Should We Code COVID19 Patients?

[WilcoWorld]

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They wanted me to intubate a 96-year old COVID positive patient last night. 96!!!

He was DNR/DNI but the spineless hospitalist made him "full code" because in his anxiety and hypoxia the patient apparently requested he be intubated.

Fortunately his ABG wasn't too bad, and I was able to punt this one so I didn't have to do something I considered unethical.

The fact that intubation was discussed or considered as a reasonable option is a problem. Someone needs to pull that hospitalist aside for an intervention.

Given:
-the low rate of survival to hospital discharge (and even lower rate of functional independence) after in-hospital cardiac arrest seen in observational studies
-the likelihood that someone with COVID19 who codes will have an even worse prognosis than the cohorts of those studies
-the fact that CPR+intubation is an intensely aerosolizing procedure
-the difficulty of maintaining appropriate PPE during a code

It would seem that the potential harm to other patients may make coding a COVID19 patient a strongly net-negative intervention.

So my question is: Should we institute a policy that makes all patients admitted to an ICU for COVID19 DNR? Why or why not?

Please:
-keep your posts factual, politics will not add to this discussion
-don't assume that your values are obvious to others; if you state the assumptions that you think can go unsaid then this discussion will be much more productive
-if you disagree with someone, address their argument or their assumptions, no ad hominem attacks

 

[bravotwozero]

ALL Patients? No. There's been younger patients with covid who ended up in the icu that survived and got discharged. ALL patients with an out of hospital cardiac arrest? Maybe.

In the US I don't see this happening though. I mean, NYC is pretty bad, to the point where Cuomo suspended med mal, but even then they didn't go this far...

 

[turkeyjerky]

To me, it seems reasonable to make intubated covid patients DNR. There's no realistic escalation of care beyond mechanical ventilation, and hence CPR is expected to be futile in these patients.

 

[ShockIndex]

I probably have a little different view on CPR than many non-intensivist or physicians from non-resuscitative specialities who offer CPR to everyone. I view mechanical circulatory support such as CPR is a bridge treatment for patients with a single failing organ system until definitive treatment can be established. We all probably agree that the quintessential example is a V-fib cardiac arrest as a bridge to defibrillation. On the other hand, CPR on patients with end-stage disease or multi-system organ failure generally futile with horrible outcomes because there is no definitive therapy.

When it comes to ARDS, patients late in the disease die from multisystem organ failure, not just hypoxia, and there is no definitive treatment once they lose their pulse. The odds of you resuscitating a patient with late ARDS to a good neurologic outcome is probably less than you infecting a member of your team in the process. So, for my patients who slowly deteriorate with ARDS with worsening PaO2:FO2, AKI, pressor requirements, shock liver, etc. I would typically consider the “code” everything done up to the point of cardiac arrest and turn off the monitor without chest compressions when they lose their pulse.

On the other hand, I might make certain exceptions in young, otherwise healthy patients early in the ARDS spectrum. Such situations include patients who lose their pulse peri-intubation.

 

[WilcoWorld]

ALL Patients? No. There's been younger patients with covid who ended up in the icu that survived and got discharged. ALL patients with an out of hospital cardiac arrest? Maybe.

In the US I don't see this happening though. I mean, NYC is pretty bad, to the point where Cuomo suspended med mal, but even then they didn't go this far...

Please note that my question was whether COVID19 patients who have suffered a cardiac arrest should be coded, not whether COVID19 patients should be admitted to the ICU. I completely agree with you that some patients with COVID19 will benefit from aggressive care and that aggressive care should be administered. I'm wondering if that aggressive care should continue after COVID19 has led to cardiac arrest.

 

[Rendar5]

Please note that my question was whether COVID19 patients who have suffered a cardiac arrest should be coded, not whether COVID19 patients should be admitted to the ICU. I completely agree with you that some patients with COVID19 will benefit from aggressive care and that aggressive care should be administered. I'm wondering if that aggressive care should continue after COVID19 has led to cardiac arrest.

