Knowing when to say 'when'....

[Frank Rizzo]

As a tangent to the 'death in the OR' thread, I am curious to see what some people's opinions are about massive resuscitation efforts in pts where the chance of survival is scant, at best. This is a dicey ethics topic. But I have been involved in more than a few penetrating trauma cases where I know the guys chances of living > than 24hr post-op, if he lives at all, are minimal. Still, products are pushed in as quick as he squirts(actually more like oozes usually) them out. Its especially painful when I see the local blood center put commericals on TV a day or two later pleading for donors becuase their current supply 'is critically low.'

Thoughts?

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[toughlife]

As a tangent to the 'death in the OR' thread, I am curious to see what some people's opinions are about massive resuscitation efforts in pts where the chance of survival is scant, at best. This is a dicey ethics topic. But I have been involved in more than a few penetrating trauma cases where I know the guys chances of living > than 24hr post-op, if he lives at all, are minimal. Still, products are pushed in as quick as he squirts(actually more like oozes usually) them out. Its especially painful when I see the local blood center put commericals on TV a day or two later pleading for donors becuase their current supply 'is critically low.'

Thoughts?

Great topic. I think the answer to your question has a medical and a philosophical answer. Our medical system has perpetuated the myth that death is optional since our technological and medical expertise allows to make miracles on a daily basis. This fuels the public's erroneous perception that no matter how sick their relative is, we can 'save' him/her.

The other aspect is whether we should give the patient a chance to live. Our own desire to live up to the public expectations almost forces us to delve in futile efforts when we know better. Doctors are ridden with guilt about not doing enough to save patients. Add to that the fact that lawyers are on stand-by ready to pick apart what you "could've, would've and should've" done and why you didn't. This drives the enourmous cost of health care even higher and makes us looks like fools to the rest of the world.

I visited a country where most of their health care resources are allocated to children's hospitals since they felt their money would be best invested in citizens that had a chance to be productive members of society one day. This is not saying that senoir citizens should be denied proper care, but we must realize that life has a beginning and an end. Instead of having ICUs full of 'living dead' we need to allow people to die with dignity. The latter requires that patients and their families understand the limitations of healthcare and that more care is not always better.

 

[173291]

Great topic. I think the answer to your question has a medical and a philosophical answer. Our medical system has perpetuated the myth that death is optional since our technological and medical expertise allows to make miracles on a daily basis. This fuels the public's erroneous perception that no matter how sick their relative is, we can 'save' him/her.

The other aspect is whether we should give the patient a chance to live. Our own desire to live up to the public expectations almost forces us to delve in futile efforts when we know better. Doctors are ridden with guilt about not doing enough to save patients. Add to that the fact that lawyers are on stand-by ready to pick apart what you "could've, would've and should've" done and why you didn't. This drives the enourmous cost of health care even higher and makes us looks like fools to the rest of the world.

I visited a country where most of their health care resources are allocated to children's hospitals since they felt their money would be best invested in citizens that had a chance to be productive members of society one day. This is not saying that senoir citizens should be denied proper care, but we must realize that life has a beginning and an end. Instead of having ICUs full of 'living dead' we need to allow people to die with dignity. The latter requires that patients and their families understand the]

I really appreciate this post. Thank you for sharing. I struggled with the whole "why are we doing this" while I was rotating in the ICU recently.

 

[Tenesma]

that is a tough question

i had 2 cases as a resident - both were elderly men involved in MVAs - both had multi-ortho trauma, liver laceration, splenic rupture, one had an intra-cranial bleed and the other had an ascending aortic tear...

both of those cases were resuscitated to the FULL tilt --- and both left the hospital 6-8 weeks later to go to rehab... both were cognitively relatively intact.

while i was doing the cases i kept on telling myself how futile the efforts were (we unloaded over 120 units of PRBCS plus myriad other products into both of those puppies)... and i was proven wrong...

 

[VentdependenT]

If they crump in the OR they are going to get a full blast, balls to the wall, no holds barred, lenghtly resuscitation effort. We'll keep slammen em with stuff and compressions for a while despite asystole.

I have cranked that pacer to max gain on the floors (different story than the OR where the response to CV/Resp instability is immediate) and had em bouncen off the gurney at 80 bpm all the way to the MICU. Not fun but it gets the job done...

 

[militarymd]

You can't predict outcome in the OR....After some time in the ICU...outcome for critically patients can be better predicted, but still not 100%.

You don't have the chance to discuss things with the family.

You don't know what the patient's wishes are.

You are not a member of the Star Chamber.

You made a committment to save lives.

