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