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."

"A DNR?"

"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... :)


Eric, AKA The Pragmatic Caregiver said...

For at least some people, sequelae are the reasons loved ones are all for the DNI vs DNR. One in particular.

Pulling the plug.

If the resus works, without requiring invasive ventilatory support, someone is "alive and not hooked to machines". Good outcome.

If it "works", and there's invasive ventilation, but the patient isn't able to be weaned, and wouldn't want to spend the rest of their "lives" machine-dependent, somebody has to make the decision to turn off a machine for a person who is still, by some measures, alive. Bad outcome.

I assure you that out in the community, people who are healthcare proxies for loved ones truly struggle with this very issue.

Right or wrong, we took a Cheap Chinese Restaurant Family-Style Dinner approach to the POLST for Cal. One from column A, two from column B, with four you get egg roll. Yes, he should be cardioverted (unless he's asystole). Yes, he should have pressors and the other drug treatments. Yes, he should have a trial of chest compression. No, he shouldn't be intubated. No, he shouldn't have invasive mechanical ventilatory support. Yes, he should have BiPAP.

The idea behind it, I think, is being able to give loved ones a reasonable fighting chance against some temporary disruption (ie, heart rhythm disturbance, in the case of my father-in-law) without the downside risk of leaving them bedridden and machine-dependent.

For the record, I'm not harboring any delusions that a DNI code is kinder or gentler than one with intubation. I know it doesn't look like ER or General Hospital or that cool bit in the last Bond movie.

In particular, I've really struggled with this for my mom, who has wildly metastatic breast cancer, but has had sustained remission (4 years, the last time) from palliative chemo and hormonal therapy. This time around, she's a little sicker, and having a rougher time with the chemo. When you're one of a relatively small data set (24-year survivors of MBrCa, late recurrences), it's impossible to predict if you'll have a good response to chemo if you'll be able to keep working and volunteering, if you'll feel "normal" again, and there are days when, if I had to make the decision in that moment, I'd have to say "She's suffered enough". It doesn't feel right to aggressively resuscitate someone with a terminal diagnosis who is in bad shape at the moment. The hesitation comes from knowing she walked out of the hospital after her last ICU admit to years of high-quality life.

Faced with these kinds of dilemmas, it's no wonder caring people choose things that look, to physicians, to be micromange-y or contradictory.


T. said...

Dear Eric,

Thank you SO MUCH for writing such a thoughtful and educational response. It helps clinicians like me tremendously to know more about patients' and families' perspectives, and so often there isn't really the opportunity to get into it in such helpful detail right at the bedside.

I am a big fan, actually, of the "Family Style Dinner Approach" and try as much as possible, when I discuss DNR suspensions for the O.R., to get a clear idea of a patient's wishes for every detail I can think of at that moment - airway management, chest compressions, defibrillation, pharmacologic interventions for rhythm or blood pressure distrubances, etc. Some appreciate this, others are more reluctant to discuss or think about so many details, or misinterpret my efforts to understand as efforts to put up roadblocks.

When there's a chance to convey how much both sides really do CARE about a patient, clinicians and family members alike, then I think the decision-making and communication processes are facilitated.

These clinical situations come up fairly often, and we constantly revisit our thinking process behind the scenes, and agonize, and reflect, and talk, and reflect some more. People don't see that side of us, any more than we are privy to the agonizing family discussions and sleepless nights that doubtless occur. Sometimes it seems there are those who don't believe clinicians sincerely want to be as helpful and caring as possible, and perhaps doctors and nurses appear to lack understanding as well of family members' efforts to be as sensitive and compassionate with their loved one as they can be. Trust can be difficult under stress, I guess, when nature takes its powerful course and we all feel a little less powerful for it.

All I can say is, your words here are truly valued and valuable, and I hope to keep reminding myself to keep my eyes and ears open not only to my sense of what's best at a given moment but also to patients' wishes for their own health, safety, and quality of life.

T. said...

All that being said, I still have uneasiness over the prospect of a patient surviving a resuscitation attempt but coming out of it with aspiration pneumonitis, from vomiting without an endotracheal tube in place (not that the tube is fool-proof protection, of course), or hypoxic brain injury or hypercarbic narcosis, from sub-par oxygen delivery or inadequate ventilation...both would significantly reduce quality of life afterward too...

Anonymous said...

How does a lay person figure this all out? My in-laws just updated their medical directives and a friend who has cancer battling against her is also updating her directive. I think I understand and have it all figured out and then I read your blog about suspending the DNR during surgery. My MIL was recently hospitalized and was told to put her directive on the bedside table in the hospital. The doctor said if she gets intubated, even accidently, that they won't be able to pull the plug. Lots of confusion to those who don't know all the inside information.