I think the answer is pretty simple.

 

[Frank Rizzo]

some good discussion so far. I think we all hope for those cases like tenesma was describing, where the pt beats all odds and survives..., truely medical miracles. I think it is that hope, along with the points Mil makes, that almost force us to keep pushing ahead. At some point though, it starts to get very fuzzy...

22 yo shot multiple times in abd arrives in ER via aircare, lethargic, pulse 140, BP 70/palp, large bore IVs/ trauma caths placed, level 1's running full tilt, no need to do a FAST as trauma surgeons know is abd is jacked up, to the OR in minutes, induced, abd splashed with betadine and ex-lap performed, massive injuries to most organs, as well as to abdominal aorta, during the controlled chaos, a-line is placed, and labs drawn. In the ten minutes it takes for the ABG to get back, you're pushing products as fast as you can. ABG returns pH 6.85, pO2 185 on 100%, pCO2 51 HCO3 25, Base Defecit -18, H/H 7/20. Surgeon tells you they're loosing a lot of blood (no sh1t), you continue to push products, and now a fair amount of pressors, including epi. Pt goes into V-fib once, CPR started, pt shocked, resumes sinus tach with pressure 68/42. More labs return, INR of 14, lactate of 12... you continue pooring products into a tank full of holes for another 30 minutes, repeat gas slightly better pH 7.01, defecit of -10. Surgical control of bleeding is getting better, but due largely to direct pressure being applied to aorta while aorta graft is placed and other large holes fixed and organs removed. Pt goes into V-fib again, CPR started, dfib times 3 gets resumes sinus tach, products conusmed to date now around 40 units PRBC, 40 FFP, two 10-pack of platelets and a unit of cryo. Surgeon states 'surgical bleeding' has stopped (a stretch by any means) but sees oozing and wants factor VII. Next set of coags return, and a little better, INR 7, fibrinogin 280, last platelet count was 120K. Codes again, after almost 5 minutes of multiple rounds of ACLS, pt still v-fib, good pressure (systolic 90 via aline) and pulse are felt thruoghout code via compressions... when do you stop???

Mil says you can't predict, but you know that anyone that rolls in with a pH of 6.85, BD of -18 and and a lactate of 12 doen't have very good odds. You also know that this was a previously healthy 22 yo male.

I'll tell you what we did, and how it ended later...

 

[urge]

22 yo shot multiple times in abd arrives in ER via aircare, lethargic, pulse 140, BP 70/palp, large bore IVs/ trauma caths placed, level 1's running full tilt, no need to do a FAST as trauma surgeons know is abd is jacked up, to the OR in minutes, induced, abd splashed with betadine and ex-lap performed, massive injuries to most organs, as well as to abdominal aorta, during the controlled chaos, a-line is placed, and labs drawn. In the ten minutes it takes for the ABG to get back, you're pushing products as fast as you can. ABG returns pH 6.85, pO2 185 on 100%, pCO2 51 HCO3 25, Base Defecit -18, H/H 7/20. Surgeon tells you they're loosing a lot of blood (no sh1t), you continue to push products, and now a fair amount of pressors, including epi. Pt goes into V-fib once, CPR started, pt shocked, resumes sinus tach with pressure 68/42. More labs return, INR of 14, lactate of 12... you continue pooring products into a tank full of holes for another 30 minutes, repeat gas slightly better pH 7.01, defecit of -10. Surgical control of bleeding is getting better, but due largely to direct pressure being applied to aorta while aorta graft is placed and other large holes fixed and organs removed. Pt goes into V-fib again, CPR started, dfib times 3 gets resumes sinus tach, products conusmed to date now around 40 units PRBC, 40 FFP, two 10-pack of platelets and a unit of cryo. Surgeon states 'surgical bleeding' has stopped (a stretch by any means) but sees oozing and wants factor VII. Next set of coags return, and a little better, INR 7, fibrinogin 280, last platelet count was 120K. Codes again, after almost 5 minutes of multiple rounds of ACLS, pt still v-fib, good pressure (systolic 90 via aline) and pulse are felt thruoghout code via compressions... when do you stop???

Mil says you can't predict, but you know that anyone that rolls in with a pH of 6.85, BD of -18 and and a lactate of 12 doen't have very good odds. You also know that this was a previously healthy 22 yo male.

I'll tell you what we did, and how it ended later...

-when pharmacy runs out of amiodarone.

 

[Gas]

It's these lawyers and our ignorant public. Doctors are under pressure to produce unrealistic miracles every day. Everyone feels they are entitled to everything, regardless of previous illness, prognosis, etc.

