How did your aortic dissection cases present?

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BoardingDoc said:
Yeah. Typo.








I don't think that counts as a typo so much as deliberate fraud.


To bring this thread back to its original point:
Last dissection presented as a syncopal episode in an older guy. LOC after a BM. Brought in by his daughter. Guy was rather demented, couldn't give much hx. Seemed fine at the time. Daughter said he had a hx of vasovagal syncope. Seemed similar. Exam entirely benign. Got basic labs. Trop was something like 0.08 with normal renal function. EKG benign. Go back in to explain it looks like it might be cardiac and she tells me he has started complaining of bad abd pain. Now diffusely tender entire abd. Stat CT shows type B dissection infrarenal to iliacs with an area that has clearly ruptured. Vascular signed off. Admitted as CMO.
Click to expand...

someone very close to me is a practicing rad and they have made the mistake of posting those comments under my user name. I have found out evidently that is against the TOS, immediately secured my account and encouraged them create an account so they can participate in SDN . Mod, feel free to delete those misleading comments as I am having trouble editing some of them (guess you can’t edit comments when the thread’s closed?)

regretably my time on this forum have been marred by harassment from
Multiple users.
 
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doctorsdatdo said:
regretably my time on this forum have been marred by harassment from
Multiple users.
Click to expand...
Are you surprised by this? Gross, flagrant misrepresentation, compounded by some spurious claim of a "typo", will tend to draw ire from people. If 10 people tell you that you stink like manure, because you do, is that "harassment"? Or are all 10 people, individually, just being malicious, to harm you?
 
Apollyon said:
Are you surprised by this? Gross, flagrant misrepresentation, compounded by some spurious claim of a "typo", will tend to draw ire from people. If 10 people tell you that you stink like manure, because you do, is that "harassment"? Or are all 10 people, individually, just being malicious, to harm you?
Click to expand...
I think I may have gotten this from you originally but...

If you go through your day and you meet an a**hole, you’ve met an a**hole.

If you go through your day and everyone you meet is an a**hole...you’re the a**hole.
 
doctorsdatdo said:
someone very close to me is a practicing rad and they have made the mistake of posting those comments under my user name. I have found out evidently that is against the TOS, immediately secured my account and encouraged them create an account so they can participate in SDN . Mod, feel free to delete those misleading comments as I am having trouble editing some of them (guess you can’t edit comments when the thread’s closed?)

regretably my time on this forum have been marred by harassment from
Multiple users.
Click to expand...

Hmm, sounds like a completely delusional narcissistic and sociopath.

I work in the ER. You think anyone has ever "tripped and fallen" on something? Nope, neither do I. The odds of your close rads friend using a medical student's account is so close to zero is almost certainly zero.
 
doctorsdatdo said:
I find it hilarious that everytime I post something people seem to absolutely lose their mind And just side track the thread.
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Get out of our forum you lying, disingenuous, egotistical medical student.

Edit: unnecessary profanity removed.
 
Two presented just like sciatica, pain radiating down the leg, couldn’t get comfortable, moderate elevation in BP. One was in rhabdo from his dead leg (diminished pulses bilaterally though), not cold.

My first had “a piece of cheese stuck in [his] throat”. Diaphoresis was the tip-off there.

Scary to think how many I’ve sent home...
 
ERCAT said:
My mind is racing because I’ve seen two aortic dissections in the last week and I feel like I could have easily missed them had I been in a rush and not prodded during the history. Makes me cringe thinking about it.

First one was a 69 year old with hypertension. Sudden onset of chest pain when watching TV. With no other symptoms at all. The thing that tipped me off is he didn’t want to move. Moving hurt his chest. Breathing hurt his chest. Me pushing on his chest made him wince. Just didn’t seem right. I thought, hmmm, CTA. He had a type I aortic dissection extending alllllll the way down to the iliacs.

The second one was scarier because it was in the fast track and the guy looked like a rose. Healthy dude in his early 40s. Waltzed in with his wife asking for an MRI for this left sided upper back pain he developed two days ago when picking up the phone. It was constant but it hurt to breathe. It was very reproducible; his wife circled the exact spot on his back with a pen and when I palpated here, he said “Ow!” Like the other guy, no other concerning symptoms like dyspnea, dizziness, belly pain, or numbness - EXCEPT just as I was pondering that maybe he just needs some Toradol, he said “my throat feels weird, too. It feels weird to swallow, like there’s something that gets stuck there.” He argues with me when I told him I was getting a CTA as he wanted an MRI to evaluate for herniated discs. He said “I know my body... I’ve had this before last year. It’s my back.” He told me his neurosurgeon wouldn’t see him without the MRI. WELL - got the CTA anyway, and he also had a type I with associated rupture... when I told him the news and that this is an emergency and that I was getting CT surgery on the line, he angrily told me to “hold on! Now it’s YOUR opinion that this is an emergency!”

