Thursday, February 7, 2008
Blowing Through Cylindrical Objects Can Be Good For You
"Attention all personnel. Attention all personnel."
The hospital operator's voice on the overhead paging system pulled me awake out of a weird dream early this morning.
"Code Blue, CCU. Code Blue CCU."
I looked at the neon red digits on the bedside clock. 4:40.
I made my way to the CCU and looked for signs that it was a real code situation. The back door of the CCU swung open after I punched in a numerical code, and I saw a family member leaning on the nurses' desk. Beyond him, a curtain was drawn across the entrance to one of the bedside areas. I could see numerous pairs of feet under its bottom fringes as well as the bright red, metallic outline of the code cart.
I slipped into the area behind the curtain, now crowded with clinicians in scrubs and white coats. An elderly woman lay on the bed, her torso uncovered, a tangle of wires attached to her chest. The respiratory therapist was mask-ventilating her at the head of the bed. I squeezed past them toward the person keeping the code record, identified myself as the anesthesia attending, and offered help if needed.
"Oh, thanks for coming, doc, but she's a DNI."
"No, a DNI - no intubations. We can do the 'R' part. Thanks anyway. We got it covered."
"Allrightythen," I said.
On my way back to the call room I stopped to chat with one of the nurses.
"So, how does that work?" I asked her. "People want to be resuscitated but not intubated? Isn't oxygenating and ventilating them a key part of the resuscitation?"
"Yeah," she said. "But people think they can just get CPR and shocked by a defibrillator, and maybe some drugs, and come back. They don't understand."
"Hmm," I said, going through, in my mind, an imaginary resuscitation without a secure airway. Not fun. And possibly less effective.
"People don't want to be hooked up to machines for a long time," the nurse continued.
"I can certainly appreciate that. But it just doesn't make sense to me to eliminate the very first step, the least violent step."
It wasn't that I wanted to be needed at that code. Frankly, I was happy to be ordered back to bed. But something bothered me. The discrepancy. In the past I've often seen DNI/DNR orders together. I haven't often come across DNI/R's. If people wanted part of a resuscitation but not all of it, it made me feel there was something half-hearted going on. Did the patient really want to survive, or want to be let go, to be allowed to die in peace? Did the patient and family really know what a resuscitation involved? It wasn't always clear. It's much easier, naturally, when people voice a desire for all or nothing.
"Isn't airway management one of the fundamental components of a resuscitation, if your goal is to 'succeed' in being resuscitated?" I asked the nurse rhetorically, knowing I was preaching to the choir.
"I know, believe me, I agree. But people just don't understand. They want resuscitation to be easy and the outcome to be rosy."
I've mentioned before that I dislike DNR's in the O.R. but appreciate them in the ICU. I have to amend that. I appreciate DNR's in the ICU but dislike DNI's.
I'm hoping chamber orchestra will meet tonight despite a little snow. I need to spend some time obsessing about a different kind of tube altogether! :)
Our chamber conductor just sent me this wonderful superbowl ad / video about oboist and football star, Chester Pitts. It's so uplifting! Best ad of all time! And Ephraim Salaam is ADORABLE. See, blowing through cylindrical objects can really be good for you... :)