Physicians don't have much of a say. We can debate this issue all we want. The fact is you will be faulted in court for not doing everything possible, even if the prognosis was crappy to begin with. In residency, we had a 20-something year old male victim of car vs. pedestrain in NYC. I didn't do the case, so I don't remember every detail, but typical massive blood loss/resuscitation/arrest in the OR/prolonged ICU stay. The guy actually lives and walks out of the hospital.

He then sues the anesthesiologist for placing an NG tube improperly. Turns out the tube was not taped securely, and created a little area of skin necrosis on his nose from the tube leaning on it. The area of necrosis was like a few millimeters in size, but this guy was some kind of model, claimed his career was over, and sued for millions. Guess what - he won. Don't you love this system?

 

[coprolalia]

Recently a patient I was ready to give up on came back to the hospital for a visit. Walked in. Gave me a hug. Said, "Thank you for saving my life."

Don't play God. Use the tools you have and do the best you can.

-copro

 

[Dr Serenity]

It's these lawyers and our ignorant public. Doctors are under pressure to produce unrealistic miracles every day. Everyone feels they are entitled to everything, regardless of previous illness, prognosis, etc.

Physicians don't have much of a say. We can debate this issue all we want. The fact is you will be faulted in court for not doing everything possible, even if the prognosis was crappy to begin with. In residency, we had a 20-something year old male victim of car vs. pedestrain in NYC. I didn't do the case, so I don't remember every detail, but typical massive blood loss/resuscitation/arrest in the OR/prolonged ICU stay. The guy actually lives and walks out of the hospital.

He then sues the anesthesiologist for placing an NG tube improperly. Turns out the tube was not taped securely, and created a little area of skin necrosis on his nose from the tube leaning on it. The area of necrosis was like a few millimeters in size, but this guy was some kind of model, claimed his career was over, and sued for millions. Guess what - he won. Don't you love this system?

You're damned if you do, and you're damned if you don't...

 

[jetproppilot]

some good discussion so far. I think we all hope for those cases like tenesma was describing, where the pt beats all odds and survives..., truely medical miracles. I think it is that hope, along with the points Mil makes, that almost force us to keep pushing ahead. At some point though, it starts to get very fuzzy...

22 yo shot multiple times in abd arrives in ER via aircare, lethargic, pulse 140, BP 70/palp, large bore IVs/ trauma caths placed, level 1's running full tilt, no need to do a FAST as trauma surgeons know is abd is jacked up, to the OR in minutes, induced, abd splashed with betadine and ex-lap performed, massive injuries to most organs, as well as to abdominal aorta, during the controlled chaos, a-line is placed, and labs drawn. In the ten minutes it takes for the ABG to get back, you're pushing products as fast as you can. ABG returns pH 6.85, pO2 185 on 100%, pCO2 51 HCO3 25, Base Defecit -18, H/H 7/20. Surgeon tells you they're loosing a lot of blood (no sh1t), you continue to push products, and now a fair amount of pressors, including epi. Pt goes into V-fib once, CPR started, pt shocked, resumes sinus tach with pressure 68/42. More labs return, INR of 14, lactate of 12... you continue pooring products into a tank full of holes for another 30 minutes, repeat gas slightly better pH 7.01, defecit of -10. Surgical control of bleeding is getting better, but due largely to direct pressure being applied to aorta while aorta graft is placed and other large holes fixed and organs removed. Pt goes into V-fib again, CPR started, dfib times 3 gets resumes sinus tach, products conusmed to date now around 40 units PRBC, 40 FFP, two 10-pack of platelets and a unit of cryo. Surgeon states 'surgical bleeding' has stopped (a stretch by any means) but sees oozing and wants factor VII. Next set of coags return, and a little better, INR 7, fibrinogin 280, last platelet count was 120K. Codes again, after almost 5 minutes of multiple rounds of ACLS, pt still v-fib, good pressure (systolic 90 via aline) and pulse are felt thruoghout code via compressions... when do you stop???

Mil says you can't predict, but you know that anyone that rolls in with a pH of 6.85, BD of -18 and and a lactate of 12 doen't have very good odds. You also know that this was a previously healthy 22 yo male.

I'll tell you what we did, and how it ended later...

I'll tell you my take on these at-first-glance-looks-like-dude-needs-a-dirt-pillow cases.

Two thoughts:

1) These cases almost all the time go to university settings. Full of residents. This is where you learn your trade, and where the surgeons learn theirs. Take away these cases by stopping early all the time and your education would be a half-written novel.