I think it would be a dangerous precedent to have a blanket policy to not do cpr in all comers who have covid. A lot of these people won’t necessarily have confirmed cases at the time of an arrest. Some arrests such as Peri-intubation arrests may have a perfectly reasonable chance of a resuscitation. This really needs to be a case by case issue. Certainly an 80 year old with confirmed covid on a vent for 3 days goinginto arrest with multi organ failure should not be a candidate for cpr. And certainly a 29 year old physician going into arrest post intubation with isolated respiratory failure should.

 

[Groove]

I gotta get ready for a shift, so I'll post later, but for now, on a related note...don't you guys know attorneys are salivating during the COVID pandemic to see what policy shifts we make that end up potentially harming patients even though our intentions are good? I actually saw an attorney's website with the following: (sorry, I don't know how to make it smaller)

The future "asbestos" and mesothelioma attorney commercials will quickly become COVID related ones I would wager...

 

[Old_Mil]

Please:
-keep your posts factual, politics will not add to this discussion
-don't assume that your values are obvious to others; if you state the assumptions that you think can go unsaid then this discussion will be much more productive
-if you disagree with someone, address their argument or their assumptions, no ad hominem attacks

Personally, I think it's an easy call not to code a COVID patient, or really for that matter most who suffer a primary respiratory arrest not secondary to a directly correctable condition (pneumothorax, bacterial pneumonia, etc). Intubation and ventilation are bridge therapies, and in situations such as permanent lung damage secondary to fibrosis or in this case COVID, it doesn't make a lot of sense. In the latter case, you're probably looking at a Viral Pneumonia with ARDS. You tubed someone and put them on the vent in the first place to buy them time. The arrest is sort of an indication that their time ran out. Code them and bring them back to what exactly...?

If patients saw intubation and ventilation for what it really was as opposed to a cure, I think much of the concerns regarding this discussion would go away.

 

[VA Hopeful Dr]

Perhaps we can all at least agree that if they’re a medmal attorney they should not be coded. Ever.

There was a great EM blog that I read in med school, "all bleeding stops" where he took care of the attorney that sued him and called him a child killer in said trial.

 

[turkeyjerky]

I gotta get ready for a shift, so I'll post later, but for now, on a related note...don't you guys know attorneys are salivating during the COVID pandemic to see what policy shifts we make that end up potentially harming patients even though our intentions are good? I actually saw an attorney's website with the following: (sorry, I don't know how to make it smaller)

View attachment 300084
View attachment 300086

The future "asbestos" and mesothelioma attorney commercials will quickly become COVID related ones I would wager...

This is exactly why we need institutional policies to give us backup. Let the hospital take on the liability.

Also, lol at suing someone for not sending a test that does nothing to inform practice. "The doctor told me I had corona but he didn't test me. I want $$$"

 

[Angry Birds]

View attachment 300084
View attachment 300086

F*** this guy

 

[Hamhock]

I gotta get ready for a shift, so I'll post later, but for now, on a related note...don't you guys know attorneys are salivating during the COVID pandemic to see what policy shifts we make that end up potentially harming patients even though our intentions are good? I actually saw an attorney's website with the following: (sorry, I don't know how to make it smaller)

View attachment 300084
View attachment 300086

The future "asbestos" and mesothelioma attorney commercials will quickly become COVID related ones I would wager...

I am unable to identify this "guy" from your post. We should find who is posting this stuff and go all John Oliver on him. This is the kind of thing that physicians can certainly cause physicians to coalesce.

Identify the bastard!

HH

 

[GeneralVeers]

This is exactly why we need institutional policies to give us backup. Let the hospital take on the liability.

The hospital will never do that. They have no incentive to take any liability away from us. If we get into the situation where we run out of vents it will be entirely on us what happens.

 

[namethatsmell]

This is exactly why we need institutional policies to give us backup. Let the hospital take on the liability.

Also, lol at suing someone for not sending a test that does nothing to inform practice. "The doctor told me I had corona but he didn't test me. I want $$$"

Yup totally agree on both points.

The medmal lawyer's examples are hysterical. They would never hold water, though yeah sure some desperate medmal lawyers may try. That will be both pathetic and awful in the short term. In the long term though it could be good if the lawyers tried anyway to the point where states felt to compelled to engage in some meaningful tort reform to push back on the medmal lunacy. Docs all over the country are finally starting to grow a pair...and I think many of us will have no hesitation to seek greener pastures by changing jobs or entering non-medical fields if we remain punching bags for society even after the pandemic ends.

