Dilemna

Busy Day. Started off with a man feeling weak who we discovered was in a rapid afib. Since the new ACLS recommendations for rapid afib are "seek expert consultation" and since he was stable, I held off on the cardizem.

We did an old woman not feeling well, a man who had a seizure, a nursing home fall, and this call:

Dispatched to a nursing home for a woman in respiratory distress. The nurse meets us at the door and says the patient's pulse SAT is dropping. "She was in the 70's, then we put her on a nonrebreather at 4lpm, and she is now down to the 30's."

Do'oh.

We try to explain that unless you have the 02 up to 12 or so, she is just going to be rebreathing her own carbon dioxide. You might as well put a plastic bag over her head. But she needed a mask, the nurse says, her SATs were dropping. We try to explain, but she doesn't get it.

I look at the patient and ask what her code status is. She is taking shallow gasping respirations. They say she is a DNR, but a do intubate. Out in the ambulance while she is still breathing I intubate her. Inside they had a BP of 50/20. We can't hear an BP or feel a pulse. She is now in full respiratory arrest. On the monitor she is in a bradycardia in the 40's. Her capnography is 20, then slowly goes down to 14. We should be doing compressions, but she is a DNR.

I find myself in a little bit of a dilemma. I intubated her when she still technically intubatable, but now that she needs resuscitation do I stop bagging her? I decide to call medical control for permission to cease, which they give me. I detach the ambu-bag. Her rhythm stays steady in the 40's. She has no pulse or detectable BP. I stare at her. My partner throws a sheet over her. But then it suddenly looks like she is moving imperceptibly or is it just the shaking of the idling ambulance? I pull the sheet back. This is very confusing to me. She is a pulseless, apneic DNR. Her pupils are fixed and dilated. But her rhythm holds steady and her capnography actually rises. Maybe if I had a Doppler it would show she had a BP, and maybe even though I can't see it she may be breathing imperceptibly. She has to be if she is generating a capnography of 14. I would think anyone with a capnography of 14 has to have some kind of perfusion going on. Admittedly I could use a course in capnography because I am still new to it and have a lot of questions. But what should I do right now? I am uncomfortable putting a sheet over the head of someone who may not be completely dead. I don't know whether to start bagging again or what. If she wasn't a DNR, I'd be doing CPR. I look at the monitor hoping for the patient to brady down, but she stays strong and steady at 40. I call the hospital back and say, "About that presumption..." I tell them I am uncomfortable putting a sheet over her just yet, and will bag her, but withhold compressions. Just then she starts to brady down, and by the time I am at the hospital, she is almost completely flat line. I have stopped bagging her again. The doctor calls her dead and that's that.

***

The doctor later tells me that he has just read her recent discharge notes from several days ago she was supposed to be a DNI/DNR. He says I had to go on what they told me.