Monday, October 29, 2007

old and trauma don't mix

I'm a firm believer that ER's get busier around a full moon. Add this month's full moon to the fact that it's Halloween weekend, and our trauma bays have been hopping.

One of today's victims is a sweet octogenarian who got hit by someone running a red light. (I wonder if he was coming from a Halloween party?) He's got 9 ribs and a scaupla fractured on one side. Alone that may not be such a bad thing, aside from the fact that it hurts. Add to that situation his age, his extensive cardiac history including an aortic valve replacement, requiring full anticoagulation, and it's a different situation entirely. For someone like this, this could be his terminal event. Even though he's a walkie-talkie (admitted walking and talking).

It reminds me of a situation I was in not too long ago. I was covering a patient who was recently extubated and was recovering from multiple rib fractures and ARDS. When he was intubated, he was fully awake and communicative, writing notes on greasboards and such. One of the repeated messages was "Get this tube out!" When we extubated him, we thought he'd fly. But he didn't.

I went up to see him before the accumulation of carbon dioxide in his blood renered him incapable of making decisions for himself. I oriented him to time, place, and situation, just to make sure we were all on the same page. I then told him that the way he was breathing would not be sustainable for much longer and if he wanted to live, he would need to be intubated again. His eyes got wide and he shook his head and hands an emphatic "NO." I told him I thought his condition was reversible with time and the tube wouldn't be permanent. "NO." I also had my head on straight that night and thought it a good idea to ask him about the specifics of his DNR wishes.

So, I called in his family so they could come and be with him in what would likely be his final hours. The daughter was first, and she really didn't know what to say. She deferred to her mother, who was the durable power of attorney.

"You have to intubate him," was the answer I got.

"I know this is a difficult situation for you, but based on what your husband told me, I can't do that. I need to follow his wishes."

"Ok. We're coming. My son lives in the area and he'll be there soon."

They were a 2-3 hour drive away. Soon the patient's son arrived and again insisted that I intubate. I tried to explain to him several times that we had a converation witnessed by at least four members of the staff whereby I could not intubate him. He started to get verbally belligerent, but I stood my ground. I knew what my patient's wishes were. And I was going to follow them.

I did. To the letter. And he died shortly after his wife and daughter arrived.

I really hope this doesn't happen to my new patient.


Christian Sinclair, MD said...

Great story LnS.

It is really tough to deal with family members who want to override the patients wishes, especially when we (the medical staff) don't always agree with the patient either. I am glad you stood your ground and backed up your stance with good medical care by asking what the patient wants.

Glad to hear from surgeons with a palliative bone.

Shazam! said...

Way to stick to your guns, doc.