The second one was more scary because if he hadn’t said the thing about the throat, and if I had bought his “I’ve had this exact same thing before and it’s a herniated disc!” I would’ve sent him home to die. Shudder.

Would love to hear your aortic dissection stories. How did they present?
Click to expand...

Ranged from a classic cant get comfortable chest and back pain with elevated dimer to an older dementia patient whose only complaint was chest pain, was resting comfortably on the bed, not hypertensive, and whose some physical exam finding was a unilaterally diminished radial pulse.

There is this for what it is worth: Could my patient have an Aortic Dissection? - CanadiEM

Throw in a CXR and a D-dimer and hope everything is negative.
 
I recently had a patient with chest pain radiating to the LLQ that made me immediately think of this thread. I CTA'd her. Fortunately, negative for dissection. Found a cause for the belly pain, though.
 
45 year old, no medical history, unknown family history, states he "felt funny at the top of a ski lift." Continued skiing all day, no chest pain, mild dyspnea, just didn't feel right, VS nl. Somehow we got from that to a dissection via a positive d-dimer. Transferred to the Big House in the middle of the night and spent 10 hours in the OR. Walked out of the hospital and flew home two weeks later.
 
MechEDoc said:
Age 50 and up, if they have back pain, I ultrasound the aorta.
Click to expand...
Please tell me you're not getting sonos on people with back pain and documenting that you have ruled out TAD...
 
jw3600 said:
Please tell me you're not getting sonos on people with back pain and documenting that you have ruled out TAD...
Click to expand...

Nope, I'm documenting that I've ruled out AAA.
 
Status epilepticus likely from alcohol withdrawal, with left pulmonary artery saddle PE, multiple subsegmental PE in bilateral lungs, multiple pulmonary emboli cavitary lesions, acute cerebral artery occlusion, and acute aortic artery dissection from aortic arch to celiac artery

Oh and he was on Xarelto.

Oh and wife wavered for 2 hrs on DNR/DNI status - wouldn’t let me intubate.
 
Porfirio said:
Status epilepticus likely from alcohol withdrawal, with left pulmonary artery saddle PE, multiple subsegmental PE in bilateral lungs, multiple pulmonary emboli cavitary lesions, acute cerebral artery occlusion, and acute aortic artery dissection from aortic arch to celiac artery

Oh and he was on Xarelto.

Oh and wife wavered for 2 hrs on DNR/DNI status - wouldn’t let me intubate.
Click to expand...
Wouldn’t LET you intubate? Like you disagree with her decision for comfort measures only? That’s someone I am adamantly trying to avoid intubating and just letting them pass away peacefully. That’s like the celestial design team giving you a gigantic sign that says “It’s this guy’s time”.
 
Zebra Hunter said:
Wouldn’t LET you intubate? Like you disagree with her decision for comfort measures only? That’s someone I am adamantly trying to avoid intubating and just letting them pass away peacefully. That’s like the celestial design team giving you a gigantic sign that says “It’s this guy’s time”.
Click to expand...

Yeah, wouldn’t let me intubate.

Imagine being in a situation of “DNR/DNI” then oh let me change my mind then change my mind again then again then again then again then more family arrives and changes again then more family talked to over the phone and it changes again then EMS arrives to take patient to another facility because they “want everything done except intubation” then EMS can’t take them right now because now they want intubation. Finally, they stick with Full Code and I can dispo the patient.

I never disagreed with what they wanted to do. The problem was the wavering of decision. Also they did not want (at any time while in the ED) comfort measures only.
 
Porfirio said:
Yeah, wouldn’t let me intubate.

Imagine being in a situation of “DNR/DNI” then oh let me change my mind then change my mind again then again then again then again then more family arrives and changes again then more family talked to over the phone and it changes again then EMS arrives to take patient to another facility because they “want everything done except intubation” then EMS can’t take them right now because now they want intubation. Finally, they stick with Full Code and I can dispo the patient.

I never disagreed with what they wanted to do. The problem was the wavering of decision. Also they did not want (at any time while in the ED) comfort measures only.
Click to expand...

