Monday, July 07, 2008

Hi yal...Can we just print this out, post it on the fridge, and be done with it?


Can we just print this out, post it on the fridge, and be done with it?
You know it's going to be a bad day when you walk in and somebody immediately calls a code.

Except this one wasn't a code. It was, technically, a "Rapid Response Team" situation, but given that the patient ended up intubated and 100% ventilated, it was a code. But I'm getting ahead of myself.

A lot of families hate the idea of signing a DNR (Do Not Resuscitate) on Grandpa or Grandmother. They think that a DNR means "Do Not Treat" or "Ignore" or "Hasten the Death Of" rather than what it actually means.

To wit: Grandpa was not in the best of shape when he came to us X days ago. He'd had two major ischesmic (clotting) strokes and a large, horrible bleed in his brain and was breathing irregularly and gaspingly when he was delivered to us by a relieved ambulance crew. Grandpa hadn't moved on his own or responded to anything short of pretty intense pain for days. Grandpa was a full-code, or a "Do anything and everything to save this person's life" when he came to us.

Let me be totally clear here: Grandpa was in no way, shape, or form, ever going to get better. The best neurologists and neurosurgeons in the country had already determined that. Okay? Okay. You got it. Grandpa's gonna die; the only question left is how.

So I wander in to work, already tired and strung out from the sort of weekend nobody wants to have. After I'd been there not three minutes, somebody hollers out of Grandpa's room to call the I did. Despite not being on the clock and not officially there yet, I called RRT. (My compassion continues to overwhelm me, as I'm sure it does you.) Then I wheeled myself and the code cart into the room and took a good look at what was going on.

What I saw was an 87-year-old man in the last stages of life. Agonal breathing, cold extremities, you name it--this guy had a bus to catch and was running after it as fast as he could. Family, being in the room, was flipping out and demanding we "do everything".

So we did. Those of you with relatives who are in the "do everything" camp might want to cut this bit out and show it to those relatives. Here's what we did:

We started three large-gauge IVs in the man's arms and legs. We called an anesthesiologist (who just happened to be wandering past) into the room to intubate, as Grandpa was not breathing well on his own and bagging him (ie, providing artificial respirations with a manual device) wasn't working.

The anesthesiologist had to try four times to intubate Grandpa. His airway had been damaged by people suctioning it out in a ham-handed fashion. When I finally got a 16-French (read: small) bougie up, Anesthesiologist guy managed to get it down Grandpa's throat at the cost of a whole lot of blood being shed from those damaged throat and airway tissues. There was blood everywhere.

At that point, Grandpa stopped breathing on his own, following the natural course of things, and we had to do chest compressions. You could hear the sound of his ribs breaking outside the room. I broke at least three of them myself, straddling this ancient man and counting "one-and two-and three-and...." and trying to get three inches depression with each push.

There were people bagging and cursing and blood flying everywhere as Grandpa's arms jerked with the compressions, ripping the needle that the respiratory guy was using to draw labs out of Grandpa's arm.

We pushed drugs you've never heard of more times than is interesting to tell about in an attempt to get a heartbeat, *any* heartbeat, on this man. You can't shock a flatline, and we didn't...but we didn't get much of anything out of him. IVs in his arms blew as we pushed drugs too fast, raising enormous discolored lumps on his arms. We replaced the IVs with ones in his legs and a central line in his groin, the only place we could find a vein that was engorged enough to poke.

Every time the doc who took over compressions from me pushed, more blood would squirt out of the various holes we'd made. This was not natural bleeding; this was artificial bleeding from a dead person that was caused by us forcing his heart to squeeze.

Finally, finally, with family in tears in the hallway, we managed to get a shockable heartbeat. And finally, finally, we put on external pacing pads that would deliver a mule-kick through the man's shattered chest every few seconds in an attempt to remind his heart to beat. And finally, finally, *finally*, with blood bubbling out of the breathing tube (from the broken ribs) and oozing out of the various holes I and my colleagues had made in him, we managed to get him stable enough to take him up to the ICU and put him on a ventilator to breathe for him and drugs and drips to keep his blood pressure stable.

That, my friends, is what a code is like.

That is what you're wanting for your family member.

And this was a clean code. That's the horrible thing: we only coded this guy for a total of about five minutes; the rest was all pre-code intubating and sticking.

If you come in with a DNR, I will bust my balls to save your life. If it comes to it, though, and you stop breathing on your own, I will not torture you in order to get a few extra minutes of fake "living" out of your cooling carcass.

If you come in as a full code, I'll bust my balls to save your life, even to the extent of breaking your freaking ribs in the process. I'll hate it, but I'll do it.

Talk to your families, people. Decide how you want to go. But please, please be aware of what you're asking when you ask for it.

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