Your blogs are very informative. Thank you.

T. said...

It IS so very complicated and confusing, for both sides. There are so many ways to approach a situation correctly (and incorrectly). A case-by-case approach, and sometimes moment-by-moment within a given clinical scenario, is our only option.

I think the most "successful" ICU situations I've been part of have in common the opportunity for candid, sometimes graphic, detailed, open communication between clincians who know the patient well medically and families who know the patient well personally and want what's best for their loved one.

When I look back on round table discussions with family members, the ones that stand out in my mind as most fruitful were the ones in which I had the chance to spend at least a good hour describing possible consequences, options, and plans, listening to loved ones' responses and trying to understand their most important concerns, and discussing reasons why for all the above.

Such discussions presuppose family members who are willing to hear and talk about some difficult things about the patient's care and prognosis and clinicians who are willing to devote time, energy, open-minded listening, and frank, unhurried conversation about tough topics.

And this is just hospital/ICU/surgical situations. Resuscitation out in the street's a whole other ballgame.

It's not easy for anyone, but I think it's ESPECIALLY hard for those who are emotionally strongly connected to the patient and have to bear the responsibility for decisions about critical medical care. I can't offer much wisdom or medical advice on this forum but I CAN offer the suggestion to keep the discussions going, and I truly hope my ponderings here don't intensify the confusion and stress of situations that are already so very challenging. Such is not my intention.

I wish your family members comfort and safety always.

Eric, AKA The Pragmatic Caregiver said...

OK, I'm game to step into this...

Being the layest of the lay people (and having been intubated m'self a few times, once while quite conscious, and being none the worse for it), I could use some better understanding of the intubation process.

I understand why I've been intubated (anaphylaxis) - the airway was closing, and the tube provided a guaranteed delivery of oxygen to the lungs. Aside from these allergic and inflamnatory responses (say, a quinsy or something), could you briefly explain how just the intubation itself promotes better oxygenation in other types of cases?

It *sounds like* the tube ameliorates the effects of imperfect ventilatory technique, rather than improving on well-performed ventilation.

Also, is it possible to say "sure, place a tube to support the resus effort, but don't even *THINK* of hooking up a vent", or "how about a time-limited trial, say, 24 hours of ventilator support?"

On a MUCH lighter note...

My mom was on an infusion pump while in the hospital this last time, and the configuration of the room meant that to move the pump from one side of the bed to the other, it had to be unplugged. So, when mom felt like getting up, I'd unplug the pump, move it as needed, and replug it if she was gong to be in that position for a bit. No big deal.

Mom noted, with some concern, that I seemed *AWFULLY* willing to just yank that cord out of the wall. I told her that I was practicing for when she *REALLY* needed someone to pull the plug for her.


Anonymous said...

Eric, That's what I wondered? Couldn't you be intubated and then in 24 hours if the plug needed to be pulled; and all of this could be written on the health care directive. What my husband understood was that once the vent is connected, even with the directive, it takes a court order to unplug the vent. Very complicated stuff.

gelci72 said...

In brief: an unintubated airway is an unprotected airway. Period.

Bag-valve-mask ventilators can deliver close to 100% oxygen to patients and are considered life-saving, especially in the field. That is, if you can perform the mask ventilation (more on this below).

Incidentally, "field" resuscitations (mentioned briefly in my third comment above) are VERY different from ICU/O.R. resuscitations. Because out-of-hospital locations are not considered "controlled" environments, current research favors not only de-prioritizing intubation but also, if you live in Europe and perhaps soon to be the case here in the U.S. as well, giving NO breaths at all and concentrating solely on chest compressions.

An ICU code can be a slippery creature. There are a few things someone like me might be concerned about when it comes to an unsecured airway during a code.

1) Operator inexperience. This is usually not an issue because the person assigned to the airway at the head of the bed is typically an expert at mask ventilation

2) Patient anatomy. Even with an expert mask ventilator at the head of the bed, the patient may be the dreaded "difficult mask airway" or perhaps even near-impossible to mask. Restricting oxygen delivery to this method only can be shooting oneself in the foot, especially for the elderly, the morbidly obese, and those with facial hair - all characteristics of people who can be difficult to mask.

3) Aspiration and its life-threatening pulmonary sequelae, already mentioned above. Patients vomit, often unpredictably. Insufflation of the stomach with mask ventilation only increases the aspiration risk. Patient diseases like diabetes, severe gastroesophageal reflux, or neurologic conditions can likewise make a person a poor candidate for a mask airway.

