Would you do this case?

[drrosenrosen]

Last case of the day yesterday - an endoscopist who always brings us sick pts. 69 y/o female, he tells me that she coded (!) last time he tried to do this procedure (push enteroscopy). So I review her old chart - indeed, 60 mg propofol, case begins, brady -> asystole. So now I review her chart - CAD, HTN, CHF, COPD - the usual. SPECT from 2005 shows major scarring throughout the left ventricle with EF of 27%. Echo from 1/07 shows EF 20%, sever PHTN. No cardiac workup or EKG since 1/07. Pt was admitted overnight from OSH where she came in for massive BRBPR, hgb was down to 5, tx'd 4 units at OSH. Now hgb is 9, she has a RIJ TL in, but she still looks like ****. Other factor is that she has anoxic brain injury from last code and has major cognitive deficit. So her daughters are there. One is an LPN, thinks she knows everything there is to know about medicine, and is the offical healthcare proxy. She wants to go ahead no matter what, and is somewhat aggressive on this point. The other daughter doesn't matter legally, but wants to stop agressive care. So I've got a sick as hell pt, a family conflict, and a case that will take anywhere from 45 min to 150 min with a potential for blood loss, in the endo suite at 1730. What would you do?

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[Planktonmd]

Last case of the day yesterday - an endoscopist who always brings us sick pts. 69 y/o female, he tells me that she coded (!) last time he tried to do this procedure (push enteroscopy). So I review her old chart - indeed, 60 mg propofol, case begins, brady -> asystole. So now I review her chart - CAD, HTN, CHF, COPD - the usual. SPECT from 2005 shows major scarring throughout the left ventricle with EF of 27%. Echo from 1/07 shows EF 20%, sever PHTN. No cardiac workup or EKG since 1/07. Pt was admitted overnight from OSH where she came in for massive BRBPR, hgb was down to 5, tx'd 4 units at OSH. Now hgb is 9, she has a RIJ TL in, but she still looks like ****. Other factor is that she has anoxic brain injury from last code and has major cognitive deficit. So her daughters are there. One is an LPN, thinks she knows everything there is to know about medicine, and is the offical healthcare proxy. She wants to go ahead no matter what, and is somewhat aggressive on this point. The other daughter doesn't matter legally, but wants to stop agressive care. So I've got a sick as hell pt, a family conflict, and a case that will take anywhere from 45 min to 150 min with a potential for blood loss, in the endo suite at 1730. What would you do?

There is 2 likely causes for her previous cardiac arrest:
1- Hypoxia leading to rapid desaturation in this pt with Pulmonary hypertension.
2- Severe vagal response.

Regardless of what happened previously she is now actively bleeding and something needs to be done as long as the health care surrogate requests it.
From the presentation you described it appears that the safest way to do this would be to secure the airway and guarantee proper oxygenation during the procedure, and because of all the other factors you mentioned I would leave her intubated and send her to ICU where they hopefully are going to properly manage her volume status and wean her gradually of the ventilator when she is more stable.

 

[Planktonmd]

And one more thing: Don't be too aggressive with your induction drugs

 

[powermd]

There is 2 likely causes for her previous cardiac arrest:
1- Hypoxia leading to rapid desaturation in this pt with Pulmonary hypertension.
2- Severe vagal response.

Regardless of what happened previously she is now actively bleeding and something needs to be done as long as the health care surrogate requests it.
From the presentation you described it appears that the safest way to do this would be to secure the airway and guarantee proper oxygenation during the procedure, and because of all the other factors you mentioned I would leave her intubated and send her to ICU where they hopefully are going to properly manage her volume status and wean her gradually of the ventilator when she is more stable.

This entitlement bullsh*t has got to stop at some point in this country.

The public must be taught how to accept DEATH. They certainly aren't going to figure it out on their own.