In general, I don't find "limited codes" to be at all helpful for the patient. I generally explain that picking and choosing among what resuscitation options (mind you, I'm talking about a full-on code situation) they will allow for the patient makes an already long-shot opportunity for ROSC even more improbable and likely only adds to the patient's suffering (in more sensitive language, of course). Did the family understand that wanting everything done short of intubation essentially rendered all potential intervention(s) for him impossible? Because it seems rather useless to transfer to another facility for further care without being allowed to use the tools necessary to actually care for the patient.
 
Not an ER guy, a simple hospitalist but these are my favorite dissection stories. BTW, I've almost NEVER seen a classic dissection presentation.

Story 1 - Spidey Senses and Back Pain

My first dissection I dx as an Attending was when I was taking night call. Patient came in earlier for chest pain (no radiation at the time), elevated BP. Admitted to rule out ACS. After midnight started complaining of lower back pain that the nurse reported as him saying it was the hospital bed. Understandable, those hospital beds give a lot of people problems. Gave some pain meds. Nurse called back saying pain was not relieved. Since I was right there, I went over and talked with the patient. Absolutely not in distress, but uncomfortable and BP was rising. I asked the nurse to check BP on both arms and I checked his pedal pulses because my spidey senses were tingling. Difference manually between both arms, 19. I said, crap. Next I ordered a stat d-dimer, checked the CXR, his Cr was bumped unsure if new or chronic over 2.0. D-dimer sky high. I call up the cardiologist, told him I'm suspecting dissection, Cr high, did he want to try a TEE or something? Cardiologist said hell no, hung up on me (it is 2 am). I ordered the CTA, the radiologist calls me and tells me I need to document I'll take all responsibility for the contrast. I do. Major dissection up and down, guy survived.

Story 2 - ER calling IM lazy

On a day shift, my shift was ending and an ER physician calls me for an admission. Young guy in 30s, atypical CP radiating to the back BP 90's slightly bumped trop, normal CXR. I asked the ER physician if they got a CTA to rule out dissection. She told me no, but she can order one and asked me to admit and followup on it. I was polite at the time, and declined. I reviewed the chart before calling her, and had noticed he was also complaining of some neurological symptoms as well. I said a dissection had to be ruled out before I admitted him to the floor. Now the ER doc got nasty, accused me of punting the work because it was nearing the end of my shift by asking for unnecessary exams. I said I can gladly come by to see the patient but under no circumstances will I admit without a CTA. She then started lecturing me about dissection, said BP wasn't high, CXR showed no widening mediastinum and again accused me of not wanting to work and that she was well over her shift and trying to get home. I calmly (I think), told her that if he has a bumped trop, chest pain that radiated to the back this could be a late stage dissection with low BP and you do NOT need to see a CXR with a widened mediastinum. She hung up on me.

Later that night as I'm walking the dog, the radiologist calls me up and asks if this is my patient. I said no, I never accepted the patient but curious why. She said the patient had dissected pretty much everything. I call up the ER, they're madly working on the patient, ER attendings changed now to the director of the ER, I tell him the story and then finish picking up my dog's poop.
 
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greatnt249 said:
In general, I don't find "limited codes" to be at all helpful for the patient. I generally explain that picking and choosing among what resuscitation options (mind you, I'm talking about a full-on code situation) they will allow for the patient makes an already long-shot opportunity for ROSC even more improbable and likely only adds to the patient's suffering (in more sensitive language, of course). Did the family understand that wanting everything done short of intubation essentially rendered all potential intervention(s) for him impossible? Because it seems rather useless to transfer to another facility for further care without being allowed to use the tools necessary to actually care for the patient.
Click to expand...

So why do you let patients, or their families, pick and choose "limited codes"? (I'm assuming, for the sake of argument, that you are referring to some sort of 'menu' in the advent of cardiac arrest. I.e. a family is requesting cardiac compressions, anti-arrythmics, but no shock or intubation. Or some sort of nonsense like that).

Either a patient is full-code or they are DNR. This only comes into play in the advent of a cardiac arrest. It has no effect on their care leading up to a cardiac arrest.

If a patient, or their family, do not want intubation prior to cardiac arrest, they automatically become DNR. If they refuse intubation when it is (definitively) indicated, they become comfort care (or at least transition to a 'limited interventions' modal of care).
 
jurassicpark said:
Not an ER guy, a simple hospitalist but these are my favorite dissection stories. BTW, I've almost NEVER seen a classic dissection presentation.