The hospital will never do that. They have no incentive to take any liability away from us. If we get into the situation where we run out of vents it will be entirely on us what happens.

False.

If you're employed by a hospital that self-insures than everybody is on the same team and policy. Many places with this setup routinely get their docs removed from suits.

 

[GeneralVeers]

Yup totally agree on both points.

The medmal lawyer's examples are hysterical. They would never hold water, though yeah sure some desperate medmal lawyers may try. That will be both pathetic and awful in the short term. In the long term though it could be good if the lawyers tried anyway to the point where states felt to compelled to engage in some meaningful tort reform to push back on the medmal lunacy. Docs all over the country are finally starting to grow a pair...and I think many of us will have no hesitation to seek greener pastures by changing jobs or entering non-medical fields if we remain punching bags for society even after the pandemic ends.



False.

If you're employed by a hospital that self-insures than everybody is on the same team and policy. Many places with this setup routinely get their docs removed from suits.

Huh? A hospital that pays for the doctor's insurance? This might exist in a few academic centers or hospital systems (Kaiser) but it's not the norm in the vast majority of the country.

 

[namethatsmell]

Huh? A hospital that pays for the doctor's insurance? This might exist in a few academic centers or hospital systems (Kaiser) but it's not the norm in the vast majority of the country.

It's true that it's not the norm, but it's also not as unusual as you may think. I've interviewed/worked at multiple places with this or similar setups. You have to look for it, but if you do you may find it more frequently than you'd expect. I've found it's most common in large systems where it makes sense for them to self-insure.

I've also found some unexpected medmal protection at smaller places as we'll, ie the equivalent of sovereign immunity for their docs granted by the state due to the amount of charity care a hospital provides. And these aren't big/fancy academic places.

I also don't get why the massive CMGs don't self-insure at this point. It'd be a major recruiting tool for them by giving them the ability to remove their docs from suits when appropriate (ie unless the doc does something insane). I mean, the CMG is paying for a massive amount of policies anyway...why not use it as a way to breed loyalty and to...*gasp*...actually make docs' lives better?

 

[cyanide12345678]

If i code as a 31 yo, i sure as hell hope someone does compressions on me

 

[Birdstrike]

If people are full code, you should intubate. If DNR/Do-not-intubate, then you should not. Keep it simple. Trying to justify going against their wishes based on a COVID-19 diagnosis is just inviting second guessing by sue-happy families after the fact. On the other hand, if you find yourself in a mass casualty situation with more patients needing intubations than vents and ET tubes, then all bets are off. You go back to mass casualty, triage basics, viable/non-viable, etc.

 

[WilcoWorld]

Some new data that might inform the discussion:

Here's a link to the article, abstract abbreviated below (emphasis mine):

Objective
To describe the characteristics and outcomes of patients with severe COVID-19 and in-hospital cardiac arrest (IHCA) in Wuhan, China.

Methods
The outcomes of patients with severe COVID-19 pneumonia after IHCA (n Wuhan, China ) over a 40-day period were retrospectively evaluated...collected according to the Utstein style. The primary outcome was restoration of spontaneous circulation (ROSC), and the secondary outcomes were 30-day survival, and neurological outcome.

Results
Data from 136 patients...ONE patient achieved a favourable neurological outcome at 30 days.

Conclusion
Survival of patients with severe COVID-19 pneumonia who had an in-hospital cardiac arrest was poor in Wuhan.

 

[Vandalia]

Several states, I know of New York in particular, have raised the standard to prove malpractice during a declared emergency to a showing of "gross negligence."

 

[Dr Mantis Toboggan]

Several states, I know of New York in particular, have raised the standard to prove malpractice during a declared emergency to a showing of "gross negligence."

useful, but I imagine the airwaves in 2 years in the tri-state area will be littered with “did you lose a loved one to corona virus in 2020?!?. Call the law firm of...”

all it takes is one expert willing to hyperbolize their opinion that you provided grossly negligent care.

 

[southerndoc]

Several states, I know of New York in particular, have raised the standard to prove malpractice during a declared emergency to a showing of "gross negligence."

This is the standard 24/7 in Georgia and should be the standard nationwide.