It's obvious to all, except the irrational health proxy, that this is a futile procedure guaranteeing nothing except a drain on valuable resources, and prolonged agony for the patient, family, and caregivers.

Who is approving payment for these futile procedures in the anoxic-brain-injured critically ill? If the payment system won't step up to the plate, doctors should. The family is going to sue anyway. Doing the futile procedure isn't going to change that.

 

[Planktonmd]

This entitlement bullsh*t has got to stop at some point in this country.

The public must be taught how to accept DEATH. They certainly aren't going to figure it out on their own.

It's obvious to all, except the irrational health proxy, that this is a futile procedure guaranteeing nothing except a drain on valuable resources, and prolonged agony for the patient, family, and caregivers.

Who is approving payment for these futile procedures in the anoxic-brain-injured critically ill? If the payment system won't step up to the plate, doctors should. The family is going to sue anyway. Doing the futile procedure isn't going to change that.

Throughout your career as an anesthesiologist you might find yourself in situations where you feel strongly that a certain treatment or procedure is futile but in the real world (I mean private practice) you need to choose your battles carefully.
It's not always Black or White, actually most of the times it's some shade of gray!

 

[Noyac]

This entitlement bullsh*t has got to stop at some point in this country.

The public must be taught how to accept DEATH. They certainly aren't going to figure it out on their own.

It's obvious to all, except the irrational health proxy, that this is a futile procedure guaranteeing nothing except a drain on valuable resources, and prolonged agony for the patient, family, and caregivers.

Who is approving payment for these futile procedures in the anoxic-brain-injured critically ill? If the payment system won't step up to the plate, doctors should. The family is going to sue anyway. Doing the futile procedure isn't going to change that.

You have learned well young grasshopper.

 

[Noyac]

I would probably do the case but I will offer another approach.

Get medical ethics involved. They will probably say "do the case". But now you have started to make others (family) think about their actions and you are now on record with your concerns should things go badly.

This is almost a Terri Shivo (?) case.

As Plank said, take her to the ICU tubed.

 

[Noyac]

Another thought, I assume she is anticoagulated. If so can she be reversed with FFP/PLTS and watched for a period of time?

 

[drrosenrosen]

So I talked with my attending about this one - he's one of the more cautious attendings at my hospital - and he decided that we should cancel pending at least a new EKG and cardiologist's note. I have a feeling that this is more for medicolegal reasons than anything else, since what are you going to learn about her that you don't already know? She has a sh*tty heart - a cardiac workup's not going to change that. She still stands as an ASA 4 with that heart, and although the procedure's not going to do anything in terms of long term survival, she needs to have it as long as that remains the plan. I talked to another attg about this case, she said she'd do it with a pre-induction aline, cardiac induction (i.e., narcotics only), run little or no gas, and leave her tubed postop. I feel bad to play a part in having this woman die in the SICU intubated rather than at home, but that's american medicine today, I guess. what do y'all think about the decision to cancel?

 

[Noyac]

what do y'all think about the decision to cancel?

Its wacked!

And why add more workup to a pt like this when what you have is fairly recent <1yr.

Cardiac induction with narc's only? Why? Not my plan for sure. But it will get the job done.

 

[jetproppilot]

So I talked with my attending about this one - he's one of the more cautious attendings at my hospital - and he decided that WE SHOULD CANCEL PENDING AT LEAST A NEW EKG AND A CARDIOLOGIST'S NOTE.....

HAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHA


Man, academic dudes crack me up.

Plank said it the best. This lady is bleeding.....family wants something done.

Yes, my thoughts are more along the lines with PowerMD from an ethical standpoint, but we are consultant physicians. Who am I to judge the primary dude's desire to do something for this lady? Whaddya gonna say to the primary dude...."Sorry bro, can't help you in this actively bleeding lady."

Only in academics do obstructionalist tactics like the above occur.

Elective case? Completely different story.