Story 1 - Spidey Senses and Back Pain

My first dissection I dx as an Attending was when I was taking night call. Patient came in earlier for chest pain (no radiation at the time), elevated BP. Admitted to rule out ACS. After midnight started complaining of lower back pain that the nurse reported as him saying it was the hospital bed. Understandable, those hospital beds give a lot of people problems. Gave some pain meds. Nurse called back saying pain was not relieved. Since I was right there, I went over and talked with the patient. Absolutely not in distress, but uncomfortable and BP was rising. I asked the nurse to check BP on both arms and I checked his pedal pulses because my spidey senses were tingling. Difference manually between both arms, 19. I said, crap. Next I ordered a stat d-dimer, checked the CXR, his Cr was bumped unsure if new or chronic over 2.0. D-dimer sky high. I call up the cardiologist, told him I'm suspecting dissection, Cr high, did he want to try a TEE or something? Cardiologist said hell no, hung up on me (it is 2 am). I ordered the CTA, the radiologist calls me and tells me I need to document I'll take all responsibility for the contrast. I do. Major dissection up and down, guy survived.

Story 2 - ER calling IM lazy

On a day shift, my shift was ending and an ER physician calls me for an admission. Young guy in 30s, atypical CP radiating to the back BP 90's slightly bumped trop, normal CXR. I asked the ER physician if they got a CTA to rule out dissection. She told me no, but she can order one and asked me to admit and followup on it. I was polite at the time, and declined. I reviewed the chart before calling her, and had noticed he was also complaining of some neurological symptoms as well. I said a dissection had to be ruled out before I admitted him to the floor. Now the ER doc got nasty, accused me of punting the work because it was nearing the end of my shift by asking for unnecessary exams. I said I can gladly come by to see the patient but under no circumstances will I admit without a CTA. She then started lecturing me about dissection, said BP wasn't high, CXR showed no widening mediastinum and again accused me of not wanting to work and that she was well over her shift and trying to get home. I calmly (I think), told her that if he has a bumped trop, chest pain that radiated to the back this could be a late stage dissection with low BP and you do NOT need to see a CXR with a widened mediastinum. She hung up on me.

Later that night as I'm walking the dog, the radiologist calls me up and asks if this is my patient. I said no, I never accepted the patient but curious why. She said the patient had dissected pretty much everything. I call up the ER, they're madly working on the patient, ER attendings changed now to the director of the ER, I tell him the story and then finish picking up my dog's poop.
Click to expand...

Curious M4 here regarding the first story. Would it have been reasonable to skip the stat D-dimer and go straight to CTA? Between your spidey senses and exam findings, I feel like a negative d-dimer wouldn’t have made me more assured even though I understand that the sensitivity is high.
 
STEMI_voy said:
Curious M4 here regarding the first story. Would it have been reasonable to skip the stat D-dimer and go straight to CTA? Between your spidey senses and exam findings, I feel like a negative d-dimer wouldn’t have made me more assured even though I understand that the sensitivity is high.
Click to expand...

Both paths reasonable given info presented imo
 
STEMI_voy said:
Curious M4 here regarding the first story. Would it have been reasonable to skip the stat D-dimer and go straight to CTA? Between your spidey senses and exam findings, I feel like a negative d-dimer wouldn’t have made me more assured even though I understand that the sensitivity is high.
Click to expand...

Although a lot of dissections will have elevated d dimers (and many have been fortunately "accidentally" diagnosed that way with confirmatory CT pulmonary angiograms) this is not considered standard of care.

I think there is some research in this area, but the conventional wisdom currently is that d dimer is not utilized to diagnose dissection, it is clinically suspected and diagnosed with a CT angiogram (rare cases TEE or MRA). I don't think any expert can tell you right now a negative d dimer "rules out" an aortic dissection. I would say it's not considered defensible if a negative d dimer is used to defend a missed dissection.

This is in part why the diagnosis remains difficult, there is no 'easy' test for it, one must for the most part proceed with advanced imaging based on clinical suspicion, and clinical suspicion may be low in the case of unusual presentations (which are actually more common that not according to the IRAD registry of cases).
 
STEMI_voy said:
Curious M4 here regarding the first story. Would it have been reasonable to skip the stat D-dimer and go straight to CTA? Between your spidey senses and exam findings, I feel like a negative d-dimer wouldn’t have made me more assured even though I understand that the sensitivity is high.
Click to expand...