On the subject of ordering clinicians not to hook up a seems like an unrealistic use of human labor to ask someone to sit up all night blowing oxygen in manually if we have the technology to do so with a machine that can actually be set to far more reliable, correct volumes, pressures, expiratory times, etc. Sometimes machines "sense" people's inspiratory efforts better and can actually synchronize delivered breaths more comfortably for the patient.

As for trying to control the time of extubation...I'm not sure how possible this is. For safety reasons and optimal outcome I would say that following the current weaning protocols and holding to established extubation criteria are probably advisable.

Celloluv, I'm too unfamiliar about court involvement in ventilator management to respond to your last note. Sometimes these issues vary from state to state. I wish I could be more helpful - there are often more questions than answers, medically, ethically, and legally, with these complicated situations.

I am sympathetic because I, too, would NOT want to be hooked up to a ventilator indefinitely. They made us all try it for ourselves when we were residents, just with a mouthpiece, and though some settings were more uncomfortable than others which mimicked natural breathing more, none of it was fun for a fully conscious person. So I really DON'T want anyone to have to go through that either.

So though I dislkike DNI's because they leave me with a feeling that I've provided incomplete care (a feeling which may be stronger among anesthesiologists, admittedly, than other doctors, simply because securing the airway is almost symbolic of our work and expertise as safety and critical care providers), I do understand people's desire to avoid the dreaded terminal ventilator.

gelci72 said...

Hi again, E & celloluv-

Just wondering if you feel insertion of a laryngeal mask airway would be acceptable, in the event that the person managing your loved one's airway has significant difficulty? It's a device that is like a small mask that can sit at the very back of the mouth(NOT in the trachea) and have breaths delivered through it through a tube attached to it. It's considered temporary and NOT meant for prolonged use with a ventilator; it does not protect against aspiration either, though, and it does have limits as to how much pressure can be applied while delivering breaths.

Eric, AKA The Pragmatic Caregiver said...

Honestly, I didn't expect anyone to bag all night; I was thinking more along the lines of tube 'em as part of the resus effort, but if they aren't breathing independently at the end of it, call it off.

I'll admit an utter lack of knowledge of weaning protocols, save that right now I have a dear young friend in ICU with complications of toxic epidermal necrolysis who is both expected to recover and on a vent, and he's only been allowed two spontaneous breathing trials in three weeks.

It seems to me that if weaning fails, the default is keep them on it. To me, the minute you hook up something automated to the tube, you've bought that tube for a long time. If it's just to protect against aspiration during resus, or to ensure a good airway on this guy, mazel tov.

So for me, it's not about the tube. It's about what you hook to the tube and how long people want to keep that tube there.

There's sort of an emerging trend to use BiPAP in lieu of a vent for some patients, no?

Anonymous said...

This has probably left me with more questions than answers but is providing me with a good starting point for discussion and research. Thanks for the input.

T. said...

Yes on the BiPap. Frankly it LOOKS quite uncomfortable to me (found good images on but I haven't tried it.

BRILLIANT photo of a probable difficult mask airway, btw!!! I give my students a similar mnemonic: when you see Santa walk in to the preop area, and he's YOUR patient, have airway plans A,B, & C ready.

Sorry for misinterpreting about manual v. machine bagging, btw, E - though really even if someone were spontaneously breathing they might not meet extubation criteria right at the end of a code, or hours later, or a day later...first the sedation and muscle relaxants have to wear off, blood gases assessed, inspiratory effort evaluated, etc...

I also appreciate the input and do realize that long vent times are frequently associated in people's minds with intubation. I always dread telling people I've had to keep their loved ones on the vent temporarily after surgery because very often they don't hear or don't believe the "temporarily" part. Not all vent times are prolonged. But it's often true that the longer you are on the vent, the longer you'll be on the vent. I guess the un-predictability of it is what is so hard & dreadful.

Nothing in this realm is simple.

Sorry for the more-questions-than-answers whole blog is riddled with instances of that, I'm afraid... :)

Eric, AKA The Pragmatic Caregiver said...

Wow, that's a pretty vintage system in those pics. The new gear is much swoopier.

Properly adjusted, especially with the nasal pillows shown at the bottom, BiPap is *CRAZILY* comfortable. Moreso than even CPAP. Patient compliance with BiPAP outpatient is markedly higher than CPAP. Buddy up to an RT and try it sometime. Set your pressures at like 5cm and 10 cm as an example, and when the straps are right and the spacing of the nasal "pillows" correct? You'll be out like a light in no time.