 

[deleted109597]

The good news, is nobody is watching. No family.
So yes, you code them to the standards of care we provide.
Full PPE first.
No compressions until intubated. If already intubated, no disconnecting the circuit without tube clamp or filter in place (should have, but many don't).
Then compressions. If prone, these are ineffective. Must flip.
After all that, if they still have a workable rhythm, then give it a go. Just don't spend all day in there, and more importantly, don't make anyone else sick.

 

[MediMike]

What standards are you basing the no compressions until intubated on? Heard this from a local EMS crew and honestly can't find anything anywhere about it.

 

[deleted109597]

What standards are you basing the no compressions until intubated on? Heard this from a local EMS crew and honestly can't find anything anywhere about it.

Compressions cause aerosolization. Basically you're making them breathe. It's why compression only CPR works.
So, no. Gotta filter that stuff out.

 

[MediMike]

Right I get that, but if you're in appropriate PPE I don't see any reason to hold compressions until intubation is complete. Also haven't seen statements from any organization or guidelines published to suggest that. AHA does suggest pausing compressions for intubation and throwing something over their face until it's complete.

Knowing that the presenting "symptom" of COVID can be dropping over dead you're effectively going to take every resuscitation back to ABC over CAB, if it's a crap-show of an airway you may end up bringing back a can of green beans rather than a patient.

But you know all of this and clearly are making decisions based on personal assessment of risk, just wanted to make sure that I hadn't missed a new "standard".

Be safe!

 

[deleted109597]

The more infectious material in the air, the higher the risk. Even with PPE, even with likely inappropriate donning and doffing. It's just a thing

Knowing that the presenting "symptom" of COVID can be dropping over dead you're effectively going to take every resuscitation back to ABC over CAB, if it's a crap-show of an airway you may end up bringing back a can of green beans rather than a patient.

If they're actually COVID and their heart stops, for literally any reason, they're pretty much DRT. There isn't much to correct there. Even if you were getting ready to tube them when the code happened, they're still going to die.
If they're not COVID and it's a defibrillatable arrhythmia, the chances are still not that great.

 

[lymphocyte]

I think we should act within the limits of what's safe, but having committee-mandated limits of care does not seem right either. I do not believe in policy-based medicine. The are way too many variables. And the observational data are skewed by much older co-morbid patients anyways.

There was a great NYT article just published about a 45 year old ED physician from the Evergreen cluster that went onto ECMO with multi-organ failure and made a full recovery. If he arrested during his admission, would anybody have supported a blanket policy to not initiate ACLS?

He Was a Doctor Who Never Got Sick. Then the Coronavirus Nearly Killed Him. (Published 2020)

Dr. Ryan Padgett, 45, once played in the Rose Bowl for Northwestern. He had rarely missed a day of work to illness. Then the coronavirus took him to the brink of death.

nyti.ms

 

[bravotwozero]

So happy to see he made a recovery, even though never met the guy. I hope there's no long term sequelae to his lungs

 

[deleted109597]

I think we should act within the limits of what's safe, but having committee-mandated limits of care does not seem right either. I do not believe in policy-based medicine. The are way too many variables. And the observational data are skewed by much older co-morbid patients anyways.

There was a great NYT article just published about a 45 year old ED physician from the Evergreen cluster that went onto ECMO with multi-organ failure and made a full recovery. If he arrested during his admission, would anybody have supported a blanket policy to not initiate ACLS?

He Was a Doctor Who Never Got Sick. Then the Coronavirus Nearly Killed Him. (Published 2020)

Dr. Ryan Padgett, 45, once played in the Rose Bowl for Northwestern. He had rarely missed a day of work to illness. Then the coronavirus took him to the brink of death.

nyti.ms

We do not practice medicine based on anecdotes.
We do not practice medicine based on anecdotes.
We do not practice medicine based on anecdotes.

 

[WilcoWorld]

I think we should act within the limits of what's safe, but having committee-mandated limits of care does not seem right either. I do not believe in policy-based medicine. The are way too many variables. And the observational data are skewed by much older co-morbid patients anyways.

There was a great NYT article just published about a 45 year old ED physician from the Evergreen cluster that went onto ECMO with multi-organ failure and made a full recovery. If he arrested during his admission, would anybody have supported a blanket policy to not initiate ACLS?