Yes it would have. The problem was several-fold though:

- Abnormal kidney function with unknown base line
- Benign symptoms and exam suggestive more of musculoskeletal, in his words it was his chronic back pain from being on the hospital bed being made worse.
- Marginal difference in BP between arms, 19
- BP while on the higher side wasn't crazy high
- It was 2am in the morning, cardiologist already made clear he wasn't going to help you deal with this
- Patient was just sitting there, chilling like a villain.

In this case, it's not that simple just ordering the CTA because with that GFr, the radiologist was woken up too. He was on the phone with me explaining the patient had a great looking CXR and that he and I would have to document that I was overriding the radiologist, and taking the responsibility on myself if I wrecked his kidneys. Now that is not an easy thing to do at 2am in the morning, especially with such a relatively benign exam and borderline hunches.

I used the d-dimer as a my justification for pulling the trigger on the CTA and potentially putting this guy on dialysis. As RoyBasch pointed out, we rarely see the classic presentation of aortic dissection, and they can be missed quite easily. Like my second story, the ER doc was lecturing me on aortic dissections while completely missing it on her patient because it didn't fit the classic profile. The D-dimer is not standard of care, but it can be a very helpful guide.
 
Agree with idea above. If low pretest probability, a negative dimer when you doubt dissection in the first place is helpful, logical, and defensible when charted appropriately.

There is literature on this. Is it as substantiated as PE literature, no, but also very different subjects.

If even some concern based on any combination of context / history / exam / spidey sense, CTA, period.
 
gutonc said:
I think I may have gotten this from you originally but...

If you go through your day and you meet an a**hole, you’ve met an a**hole.

If you go through your day and everyone you meet is an a**hole...you’re the a**hole.
Click to expand...
If you go through your day and everyone you meet smells like ****, check your shoes.
 
turkeyjerky said:
So why do you let patients, or their families, pick and choose "limited codes"? (I'm assuming, for the sake of argument, that you are referring to some sort of 'menu' in the advent of cardiac arrest. I.e. a family is requesting cardiac compressions, anti-arrythmics, but no shock or intubation. Or some sort of nonsense like that).

Either a patient is full-code or they are DNR. This only comes into play in the advent of a cardiac arrest. It has no effect on their care leading up to a cardiac arrest.

If a patient, or their family, do not want intubation prior to cardiac arrest, they automatically become DNR. If they refuse intubation when it is (definitively) indicated, they become comfort care (or at least transition to a 'limited interventions' modal of care).
Click to expand...
That is literally what he is saying in response to the guy that sounds like he was allowing the family to pick and choose interventions.
 
The literature as I understand it says you can rule out dissection with a negative d dimer in low risk patients only. Part of the low risk definition includes no chest pain, so you can pretty much say no one we're considering it in is low risk. So I guess you can order it on everyone else (UTIs, work notes, etc) and if negative it's not a dissection, but you'll have to be willing to get a couple CTAs per day before writing a 9928worknote.
RoyBasch said:
Although a lot of dissections will have elevated d dimers (and many have been fortunately "accidentally" diagnosed that way with confirmatory CT pulmonary angiograms) this is not considered standard of care.

I think there is some research in this area, but the conventional wisdom currently is that d dimer is not utilized to diagnose dissection, it is clinically suspected and diagnosed with a CT angiogram (rare cases TEE or MRA). I don't think any expert can tell you right now a negative d dimer "rules out" an aortic dissection. I would say it's not considered defensible if a negative d dimer is used to defend a missed dissection.

This is in part why the diagnosis remains difficult, there is no 'easy' test for it, one must for the most part proceed with advanced imaging based on clinical suspicion, and clinical suspicion may be low in the case of unusual presentations (which are actually more common that not according to the IRAD registry of cases).
Click to expand...
 
turkeyjerky said:
So why do you let patients, or their families, pick and choose "limited codes"? (I'm assuming, for the sake of argument, that you are referring to some sort of 'menu' in the advent of cardiac arrest. I.e. a family is requesting cardiac compressions, anti-arrythmics, but no shock or intubation. Or some sort of nonsense like that).

Either a patient is full-code or they are DNR. This only comes into play in the advent of a cardiac arrest. It has no effect on their care leading up to a cardiac arrest.

If a patient, or their family, do not want intubation prior to cardiac arrest, they automatically become DNR. If they refuse intubation when it is (definitively) indicated, they become comfort care (or at least transition to a 'limited interventions' modal of care).
Click to expand...

