Radiolab: End of Life Care

radiolab_logoThere was an amazing piece on the Radiolab podcast this week (Jan 15, 2013) on perceptions of end-of-life care. This is an issue that we face in the Emergency Department as we see many patients who present in their last minutes. This may be an acute exacerbation of a chronically ill person or an acutely injured patient.

Our instinct and training is to “do something,” so it is hard to sit on the sidelines and do nothing. Sometimes the family or patient can give us an indication of what their wishes are. Sometimes we are faced with the decision of discontinuing a resuscitation which may be pointless.

Listen to the podcast and feel free to comment below. There are no right or wrong answers, just a discussion. Let me know what you feel about it.

http://www.radiolab.org/widgets/ondemand_player/#file=%2Faudio%2Fxspf%2F262588%2F;containerClass=radiolab

Article: End of Life Issues in the Acute and Critically Ill Patient
Blog post from doctor mentioned in podcast: How doctors die

Neonatal Resuscitation

If resuscitation of children is anxiety provoking, resuscitation of neonates is downright terrifying.

Here we go through the 2010 Guidelines for the management of the neonate or newly born child requiring resuscitation. Remember that these are predominantly respiratory emergencies, even when presenting with bradycardia.

Here’s part I

and part II

And here’s the worksheet for these videos.

Reversing Anti-Coagulation

So you got a patient who’s throwing up blood all over the place, is on coumadin and has an INR of 400. What do you do? Well, after you change your underwear.

The first two videos go over the basic science of clotting (platelets and the coagulation cascade) and the next three then go over what to do in the above situation. Please feel free to put any questions or comments below.

Primary Hemostasis

Secondary Hemostasis

Reversing Coumadin

Reversing Other Drugs

End Tidal CO2 Monitors

We have some new toys in the ER, end-tidal CO2 monitors. The 2010 ACLS Guidelines incorporates these so we better learn how to use them. In this video, Tess shows us how to hook them up (and just how tachypneic she is).

In the second half of the video, we look at the waveforms. Namely, for use in

  • asthmatics,
  • during procedural sedation monitoring, and
  • during resuscitations.

If you have any questions, please put them in the comments below.

First Minute Of A Code

Objectives

  • Describe how you would control the room within the first minute of a code.
  • Explain why you would or wouldn’t want family presence during resuscitations.

One of the defining aspects of emergency medicine is the ability to manage acutely ill patients. Handling these patients effectively requires skills in:

  • Controlling these potentially chaotic and stressful situations,
  • Managing a patient’s airway,
  • Establishing effective breathing and
  • Improving with circulatory failure.

This is your primary survey: the ABC’s of emergency medicine. These issues must be under control before moving on to other aspects of patient care. If these are not immediately corrected, there’s a good chance your patient will die. And if the patient ever detioriates, reassess your ABC’s until they are corrected once again.

“Normal Variants” to the ABCs

The primary survey is fairly constant, though there are a few variations on this theme.

  • In trauma, cervical spine injury must be considered in conjunction with the airway. Moving a broken neck while trying to intubate can lead to a severed spinal cord and severe neurologic consequences. Think of c-spine with airway. Airway/c-spine, breathing, circulation…
  • Additionally the trauma primary survey is extended two more letters to ABCDE to include disability (a neurologic assessment) and exposure (remove all clothing from the patient and prevent hypothermia). There’ll be more on this in the trauma section.
  • For patients in ventricular fibrillation, the success of defibrillation depends on the time elapsed till a shock is administered. In this case, improving circulation via defibrillation takes precedent over airway and breathing. In fact, the new 2010 ACLS guidelines stress that for adult patients presenting in cardiac arrest (not respiratory or traumatic), most of the time it will be cardiac. Start chest compressions before giving rescue breaths.
  • For the radiologically, chemically or biologically contaminated patient, healthcare worker safety is the first concern. The same poison that affected the patient can incapacitate the doctors and nurses–if you’re poisoned, you’re not going to be able to help anyone. In these cases, the patient must be decontaminated prior to initiating any treatment.

The First Minute Of A Code

It is no surprise that critical patients evoke anxiety in ED staff; the responsibility of someone’s life rests in our hands. Resuscitations can quickly deteriorate into chaos unless the team leader takes control. There are a few steps you can take within the first minute while you are assessing the patient’s primary survey.

Call for help

Once you’ve determined that your patient requires immediate resuscitation, call for help. Running a code is a team effort and you’ll need the help of various staff members: nurses, ER techs, respiratory techs, the chaplain and/or social worker, pharmacists and other personnel. You can’t do it alone.

Look calm, even if you’re not

Everyone deals with stress differently, but the team will look to their leader for strength. Even though you may be panicking on the inside, try to project calm. Your demeanor will permeate the room and affect the way everyone else behaves. Once your team feels confidence in you, they will be able to carry out their duties more effectively.

Who really needs to be in this room?

Part of the anxiety that builds comes from the extraneous people who are watching. Whether they are contradicting your orders or just standing there as an obstacle to good flow in the room, they are not necessary. Ask them politely to leave. If they don’t leave, ask them rudely. There should be only one leader of the code and it should always be clear to the team who that person is.

Two notable exceptions I’d like to mention are family & medical students. Both of these groups are commonly pushed out of the resuscitation room, but I believe have an important role to play there. Family presence during resuscitations helps the family initiate the grieving process and allows them to be with their loved ones in their time of need. Medical students (in addition to being excellent chest compressors) need to learn effective resuscitation management, and this cannot be done unless they are allowed to witness codes.

Call ’em by name

There should also be no doubt of each person’s responsibility. Assign duties to people by name. If you ask someone to start chest compressions, everyone will look around for someone else to start. Instead, pick someone, call their name, and tell them what you’d like them to do. For example: “Alan, please start chest compressions. Deb, please be the code recorder. Tracy, please put the patient on a monitor and oxygen. Lisa, please start a line.” Use their names so everyone knows their job.

Your resuscitation mantra

Remember this mantra: “IV O2 Monitor.” You will likely need all three of these things, and if not, they can’t hurt.

Always assess and reassess your ABC’s

While all this is occurring, you should be assessing your patient’s ABC’s.

  • Is the patient’s airway patent? Are they unable to handle their secretions? Is their tongue or neck swelling?
  • How effective is their breathing? Are they cyanotic? Are they tachypneic or severely bradypneic? Are they becoming increasingly fatigued?
  • What is their circulatory status? Do they have a pulse or blood pressure? Is their heart rhythm effectively pumping blood?

A good practice is to quickly reasses the ABC’s after each intervention.