I figured Dr Weil was like the worst case scenario - he's not particularly obese, but he's got a big neck, that giant beard and would probably be attempting to scream for a herbalist. ;0)

Eric, Hoping To Never Have To Ponder ANY Of This, But Knowing Better.

T. said...

LOL, yeah, even the BiPap that was on the patient described in this blog post looked more 21st century, but I gotta admit, it was STILL essentially tight-looking black straps and a plastic mask that looked pretty darn claustrophobia-inducing...

I do have some RT pals I can go to for a demo. I'll try to work up the nerve. Dunno...looks scaaaaaaaa-aaaareeeeeeee... :) I've talked to so many obstructive sleep apnea patients that can't tolerate their CPAP contraptions...

But hey, if I could try out the ventilators without any benzos or propofol to take the edge off, I guess I oughta be able to check out some BiPap, right? :)

Thanks for the tip!

Eric, AKA The Pragmatic Caregiver said...

The CPAP compliance issue hits extremely close to home for me - my partner has a fat neck, a relatively small nose, seasonal allergies and uses CPAP.

Without going too far off-track here, in the experience of my RT buddy, it's possible to get almost everyone compliant and well-saturated with trials of various interfaces and vent settings, and especially, use of a humidifier. The elastic isn't nearly as strong as a pair of swim goggles. It's very much a case of trying a bunch of combinations until people find something that works.

Non-politically-correctly, many OSA patients are BMI>40 and not used to experiencing even minor discomfort in their day-to-day life.

Anonymous said...

So at the risk of adding something after this discussion has quieted down... The science of the comments in this section is out of my league: which is exactly why I do not want to make the DNI/DNR determination for myself or for my loved ones. The issues raised in the ER/OR/ICU/long term care setting are medical issues which require informed medical judgment. To the extent they require discretion (i.e. how aggressively do you attempt to revive an 85 year old with end-stage cancer?), I would prefer to be guided by a physician who can keep the best interests of the patient at heart (as opposed to my personal desires for mom/dad/etc). Are physicians uncomfortable with being asked to make these judgments? Is it because some members of my profession have pursued physicians for doing so?

T. said...

Hi, justanotherlawyer-

Thanks for stopping by. In answer to some of the questions you raise, I can only speak for myself and not anyone else in the medical profession, but in essence, I agree with you that medical judgments should be left to medical professionals. I think the concerns of family members should be heard and heard WELL, and cared about, and discussed, but I think ultimately when a judgment takes some expertise to make it should be made by trained experts.

That said, a medical expert can certainly recommend treatments that patients and their families are free to refuse.

I think the judgment for the need to intubate is a MEDICAL judgment and that a DNI is essentially a formal refusal of recommended medical treatment - but certainly one that I myself might consider implementing if I felt the treatment would be worse than the condition being treated. It really depends on a lot of things. If I were a huge aspiration risk I'd really rather NOT exit this world by drowning in my own acidic gastric fluid. If I were having trouble breathing on my own and experiencing air hunger, I might actually prefer to be comfortably sedated and have a machine giving my tired respiratory muscles a rest for a while. But if I were like the gentleman I wrote about on my amputation post, then I certainly WOULD NOT want to hang out in an ICU on a ventilator for the rest of my miserable life either. As I've already stated, none of this is simple.

I think being comfortable with making some of these difficult judgments depends largely on the details of a given situation. I recall another occasion that I've written briefly about before that also involved a DNR/DNI situation. I met with the family and had a long, frank conversation with them in which I basically told them their loved one's only chance of surviving was the operation suggested by the surgeon; that their loved one may not survive the actual operation; that I could NOT allow the operation to take place WITHOUT intubation, but that having intubated their loved one, I was unlikely to be able to remove the tube any time soon. I felt very comfortable in that situation because I had a patient who was clearly not going to survive unless we took aggressive steps, and I had no problem being completely honest with the family about my judgments. But there are other situations in which the details can get pretty complicated, and I can see how these could make the judgment call a little dicey.

I don't know how much your profession lurks as a worry in the back of physicians' minds during these tough calls. I get the feeling from my own experience and observations that we're mostly worried about doing what's most physically and emotionally comfortable for the PATIENT. Patient needs first, family next, lawyers last! :) (Only ribbing you because I can, with relative impunity...)

Anonymous said...

Of course you can rib me as much as you want! I can only say that if I ever need anesthesia, or (dear God) intubation, you better come and do it! :)

T. said...

I'll be sure to bring the SPECIAL baseball bat, just for you...!