ability to respond is slipping away rapidly. I don't want to interrupt the doctor and the man's daughter, while they decide, but I feel I should speak up. The doctor is staring at the woman as she sobs and shakes her head. "I don't know. I don't know," she says.
I wait. I wait.
Finally, I break in. "Excuse me, I hate to interrupt," I say. "Come, take your Dad's hand," I say. "Tell him you're here. Talk to him. He can probably hear you."
She takes his hand. His eyes are closed. His breathing is shallow, irratic. She kisses his head. "Dad. It's me. I'm here. Can you squeeze my hand?"
I look down at where she holds his hand. There is no movement.