He Was a Doctor Who Never Got Sick. Then the Coronavirus Nearly Killed Him. (Published 2020)

Dr. Ryan Padgett, 45, once played in the Rose Bowl for Northwestern. He had rarely missed a day of work to illness. Then the coronavirus took him to the brink of death.

nyti.ms

He didn't arrest. So his case is not relevant to this discussion. His cardiovascular collapse was stopped in advance by ECMO. If the discussion was "Should We Put Front Line Providers Who Contract SARS-2 On ECMO", then his case may be relevant.

 

[deleted109597]

He didn't arrest. So his case is not relevant to this discussion. His cardiovascular collapse was stopped in advance by ECMO. If the discussion was "Should We Put Front Line Providers Who Contract SARS-2 On ECMO", then his case may be relevant.

Also, if he arrests on ECMO, then he doesn't "die" per se. But if the heart doesn't start back up, then yeah, he's dead.

 

[Hamhock]

Over the past few week in my ICU, we have "coded" three times. Each were easy resuscitations (basically ventilation/oxygenation and atropine). All three left the ICU at the end of my week.

HH

 

[BAM!]

Over the past few week in my ICU, we have "coded" three times. Each were easy resuscitations (basically ventilation/oxygenation and atropine). All three left the ICU at the end of my week.

HH

This discussion isn't about symptomatic bradycardia. It's about pulseless arrest.

 

[RustedFox]

Over the past few week in my ICU, we have "coded" three times. Each were easy resuscitations (basically ventilation/oxygenation and atropine). All three left the ICU at the end of my week.

HH

But how did they leave the ICU?
Step-down, or DC to JC?

 

[Birdstrike]

We do not practice medicine based on anecdotes.
We do not practice medicine based on anecdotes.
We do not practice medicine based on anecdotes.

Yes you do.

 

[Birdstrike]

Our practice of medicine is heavily influenced by our clinical experience. Our clinical experience is the sum total of our personal anecdotes.

 

[Brigade4Radiant]

We do not practice medicine based on anecdotes.
We do not practice medicine based on anecdotes.
We do not practice medicine based on anecdotes.

Actually we do hence the art in medicine and case reports are anecdotes.

 

[deleted109597]

I simply can't anymore.
I have to deal with people actively denying science all day every day.
I wouldn't expect physicians to also do so, but here it is.

 

[Apollyon]

I simply can't anymore.
I have to deal with people actively denying science all day every day.
I wouldn't expect physicians to also do so, but here it is.

Come on, dude. There's quite a wide gulf between "science denial" and EM docs (among other docs) using what works best for them, even if, for some dumb, unreviewed, vague reason it works. When you're a med student, you have to show your work. When in practice, you use science, I spin around three times and bark at the moon, and we both get the result we hope. When someone else does what I do, and it fails, that's kismet, or gestalt, or whatever, but that's because they can't repeat what I do, on the molecular level. If I don't know why it works, I certainly can't explain how to do it to you.

But, for you to say there's black letter science denial, as I say, that's a reach.

 

[Birdstrike]

We should use science. Have a medical student follow you around all day and every time you make a clinical decision he asks you, "What level I evidence did you use to make that decision?" You can't do it as often as you think. We augment the science with the Art of Medicine, often.

Or tell your CEO your failing Press-Ganey scores were because, "I did what science told me." You can't. It's the Customer Service of Medicine

"Medicine in 2020 = 1/3 Science, 1/3 Art, 1/3 Customer service" -Greek Philosopher, Birdstricrotes

 

[Birdstrike]

There was a great EM blog that I read in med school, "all bleeding stops" where he took care of the attorney that sued him and called him a child killer in said trial.

I once took care of a local malpractice attorney for his heart attack. A few years later he sued me for a case where I was innocent. During a deposition he tried to rattle me by asking, "Are you on drugs!?"

After an uproarious round of objections by attorneys, I answered with a deadpan, "No."

I was eventually dropped from the case, which I wrote about here. But I'll never forget having saved this guy's life only to turn around later and he falsely accuses me of malpractice and slanders me in court.

