Should We Code COVID19 Patients?

[SXMMD]

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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.

Agreed but I still have an issue with the ethical practice (or lack thereof) of lawyers. The impact of their work is devestating, but they aren't held to standards of accountability like we are (when was the last time a lawyer lost his license for winning a case, even when defendent was innocent?). I'm sure there is still some nobility in it somewhere (something something justice, rule of law), but I feel like in term of professional ethics law has fallen further than medicine...

 

[VA Hopeful Dr]

Agreed but I still have an issue with the ethical practice (or lack thereof) of lawyers. The impact of their work is devestating, but they aren't held to standards of accountability like we are (when was the last time a lawyer lost his license for winning a case, even when defendent was innocent?). I'm sure there is still some nobility in it somewhere (something something justice, rule of law), but I feel like in term of professional ethics law has fallen further than medicine...

In fairness, we rarely lose our licenses over just bad outcomes.

That aside, just like us, you'd have to convince a jury that the lawyer's screw up lead to definite harm (lawyers can be sued for malpractice same as we can). That's hard to do given the kind of work most lawyers do but it does happen.

 

[chocomorsel]

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

Totally not my experience. They coded and coded again and all eventually died.
Vtach, Vfib asystole. They all die again.
Only ones who do well are the ones who have respiratory arrest before they get a tube.

 

[Hamhock]

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....

All left the ICU for the floor and I suspect headed home or SNF/rehab (disposition is difficult).

All were already vented. One doesn't count for your purposes of the purposes of the EM community in general, as his trach was dislodged and most of what got him back was emergent replacement and then ventilation with a bit of ACLS.

Two others were (I think) brady arrests (I reviewed the tele carefully and bradycardia/asystole preceeded desaturation). Both times I was down the hall and so I didn't get a full sense of the immediate clinical course, but both responded to transient chest compressions with epi then atropine for one and the other just got atropine (as I heard the story quickly and had some experience at this point). Perhaps there was too much carvedilol complicating one of the cases.

I am not sure if these cases are relevant for COVID OOHCA or for arrest in the ED (although I suspect those are more likely pure hypoxia arrests); but I think they are very relevant as arguments against some administrators and "directors" who were pushing the idea of that all COVID ICU admits should be DNR.

Totally not my experience. They coded and coded again and all eventually died.
Vtach, Vfib asystole. They all die again.
Only ones who do well are the ones who have respiratory arrest before they get a tube.

Yeah, I hear you. There still seems to be more clinical heterogeneity than I would expect at this point in our understanding of COVID.

However, after returning to my primary hospital (the above arrests were at a "smaller" community hospital) I discussed COVID experiences with a few intensivists at the "bigger" house. They all had multiple brady arrest patients who responded to either epi or atropine quickly. In fact, a few patients, they said, had epi/atropine at the bedside and nurses were ready to respond and "save" a code. They looked at me like this was "obviously the way this disease acts".

Until we have a better understanding of this disease (at least to the sub-acute stage), I think administrative directives declaring all COVID ICU admits DNR are unacceptable.

Before my first week in the COVID unit, I heard the mortality of ventilated patients was 80%! ...which is obviously laughable now (vent mortality <10%)...we must increase our knowledge and experience much much more before committing our fellow townsfolk, family, and friends to DNR death by fiat.

HH

 

[chocomorsel]

All left the ICU for the floor and I suspect headed home or SNF/rehab (disposition is difficult).

All were already vented. One doesn't count for your purposes of the purposes of the EM community in general, as his trach was dislodged and most of what got him back was emergent replacement and then ventilation with a bit of ACLS.

Two others were (I think) brady arrests (I reviewed the tele carefully and bradycardia/asystole preceeded desaturation). Both times I was down the hall and so I didn't get a full sense of the immediate clinical course, but both responded to transient chest compressions with epi then atropine for one and the other just got atropine (as I heard the story quickly and had some experience at this point). Perhaps there was too much carvedilol complicating one of the cases.

I am not sure if these cases are relevant for COVID OOHCA or for arrest in the ED (although I suspect those are more likely pure hypoxia arrests); but I think they are very relevant as arguments against some administrators and "directors" who were pushing the idea of that all COVID ICU admits should be DNR.



Yeah, I hear you. There still seems to be more clinical heterogeneity than I would expect at this point in our understanding of COVID.

However, after returning to my primary hospital (the above arrests were at a "smaller" community hospital) I discussed COVID experiences with a few intensivists at the "bigger" house. They all had multiple brady arrest patients who responded to either epi or atropine quickly. In fact, a few patients, they said, had epi/atropine at the bedside and nurses were ready to respond and "save" a code. They looked at me like this was "obviously the way this disease acts".

Until we have a better understanding of this disease (at least to the sub-acute stage), I think administrative directives declaring all COVID ICU admits DNR are unacceptable.

Before my first week in the COVID unit, I heard the mortality of ventilated patients was 80%! ...which is obviously laughable now (vent mortality <10%)...we must increase our knowledge and experience much much more before committing our fellow townsfolk, family, and friends to DNR death by fiat.

HH

I think the mortality rate is region specific. It’s probably much closer to 80% in NYC and surrounding areas than it is in the South or Midwest. A paper just came out actually showing 88% or something.
But yeah, one size doesn’t fit all. But when the system is overwhelmed you focus on the ones most likely to survive.

 

[Hamhock]

I think the mortality rate is region specific. It’s probably much closer to 80% in NYC and surrounding areas than it is in the South or Midwest. A paper just came out actually showing 88% or something.
But yeah, one size doesn’t fit all. But when the system is overwhelmed you focus on the ones most likely to survive.

Right. There was a point in the beginning when I thought we were going to be overwhelmed (ie NYC) and I envisioned the mortality >50%...but we didn't get to that point, held on with traditional supportive CCM and we will be <10%.

I suspect higher mortality is due to the systems, clinicians, and communities becoming overwhelmed...of course, this is worse in cities with dense populations of baseline unhealthy people.

HH