Wednesday, October 20, 2004

Chronic Dyspena

Hello all, good to be typing to you again. Here is another case study for your input.

Can't breathe. Consider this:

You are called to an assisted care facility (nursing home) to transport a patient to the local ER for difficulty breathing. When you arrive on scene you are met by the staff that tell you that "Mary" has been having more trouble breathing than usual.

As you approach Mary and try to talk to her she presents as an elderly female in her mid to late 80s with a Hx of COPD and heart failure. The staff tells you that her SP02 has been 89-90 % all week and now she is down to 74-79%. She cant complete even the shortes sentence and is working hard to breath.

You follow your local protocol and take mary to the hospital, providing her O2 and a breathing treatment. On 15lpm of O2 you manage to get her to 93-94% after a breathing treatment. IV established at KVO. Monitor shows sinus tach at 140

About 4 hours later the ER calls you to return Mary to the nursing home. When you arrive you get the report from the nurse and you load Mary into the back of the squad.

Here is the problem. Mary is returning to the nursing home on her standard 2 lpm O2 by cannula. She now has DNR papers. She might have had them before, but they were not presented to you at the nursing home. She tells you that she feels a little better but her heart rate is in the mid 120s and her color is ashen and grey at the hands and arms. She is still breathing with pursed lips and appears to be struggleing very hard to maintain air. SP02 will not come up above 88% at 2lpm.

What are your thoughts? Do you return to the ER and tell them that she is still having trouble? Surely they know, they are releasing her to go back. Do you continue your transport to the nursing home and transfer care to the resident nurse? Surely they will send her back out, because she appears worse now than when she went in. Do you call your supervisor for advise? Do you call your medical control and ask for clarification?

You know she has a DNR, therefor you KNOW what you can and can not do. You KNOW that she wont be able to sustain life long working that hard to draw breathe.

So now it's your turn. What would you do?


Nurse Mia said...

I strongly disagree. I think you need to ask Mary how she is feeling. Tell her, "It looks to me like you are still having a hard time breathing? Do you feel comfortable going back to the nursing home?" She may have a DNR, but that does not mean that she should be discharged without her symptoms being adequately treated. If her dyspnea is that bad, she needs to stay at the hospital until an adequate medication regimen can be establish to keep her comfortable at the nursing home. Or in the other extreme, she may need to die in the hospital on a morphine drip if that is necessary to cover her dyspnea. I *love* the thought provoking situations you describe in your posts. I hope you'll keep it up.

Carsten said...

Well the problem is that it is chronic medical problem that a return trip to the ER will not fix. The doctors were aware of the patient's respiratory status upon discharge so they must have been satisfied that they got the patient over the crisis back to their usual state of health, even if that usual state of health isn't that good. Yes, you may be taking the patient back to the nursing home to die, but she is clearly ok with that, as evidenced by her signing a DNR. Yes, a DNR does not mean Do Not Treat, but there needs to be a careful balancing of patient wishes, probable outcomes and cost. Yes, I said it, cost. We spend extraordinary amounts on generally fruitless end-of-life care that could be more effective if allocated elsewhere.

monkeyboy14 said...

I like the site but i think you should post alittle more. I live in metro detroit. Im a 14 year old male named andrew. Im in the US Naval Sea Cadet Corps. Im my divisions "Doc". I want to be in the navy and go FMF. When i get out i want to become a FDNY paramedic. Well come by my site its nice.
Well im out.

Doc Venier

BiffMalibu said...

We are small cogs in a BIG machine. You are correct in everything you are saying and feeling. In the end, the answer is SO WHAT and NO ONE CARES WHAT YOU THINK. Not the hospital, not the nursing home. Therefore, you do your job, take her back to the concentration camp, er, nursing home dump her, and expect to get called back in probably an hour or less for the same damn problem. Of course medicare will be more than happy to pick up the tab for all this and everyone will line their pockets (except of course, US).

PunkClown said...

If Mary has a DNR order then perhaps appropriate palliative care needs to be set up for her. ED is probably not an appropriate place to treat a patient whose condition is never going to improve and who is not for active resuscitation. She does however have the right to be free from suffering and inabilitry to breath without effort is suffering. The nursing home in consultation with her usual treating doctor/LMO should put in place appropriate treatment plans to address the problem and help Mary in what seems to be end stage COPD. If they can't cope with that task then she may need placing in a higher care facility that can deal with these problems. Either way repeatedly and fruitlessly using ambulance and emergency department resources is doing no-one any good, least of all Mary.

Tristan said...

Surly I feel uncomfortable second guessing those who work in scrubs, or the docs in the ED. It seems to me whenever I ask for clarification I get put into my place. I would call my supervisor for advice, and explain to him/her that I feel uncomfortable with the situation. And again, ask the patient how she feels. If she feels ill at ease, that’s reason enough to pull a 180 with that wheelchair.


JT said...

Just found your site and found it nice and provoking.
Anyway onto your post. I have been in the exact situation regarding this issue before. So what did I do. Well techincally as an EMS provider you are under a Dr's Liscence. Yes we are certified but we ride the skirt tails of another mans work. So the moral is. You do what the Dr ordered. You take her back to her nursing home. However you are a person who cares, and you realize that she isnt going to be staying long, so you stay in the area... go grab lunch... etc.
But in all seriousness this is what we did. It was approx 2300H, and the ER just wanted to free up a room. Our patient was still in obvious distress, her SaO2 was around 82%. Though they did have her on a NC. It was however not hooked to any O2 supply. I mentioned to the nurse that was discharging her that her Sats were low (I have a small finger Nonin Pulse ox with my stethascope). The nurse looked at me and said clearly. "Shes fine, the dr discharged her, so you better not refuse." So we loaded the PT up and transported her the whole 2 miles to her nursing home. The RNs at the SNF were not happy with her condition, and asked why we brought her back. So we told them the truth, we were ordered to by a DR. WE have to do what a DR orders. We casualy let slip that if their DR ordered her back to the ER we would have to do so, and we would be willing to wait down the block for them to call us back.
Yea its walking the fine line, but we cant really go against a Drs orders if you want to hang onto your cert for long. So I have found its the ability to walk the VERY FINE LINE, about doing what your allowed and whats right.
Hope this helps.

signs of heart attack said...

When i get out i want to become a FDNY paramedic. Well come by my site its nice.
Well im out.