 

[thegenius]

I once took care of a local malpractice attorney for his heart attack. A few years later he sued me for a case where I was innocent. During a deposition he tried to rattle me by asking, "Are you on drugs!?"

After an uproarious round of objections by attorneys, I answered with a deadpan, "No."

I was eventually dropped from the case, which I wrote about here. But I'll never forget having saved this guy's life only to turn around later and he falsely accuses me of malpractice and slanders me in court.

Unbelievable.

Did your attorney know that you helped save his life?

 

[thegenius]

We should use science. Have a medical student follow you around all day and every time you make a clinical decision he asks you, "What level I evidence did you use to make that decision?" You can't do it as often as you think. We augment the science with the Art of Medicine, often.

Or tell your CEO your failing Press-Ganey scores were because, "I did what science told me." You can't. It's the Customer Service of Medicine

"Medicine in 2020 = 1/3 Science, 1/3 Art, 1/3 Customer service" -Greek Philosopher, Birdstricrotes

Yea I think largely there isn't science to back up most of our medical decision making.

It's kind of nice to tell patients "Well, in fact the science around your treatment is settled. They have done numerous studies and the answer is to NOT give antibiotics." Can't say that too often.

 

[Birdstrike]

Unbelievable.

Did your attorney know that you helped save his life?

I'm sure he did although I never brought it up. It wouldn't be worth spending the extra five seconds in the presence of the guy to find out. But my assumption is that he did. That's the kind of thing you never forget: The face of the doc when you're in the ED with your MI.

 

[VA Hopeful Dr]

I'm sure he did although I never brought it up. It wouldn't be worth spending the extra five seconds in the presence of the guy to find out. But my assumption is that he did. That's the kind of thing you never forget: The face of the doc when you're in the ED with your MI.

Lawyers look at this stuff as just business. Attorneys on different sides of a case like this can go get a beer after the case.

We don't see it that way. Be nice if we could.

 

[Apollyon]

Lawyers look at this stuff as just business. Attorneys on different sides of a case like this can go get a beer after the case.

We don't see it that way. Be nice if we could.

Because those pieces of **** look at it as a game; they aren't the ones that can't sleep, or get chronic GI issues, or start drinking/drink more. No matter what people on here say ("not worth it/cost of doing business/NBD"), because of who we are, we take it personally. For the lawyer ****bags, it's strictly a paycheck. You're right, absolutely, but it stinks of (to the point of reeking) either a personality disorder, or just being a ****ty person.

 

[thegenius]

You know, I've had fantasies about saving some guys life in the ED, and I somehow find out that he's a wealthy guy who has golf membership(s) at various elite golf clubs. Like Cypress Point in Monterey or The San Francisco Golf Club in SF. He comes back later after he's recovered and said "is there anything I can do to thank you?" and I say "Nah...not really. I'm just doing my job. Well.....hmm......well maybe there is something....can you get me into Cypress Point?"

That's my dream.

(Well....my dream actually is to go back in time and follow the Dead around for a few years in the Early 70s. with a full bank account and a steady supply of money. Nothing worse than being a hippie than being a broke ass hippie, which most hippies are . I wouldn't be a hippie but maybe be close)

 

[turkeyjerky]

Over the past few week in my ICU, we have "coded" three times. Each were easy resuscitations (basically ventilation/oxygenation and atropine). All three left the ICU at the end of my week.

HH

Can you elaborate on the circumstances? Were these patients already vented? If so, were they experiencing a progressive decline, or was there a sudden precipitant, such as tube displacement or something like that?

Also, I'm assuming you mean they left your ICU to the floor or home, not to the morgue....

 

[VA Hopeful Dr]

Because those pieces of **** look at it as a game; they aren't the ones that can't sleep, or get chronic GI issues, or start drinking/drink more. No matter what people on here say ("not worth it/cost of doing business/NBD"), because of who we are, we take it personally. For the lawyer ****bags, it's strictly a paycheck. You're right, absolutely, but it stinks of (to the point of reeking) either a personality disorder, or just being a ****ty person.

Its all in the training. We're trained to sacrifice a lot for our patients, to worry about them even when we go home, and to care about the outcomes.

They're trained to follow the rules of a game only they know how to play and to realize its only a job and what they do doesn't matter once its done.