Emergency case? Do whatcha gotta do, then render your opinion on the case's ethics after you are done. May steer the primary dude down another path should the patient "need" another procedure.

 

[powermd]

HAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHA


Man, academic dudes crack me up.

Plank said it the best. This lady is bleeding.....family wants something done.

Yes, my thoughts are more along the lines with PowerMD from an ethical standpoint, but we are consultant physicians. Who am I to judge the primary dude's desire to do something for this lady? Whaddya gonna say to the primary dude...."Sorry bro, can't help you in this actively bleeding lady."

Only in academics do obstructionalist tactics like the above occur.

Elective case? Completely different story.

Emergency case? Do whatcha gotta do, then render your opinion on the case's ethics after you are done. May steer the primary dude down another path should the patient "need" another procedure.

I agree with your point that we are consultant physicians here, and as such, the decision has already been made to proceed. I certainly would not obstruct at that point, except perhaps to put my opinion on record. Whether or not that's meaningful, I don't know.

My point was that this nonsense needs to stop at the source. This patient should not be considered a candidate for the endoscopy, period. The GI should have stepped up on this one, and had a real "goals of care" talk with the family. Remember, this patient is barely a person at this point. Maybe we can "save" her in the short term. But should we? The answer to that question ought not to be left entirely to the grieving, irrational family members.

 

[UTSouthwestern]

It's definitely wise to pick your battles. At times you may feel a procedure is futile, and in a family conflict situation, nothing becomes easier.

Case in point: Case from Monday - 67 y/o male with 100+ pack year history, severe emphysema, severe mitral stenosis (MVA 1.1 cm by cath, 1.3 by TEE), 8 episodes of florid CHF in past 9 months, 4 months total of hospitalization, PA pressures 90/60 in cath lab, 70's/40's on iNO, HTN, GERD, hypothyroidism, borderline DM. Patient waffling on whether to proceed or just die, family tells him "you've had a good life, we don't want to see you suffer." He decides at the last minute to go ahead with surgery.

I see cross signs on his eyelids, but I won't let him die in the OR.

Go back after awake A line and 14 ga IV in. No premeds. Have him hyperventilate himself for 5 minutes (literally told him to breath a hundred times a minute). Versed 5 mg, propofol 80 mg, esmolol 30 mg, sux, tube in, Nimbex given, hyperventilate patient to EtCO2 of 24. CVP, PAC, and TEE go in and patient has opening PAP of 60/38. Get the nitro going, have nitric oxide ready to go. Procedure gets started and after 3 hour pump run (heavily calcified mitral annulus, eccentric annulus, 3 jumps, slow surgeon), patient flies off pump with milrinone, levophed, and overdrive pacing to 90 bpm with PR interval extended to 0.2.

Take him back to ICU after a tail bolus of 0.4 mg of Dilaudid. In ICU 10 minutes after arrival, patient wakes up fully, comfortable, pulmonologist and I agree on extubation with his numbers looking good.

Saw him today, and he is out of bed in a chair, Swan shows PAP 38/17, even though he is asleep and snoring, and off all meds. Wake him up and listen to his lungs and he has NO crackles whatsoever and he is heading to stepdown and then home in two or three days.

It was a difficult choice that even the patient himself wasn't sure of, but the pathology was clear as was the solution. It's a delicate balance we strive to maintain as physicians that must see both the utility and futility of the procedures we do and decisions we make. Just make sure that you aren't swayed one way or the other by too many voices.

 

[huktonfonix]

Good stuff UT. Thats why I love this board. The idea of having them hyperventilate themselves is great. Gonna try that on my next few pulm htnsives. sometimes we're so used to taking over everything for the patient that we forget that an awake cooperative pt. can do a lot of things for themselves, i.e. valsalva to blow up the IJ for line placement.

 

[Laurel123]

Whoa! From what I gathered, this case is emergent and we have some near death woman bleeding out her gut.. There is no time for a cardiac workup! And then the question is what you would do with the information frm a cardiac workup. Put a stent in? Cabg?