I almost always don't let them choose limited codes, but given how our order system works in hospital, there are a number of different resuscitation options to "pick and choose" from should the patient or family state they do or do not want certain things to be done. What I was saying was that I don't find allowing for "picking and choosing" to be particularly useful in the grand majority of cases, seeing as how even allowing for "everything to be done" is already a long shot as it is, and limiting your treatment options is essentially tying your arm behind your back. I find that it only creates the illusion of being able to escalate care without actually providing much, if anything, in the way of giving the patient a fair chance if the situation begins to go sideways. That being said, I find that when patients or families choose the "limited" option, it is based on an often limited understanding as to what resuscitation actually entails, and that by breaking the process down for them, more often than not they will either choose "full code" or "DNR/DNI."

I'm not faulting the person I was originally quoting; I just found it unusual that the family was asking for a transfer to a different facility without allowing what would be an inevitable/necessary intubation to occur; did they think he was going to the OR without needing to be intubated? What that tells me is that the family did not have reasonable expectations with regard to this patient's likely poor outcome, made even more of a long shot by not allowing full resuscitation efforts (which were almost guaranteed to be needed). If I was at the accepting facility, I would have wondered what exactly the family expected me to do in this situation, as simply moving the patient to a different facility under these circumstances doesn't do much to change the patient's outcome.
 
greatnt249 said:
I almost always don't let them choose limited codes, but given how our order system works in hospital, there are a number of different resuscitation options to "pick and choose" from should the patient or family state they do or do not want certain things to be done. What I was saying was that I don't find allowing for "picking and choosing" to be particularly useful in the grand majority of cases, seeing as how even allowing for "everything to be done" is already a long shot as it is, and limiting your treatment options is essentially tying your arm behind your back. I find that it only creates the illusion of being able to escalate care without actually providing much, if anything, in the way of giving the patient a fair chance if the situation begins to go sideways. That being said, I find that when patients or families choose the "limited" option, it is based on an often limited understanding as to what resuscitation actually entails, and that by breaking the process down for them, more often than not they will either choose "full code" or "DNR/DNI."

I'm not faulting the person I was originally quoting; I just found it unusual that the family was asking for a transfer to a different facility without allowing what would be an inevitable/necessary intubation to occur; did they think he was going to the OR without needing to be intubated? What that tells me is that the family did not have reasonable expectations with regard to this patient's likely poor outcome, made even more of a long shot by not allowing full resuscitation efforts (which were almost guaranteed to be needed). If I was at the accepting facility, I would have wondered what exactly the family expected me to do in this situation, as simply moving the patient to a different facility under these circumstances doesn't do much to change the patient's outcome.
Click to expand...
It sounded me like in Porfiro's case, the family kept on changing their mind regarding whether to allow intubation or not. Indication was likely for expected clinical course. I agree that it's extraordinarily frustrating when a patient or their family, can't make up their mind about this (or any other significant intervention)

Sorry to everyone else for the sidetracking, and I assume we feel pretty similarly on the issue. My point is that actual 'code status' is and should be a binary decision.
Yes or No.
Full-code or DNR.

I've not seen a hospital form that allows patients to pick and choose interventions in the event of cardiac arrest. I have seen the misapplication of forms dictating allowed interventions in critical pre-arrest situations. These forms always have a section specifiying that the patient is DNR in the event of actual arrest. Sometimes clinicians don't realize this though and it leads to nonsensical events like 'chemical codes' and so on.
 
Previous EMR system was set up for goals of care invasive measures written into a DNR order.
So you could be no code but if still alive be okay with NIPPV, intubation, cardioversion, etc.
turkeyjerky said:
It sounded me like in Porfiro's case, the family kept on changing their mind regarding whether to allow intubation or not. Indication was likely for expected clinical course. I agree that it's extraordinarily frustrating when a patient or their family, can't make up their mind about this (or any other significant intervention)

Sorry to everyone else for the sidetracking, and I assume we feel pretty similarly on the issue. My point is that actual 'code status' is and should be a binary decision.
Yes or No.
Full-code or DNR.

I've not seen a hospital form that allows patients to pick and choose interventions in the event of cardiac arrest. I have seen the misapplication of forms dictating allowed interventions in critical pre-arrest situations. These forms always have a section specifiying that the patient is DNR in the event of actual arrest. Sometimes clinicians don't realize this though and it leads to nonsensical events like 'chemical codes' and so on.
Click to expand...
 
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