What would you expect to be done?

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So one of the other questions we have to answer is how far does the trauma
team go with a patient that is no longer dying of cancer but had the DNR
form written back when she was? In the situation the "30 pages" serves as
being more confusing then covering every angle. Remember this patient was
living in her own home and taking care of her own ADLs. 

I realize "talk to the family" is going to be a common answer, but lets
think about the Golden Hour and the direct to the OR patients. We know
family is often not available in that time. The daughter I had with me
refused to make a decision until she had talked with her sister who was not
answering the phone.

In my head, without a CT, I couldn't know if this was a mortal injury, or an
"easy" fix. 

So, how far do you go with a trauma patient who has a DNR?

-----Original Message-----
From: Gross, Ronald [mailto:Ronald.Gross at baystatehealth.org] 
Sent: Monday, October 25, 2010 1:38 PM
To: 'trauma-list at trauma.org'
Subject: Re: What would you expect to be done?

WHOA!  No one is second guessing - we were asked "what would YOU do?" And we
responded with exactly that.  No more, no less.
Typed (poorly) with my thumbs on my Blackberry!

----- Original Message -----
From: Forrest Robleto [mailto:farcpr at gmail.com]
Sent: Monday, October 25, 2010 03:28 PM
To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
Subject: Re: What would you expect to be done?

Thanks Pret.  It's often easy for folks with eight or more years of medical
education to second guess an EMT with 115 hours of education or even a
paramedic with 2 years.  Easy but certainly not fair.

V/R

Forrest Robleto, NCEE
R House Health & Safety
www.RHouseTraining.com
FRobleto at RhouseTraining.com
609-792-9047






On Mon, Oct 25, 2010 at 3:24 PM, Bjorn, Pret <pbjorn at emh.org> wrote:

> In fairness, it's too easy for most of us to pretend that "DNR" has a
> single meaning which is evident, absolute, immutable, and applicable
> even to unforeseen circumstances -- like trauma.
>
> Whatever the spirit of the document, I think we should forgive
> prehospital providers for deferring the invocation of a DNR document to
> the relatively safe and resource-rich environs of the local hospital.
>
> After all, somebody called an AMBULANCE...
>
> Pret
>
>
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Gross, Ronald
> Sent: Monday, October 25, 2010 10:06 AM
> To: 'Trauma-List [TRAUMA.ORG]'
> Subject: RE: What would you expect to be done?
>
> Unless I missed something, the patient was being transported with her 30
> page DNR document.  Seems like a pretty iron-clad set of instructions by
> the patient.  The question now becomes do you read the document in its
> entirety?  Heck NO.  Do you take the spirit of the document as your road
> map?  I would.  And have.
> RIG
>
>
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Krin135 at aol.com
> Sent: Monday, October 25, 2010 10:02 AM
> To: trauma-list at trauma.org
> Subject: Re: What would you expect to be done?
>
> I've got to agree with Bill in general. There are only a few cases  when
> I
> would support an EMT not starting basic life support in this kind of
> case,
> and all of those would involve situations where the locale has a strong
> DNR
> policy, including some form of bracelet or tag that the patient is
> wearing,
>  along with family concurrence.
>
> Otherwise, including cases where the family is NOT exhibiting strong
> concurrence, start life support ( up to and including ALS airway
> measures), and
> transport to the nearest qualified ED for further  evaluation.
>
> I believe that case law here in the US indicates that if ANY relative
> in
> contact with the medical team protests the DNR in a time of crisis, it
> is
> best to at least start treatment, and then discontinue it later.
>
> ck
>
>
> In a message dated 10/25/10 08:46:14 Central Daylight Time,
> brombwi1 at memorialhealth.com writes:
>
> I am  going to disagree with your disagreeing :-)  the house or the back
> of
> the  rig is no place to be making irrevocable decisions. Remember that
> although the  enactment of a formal Living Will requires all of those
> things you
> note, the  revocation requires nothing more than the statement of the
> patient or their  surrogate acting in the patient's best interest. it is
> unfair
> to require EMT  level staff to make instantaneous life or death
> decisions in
> the absence of  protocols to support their decision.
> Bill Bromberg
> >>> "Gross,  Ronald" <Ronald.Gross at baystatehealth.org> 10/25/2010 6:57
> AM
> >>>
> I am going to have to disagree.  Unfortunately it is not  our right or
> privilege to be comfortable with a DNR paper.  It either  exists or it
> doesn't
> exist.  When it does, it has been drawn up by a  lawyer and the patient,
> and
> signed by both in the presence of a witness, under  the free will and
> hand
> of the patient.  That is all you need to  know.  And as one who has
> taken
> many pre-hospital bus and helicopter  rides, I would challenge the ivory
> tower
> concept - as would our friend  Mark.  Regardless of the tower you reside
> in,
> or fall from, we all MUST  practice the same - and that puts the
> patient's
> wishes ahead of all, and that  includes our personal comfort levels,
> family
> wishes, and any other excuse we  might want to make when ignoring the
> wishes
> of the patient we have been given  the privilege to care for.
>
> 'Nuff said,
> Ron
>
>
> -----Original  Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Blueflightmedic
> Sent:  Saturday, October 23, 2010 1:25 PM
> To: 'Trauma-List  [TRAUMA.ORG]'
> Subject: RE: What would you expect to be done?
>
> To  tease a friend gently, Mark is indeed ivory towered; few of his
> patients
> arrive speaking.
>
> You are dealing with a rapidly  deteriorating patient, a dismayed
> relative
> right on your lap, a set of  contradictory protocols and what may or may
> not
> be a valid DNR.
>
> I  agree entirely with your actions; do all to preserve life such as it
> is
> until such time as you can get control, get some other opinions and have
> an
> idea what you are dealing with.
>
> So airway and breathing control  to your max allowed - you can RSI and
> as
> you
> say, the call went easy once  you did that.
>
> There is no such thing as informed consent in emergency  medicine and
> while
> there might be a valid DNR out there somewhere nobody  has shown me one
> that
> I am comfortable with.
>
> You have to be seen to  be doing 'something' that looks helpful for the
> relative whose dismay is  rapidly becoming distress, and you did that.
>
> You have a silly set of  rules that need review about tubes, trauma
> centres
> and the like which need  bypassing or a get-out clause. A tube can
> always be
> taken out again but you  don't get a second chance if you vote no first
> time.
>
>
> I think you  did brilliantly and I would congratulate you if you pitched
> up
> at my front  door for skilful handling. Why are you losing sleep?
>
> -----Original  Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Mark Forrest
> Sent:  23 October 2010 09:50
> To: Trauma-List [TRAUMA.ORG]
> Subject: Re: What  would you expect to be done?
>
> Lori
> Easy to be critical for those not  there but you faced some difficult
> and
> morale issues.
> As an intensivist  I guess if you rang me with this story from the ED I
> would
> point to the  history of events, poor clinical condition, liklehood of a
>
> very
> poor  outcome and the inevitable requirement for ventilation after RSI.
> All
> in  the face of strong evidence that it is against the patients wishes.
> I
> would  then refuse ITU level support. But that's me in my critical care
>
> ivory
> tower.
>
> Gold standard is obviously a tube, a scan then some  effective decision
> making based on all the evidence.
>
> I guess if you  had called me from the back of the bus, in the light of
> her
> expressed  wishes, I would have said no tube, keep it simple, basic
> airway
> care as  best you can, CT on arrival and then decisions.
>
> Whatever we do, I  cannot see a good out come for this lady.
>
> DNRs are something fairly  new to our fire responders and we currently
> suggest, if in doubt then do  the best you can, as you clearly did.
>
> An interesting and increasingly  common dilemma.
> Regards
> MarkF
> Uk
>
> Sent from my iPhone
>
> On  23 Oct 2010, at 01:50, "Lori Richmond" <lrichmond at emprep.net>
> wrote:
>
> >
> >
> >
> >
> > I have been doing my  job for a while.  It is not difficult, but it
> takes
> > practice, so  when I found this list I sort of "geeked" over it
> because I
> am
> >  excited about finding something that gives me an edge in the field.
> We
> don't
> > have a 7-9 years learning curve so when we are doing our  jobs there
> is
> very
> > little oppurtunity for us to ask, what should I  have done better. So,
> I
> hope
> > this is appropriate use of this  medium. I look forward to
> constructive
> > critisim.
> >
> >
> >
> > A couple years ago I was called to a private residence of a  70 F who
> was
> > found by her daughter. Her daughter talks to her mother  every night,
> the
> > patient did not answer her phone the night before so  first thing in
> the
> > morning the daughter came over to check on her,  found her laying on
> the
> > floor, dressed in her pajamas, an evening  snack spilled on the
> hardwood
> > floor. Daughter called 911  immediately.
> >
> >
> >
> > I arrived to find the fire  department (ALS non-transporting first
> responder)
> > holding c-spine,  stating patient is breathing irregularly, no signs
> of
> > broken bones,  responded to loud voice with garbled speech when they
> arrived.
> > She  is laying on her side with pressure sores filled with fluid on
> her
> right
> > side. She is incontinent of urine. Appears to have a  thick sticky
> saliva
> > that we are suctioning from her mouth. This is  when her daughter
> informs
> us
> > that she is a DNR. "She doesn't want  to be on a ventilator."
> >
> >
> >
> > On secondary exam I  found blood in her right ear canal. This is when
> we
> > really stepped up  our game. Upon moving the patient to her back onto
> a
> LBB
> > her mentation  changed to non purposeful movement with painful
> stimuli.
> The
> > daughter  was with us the entire time and once we got into the
> ambulance I
> > was  able to examine the DNR document, which was instead a 30 page
> POLST
> with
> > Power of Attorney. At the point I thought we had a DNR I  sent the
> First
> > Responders on their way and started enroute to the  closest facility
> (not
> a
> > trauma center).
> >
> >
> >
> > ***in our area we operate under a trauma system patients that meet
> trauma
> > entry criteria may pass a closer facility enroute to a trauma
> hospital.
> > Usually DNR patients would not qualify for trauma system  entry****
> >
> >
> >
> > I started engaged more with the  daughter while we driving, all the
> while
> > suctioning, inserting oral  airways, starting IV's, ect., she is
> having
> > second thoughts, the  patient starts profusly vomiting and decorticate
> > posturing. I send my  driver towards the trauma center and ask for
> another
> > responder to meet  us enroute.
> >
> >
> >
> > The daughter is watching me  not able to suction fast enough, the
> patient
> is
> > drowning in her  vomit. She is on the phone with her sister in the
> back
> while
> > I am  suctioning and drawing up RSI meds going back and forth in my
> head
> if
> >  I'm going to RSI this patient, and I still have to decide about
> making
> this
> > a trauma entry.
> >
> >
> >
> >  This POST form was created 2 years ago when she was treated for
> somekind
> of
> > CA. She has been in remission. She lives alone. Her  home was clean
> and
> well
> > managed. She drives. And apparently makes  her own meals.
> >
> >
> >
> > At the hospital I was not  looked on favorably because I 1. Intubated
> a
> DNR
> > 2. Made a cancer  patient a trauma entry and I will admit at some
> point in
> > the confusion  I said to the daughter 3. There is a better way to let
> her
> die
> > then  this.
> >
> >
> >
> > BTW: The RSI went quite smoothly and  after the patient was intubated
> the
> > rest of the call was very  easy.
> >
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