If the family wants something done then I would tell them about how sick she is blah blah blah, tube her with versed and maybe a little relaxant and do what we have to do. Probably put in an aline and some large bore ivs.

 

[Tenesma]

guys

this is an easy case...

1) health proxy requests it
2) patient (kinda) needs it considering bleeding issue
3) she had an anoxic arrest - so technically there isn't much brain tissue

therefore

1) no anesthesia
2) just paralyze her
3) intubate
4) give her some beta blockers and a touch of fentanyl here and there
5) and also get the gen surgeons involved so they can either trach her if she is still stable or put her on the list to be trached in the next few days

and also find out if she is DNR because if she goes asystolic again you can just leave the epi syring alone...

don't see much complexity to this case

oh... and skip the BIS monitor...

 

[jetproppilot]

I agree with your point that we are consultant physicians here, and as such, the decision has already been made to proceed. I certainly would not obstruct at that point, except perhaps to put my opinion on record. Whether or not that's meaningful, I don't know.

My point was that this nonsense needs to stop at the source. This patient should not be considered a candidate for the endoscopy, period. The GI should have stepped up on this one, and had a real "goals of care" talk with the family. Remember, this patient is barely a person at this point. Maybe we can "save" her in the short term. But should we? The answer to that question ought not to be left entirely to the grieving, irrational family members.

Very well said.

Rhetorical, but well said.

And it'll remain rhetorical, in this litiginous american society we live in, until there are broad standard-of-care-like decisions made that are accepted by, and instituted by physicians who firmly help families make difficult decisions.... that seem counterintuitive to them in the moment...through trying times.

 

[drrosenrosen]

The case was not as emergent as y'all seem to think. She was hemodynamically stable, hct was stable, she was not bleeding at the moment. So yes, it needed to be done because she definitely has a bleeding AVM in her small bowel, but it's not like she was exsanguinating from her rectum before my eyes. I felt like I could have pushed this attending to go through with the case, but was not feeling the most comfortable with how to do it myself, and he was not the attending you'd want to have with you when things go badly. Ours is a more graduated, heirarchical program and as a new CA-2, I don't have a ton of experience dealing with real sickies (e.g., I've never done a cardiac case - cardiac rotation is next month) So with this guy at my side, I was willing to let him say cancel, since I knew that when the **** hit the fan, he'd be not much help. I recognized it as a soft call, and I knew that the cardiologist wasn't going to tell us anything that would alter managemnet. Rookie mistake, I guess. If I'd have felt more comfotable doing the case myself, I would have gone ahead with it, but at this point in my training, I was honestly a little nervous about it, and let the attending stall. Lesson learned, I guess. I appreciate everybody's input on this case.

 

[jetproppilot]

The case was not as emergent as y'all seem to think. She was hemodynamically stable, hct was stable, she was not bleeding at the moment. So yes, it needed to be done because she definitely has a bleeding AVM in her small bowel, but it's not like she was exsanguinating from her rectum before my eyes. I felt like I could have pushed this attending to go through with the case, but was not feeling the most comfortable with how to do it myself, and he was not the attending you'd want to have with you when things go badly. Ours is a more graduated, heirarchical program and as a new CA-2, I don't have a ton of experience dealing with real sickies (e.g., I've never done a cardiac case - cardiac rotation is next month) So with this guy at my side, I was willing to let him say cancel, since I knew that when the **** hit the fan, he'd be not much help. I recognized it as a soft call, and I knew that the cardiologist wasn't going to tell us anything that would alter managemnet. Rookie mistake, I guess. If I'd have felt more comfotable doing the case myself, I would have gone ahead with it, but at this point in my training, I was honestly a little nervous about it, and let the attending stall. Lesson learned, I guess. I appreciate everybody's input on this case.