2)Ya just never know. Some of these do-you-know-the-name-of-the-nearest-funeral-home cases walk outta the joint after heroic efforts. I've had several in eleven years. Not a ton, not alot, not many, but several.

A few of my several went home to productive lives and families that loved them.

A few of my several went back to gangsta lives and families who loved them.

Great topic.

I don't know the answer, Dude.

So I'll just post my thoughts.

 

[militarymd]

Recently a patient I was ready to give up on came back to the hospital for a visit. Walked in. Gave me a hug. Said, "Thank you for saving my life."

Don't play God. Use the tools you have and do the best you can.

-copro

that's happened to me enough times for me to know that ...you never know.

 

[jetproppilot]

that's happened to me enough times for me to know that ...you never know.

Amen!!

And I remember the dirt pillow saves I've been priveleged to experience in my eleven years of this private practice biz like they happened yesterday.

Have posted lengthy posts about some of them, if ya'll care to sift for them.

 

[deleted59964]

i've been in 2 situations where stopping resuscitation acutally saved the patient

1. single lung transplant - gas trapping post op in icu --> EMD ---> CPR/adrenaline etc --> eventually stop bagging --> L O N G expiration follows --> ST, BP 200/100

2. post CABG pt in ICU, hypotensive episode --> arrest --> CT surgeon reopens chest, CPR etc ... no use, stop CPR, graft seems somehow to become patent again --> MAP 60

-- not saying these are great examples of resuscitation just thought i'd share

 

[Frank Rizzo]

I'll tell you what we did, and how it ended later...

We continued ACLS for another couple of minutes, got a pulse and pressure back. Surgery lasted about another 1.5 hours with no more episodes of Vfib. Took him to SICU where he continued to ooze, but was stable. Factor VII given a second time later that night. Trouble ventilating on POD#1, bladder pressure high, taken back to OR for abd compartment syndrome, 2 days later, the patient went into a wide-complex vtach, code called after 45 min of ACLS. Final tally of blood products used during his few days with us... roughly 300 units of various blood products, and Factor VII x2.

I can't vouch for anything that happened in the SICU since I wasn't there, but I don't think I would have done anything different in the OR. I'd be lying though if I didn't admit that during the case, in the back of my mind, there was a nagging question... 'why are we doing this???... hes going to die.' I guess the answer is that you just never know... Hell, he made it out of the OR, and I didn't think that was going to happen!

 

[Tenesma]

if you look at it from a financial point of view then I would argue that we should be calling codes a LOT earlier....

if you look at it from an OR vs ICU point of view - it always surprised me how in the OR we tend to be way over-heroic and in the ICU we tend to give in a bit sooner... of course the surgeons know this, so they will pull the "lets transport to the ICU for the patient to stabilize - and then maybe take him back to the OR in a few hours", pack the patient's belly and transport only to call it 30 mins later in the ICU

like they say: nobody dies in the OR (well - during all my training I only saw one guy get called on the OR table - and he had advanced metastatic disease).

there is a line in the CPR textbooks that say we can call it if it appears to be futile --- with a ph <7.00 with multiple v-fib arrests i would have called it sooner... the problem with litigation is that the lawyer could always say: "well if you had given more amiodarone things may be different"

 

[ZA_Gasman]

I guess the decision depends on the case involved. I know that it seems to be soul destroying to cane it on a polytrauma case only for the guy to box in ICU 40 days down the line after his 17th relook laparotomy. However, I find that going all out on the ICU for patient with neutropaenic sepsis immensely satisfying. If we had to compare the cases, survival is probably similar. So where do we draw the line?

There has to be a point where we say this far, and no further. I have an unofficial line at our institution (level 1 trauma centre, at least one penetrating high velocity trauma per night), of 3mcg/kg/min adrenaline. Break that, and we start to look for reasons to stop. Sounds harsh, but it usually indicates more extensive problems, and DIC, hypothermia and sepsis are the handmaidens of this kind of inotropy.

I make no claims to have it, but knowing when to stop is an indicator of medical maturity. Someone once said, just becaus eyou can stand up in a canoe on a whitewater rapid, doesn't mean it is a good idea. Futility comes around more often that we think, and in a resource limited environment, we need to be aware of this and act accordingly. I'll get off my soapbox now....

 

[Arch Guillotti]

There has to be a point where we say this far, and no further. I have an unofficial line at our institution (level 1 trauma centre, at least one penetrating high velocity trauma per night), of 3mcg/kg/min adrenaline. Break that, and we start to look for reasons to stop.

3 mcg/kg/min of epi, damn.