Dude, when you are a resident it aint your call. So when you said you made a rookie mistake, you didnt. No criticism of you at all. Just opinions about your attending's decisions.

Tenesma posted about the fact that she had an anoxic brain injury so just paralysis may be ok......I think when an insult to the brain occurs we are sometimes too quick to assume that its an irreversible thing....case in point....preopped a 37 year old lady admitted for acute cholecyctitis & biliary colic....in hospital a cuppla days...once her LFTs chilled out a bit she was scheduled for lap chole. Anyway, like I said I preopped her the night before. Skinny lady, only previous surgery breast augs, smoker, no other issues.

Next morning I come in, run into the surgeon.....lady coded that night..
Family member in room awakened by pt making unusual snoring noises....nurse called....pt unresponsive, nurse calls code team, lady has episode of v fib while code team is present, shocked, converted, intubated, etc etc.

Transferred to ICU, pupils large and unresponsive. Everyone in shock....many studies done....I thought surely an embolic event but no evidence of PE.....no real underlying issue found to explain what happened.

Several days go by, no change.

About day 4 or 5 she wakes up, albeit slowly....begins by having purposeful movements, then follows commands, etc etc....all over about a 24 hour period. Next day extubated.

No neuro deficits.

Cardiology/neurology/etc cant identify what happened.

Week later she looks normal again. Still needs her gallbladder out, so we do the case. 30 minutes later she's in the recovery room, no problems.

This case is one of those where the scientist in us tries to explain what happened, but cant. I'll reserve my non-secular opinions about cases like this except to say I believe when your number is up, its up. Wasn't her time to go.

But back to the issue.....I'm not so quick to judge brain injury patients anymore. Neuroscience knowledge is very limited when it comes to understanding an injured brain....why, where, when, and if someone is gonna recover....

It's not my job to decide when to right them off.

I'll leave that to the man upstairs.

 

[Planktonmd]

Dude, when you are a resident it aint your call. So when you said you made a rookie mistake, you didnt. No criticism of you at all. Just opinions about your attending's decisions.

Tenesma posted about the fact that she had an anoxic brain injury so just paralysis may be ok......I think when an insult to the brain occurs we are sometimes too quick to assume that its an irreversible thing....case in point....preopped a 37 year old lady admitted for acute cholecyctitis & biliary colic....in hospital a cuppla days...once her LFTs chilled out a bit she was scheduled for lap chole. Anyway, like I said I preopped her the night before. Skinny lady, only previous surgery breast augs, smoker, no other issues.

Next morning I come in, run into the surgeon.....lady coded that night..
Family member in room awakened by pt making unusual snoring noises....nurse called....pt unresponsive, nurse calls code team, lady has episode of v fib while code team is present, shocked, converted, intubated, etc etc.

Transferred to ICU, pupils large and unresponsive. Everyone in shock....many studies done....I thought surely an embolic event but no evidence of PE.....no real underlying issue found to explain what happened.

Several days go by, no change.

About day 4 or 5 she wakes up, albeit slowly....begins by having purposeful movements, then follows commands, etc etc....all over about a 24 hour period. Next day extubated.

No neuro deficits.

Cardiology/neurology/etc cant identify what happened.

Week later she looks normal again. Still needs her gallbladder out, so we do the case. 30 minutes later she's in the recovery room, no problems.

This case is one of those where the scientist in us tries to explain what happened, but cant. I'll reserve my non-secular opinions about cases like this except to say I believe when your number is up, its up. Wasn't her time to go.

But back to the issue.....I'm not so quick to judge brain injury patients anymore. Neuroscience knowledge is very limited when it comes to understanding an injured brain....why, where, when, and if someone is gonna recover....

It's not my job to decide when to right them off.

I'll leave that to the man upstairs.

Off the subject, but this has medication error written all over it.

 

[Noyac]

Off the subject, but this has medication error written all over it.

Exactly what I was thinking. PCA with mom pushing button or something like that.