Source: phlebotomist.net

Source:LaboratoryTechnician.org

Just the other day I was called to see a patient coming up to the Intensive Care Unit with a diagnosis of pneumonia. Upon my arrival the patient is “hanging in there” with the blood pressure in the 60’ and 70’s systolic.

This is a no-brainer situation - the patient is in sepsis and septic shock. Early intravenous antibiotics and aggressive resuscitation is what this gentleman needs right now. Per the ER report he had already been given three liters of intravenous fluids with the blood pressure barely budging.

The patient needs a central venous catheter so that the vasoactive medications (vasopressors) could be given to maintain his blood pressure.

As I am grabbing the central line kit, the nurse is trying to reason with me - “Why do a central line if he is DNR (Do Not Resuscitate)?"

The patient was, indeed, DNR which means no aggressive treatment like mechanical ventilation or chest compression in case of a cardiac arrest. So, where do you draw the line between treatment, aggressive treatment and resuscitation?

There is no easy answer. It all depends on individual circumstances. Thus, there is a great deal of confusion among the general public and even health care professionals about this.

Talking to the patient (or the family if the patient is unable to communicate) is probably the only way that those important decisions should be made.

What to do if there is no time to talk, just like in the case above? In these cases we, physicians, often have to make that decision on behalf of the patient. The default tactic in most cases is to do everything you can to stabilize the patient first and then have a discussion with the family or the patient.

Not that you have to exclude the family at any point in the patient care process, it’s just that a Code Status discussion is better to have when things are relatively stable. The discussion often goes way beyond the question - “Do you want us to resuscitate him/her or not?”.

The family has to understand the implications of the decision they are making in the current situation.

Often, when asked about the code status for their loved one the family produces a living will - the document that is supposed to clarify the patient's preferences on this matter.

Having read hundreds of those documents I can attest that the wording in most of those documents is just too general. Most living wills state something like: “If I am in a terminal condition and there is no reasonable hope for recovery...do not resuscitate.”

In some cases it is plain obvious that the patient is not going to do well. If the patient comes with a massive brain insult of whatever cause there is, indeed, no hope for recovery. Most cases, though, fall into the gray area.

Often, it is obvious that the patient is sick but things could go either way. And in the case of an adverse outcome the physician should be aware about what the patient's wishes are regarding aggressive treatment and resuscitation.

The bottom line is - there is still plenty of confusion about the resuscitation status among patients and even healthcare professionals. Careful and timely discussion with the patient and the family is, really, the only way those decisions should be made.

How many times have I been asked by the trauma surgeons to see a trauma patient for respiratory failure? The reason for intubation and ventilatory support – being combative and non-cooperative.

Intubating, sedating and sometimes even paralyzing a combative patient is an established practice. Combative patients are dangerous to themselves and to the medical staff. Clinical and radiological evaluation of these patients is difficult as well. Asking “What is hurting, Sir” if the patient is kicking, screaming, biting and spitting is unlikely to yield any clinically useful information. Getting an extremely agitated patient to a CT scanner could be a great challenge.

Most of those patients end up on a ventilator only temporarily. Once the effects of alcohol and drugs that had been taken wears off the patient is taken off the ventilator. In some cases serious injuries could be found that would require extended ventilatory support.

Intubation or insertion of a breathing tube could be associated with complications. Especially when performed urgently and in the field conditions, the patient can experience hypoxemia (low oxygen level), aspiration of gastric contents into the lungs and damage to the vocal cords. Sedatives and paralytics used for intubation can interfere with the neurological exam and clinical evaluation.

A study published in the June issue of the Journal of Trauma compares outcomes between two groups of patients. The patients in the first group were intubated for combativeness. The patients in the second group were similar patients in all aspects, yet they were not intubated.

The results of this study are not surprising. When intubated for combativeness, patients had longer hospital stays, more frequent respiratory complications and poorer discharge status.

The authors proposed that combativeness in some patients could be a manifestation of a traumatic brain injury even if a CT head was negative for acute pathology. It is true – some patients with head injury could have an unremarkable CT scans.

The authors also suggested using sedating medications like Haldol and Benzodiazepines to control agitation and avoid intubation.

In my personal experience, many combative patients “fail” a less radical sedation prior to being put on a ventilator.

Interestingly, even though this is a very recently printed article, it was submitted for publication back in July of 2006. Using a newer drug Precedex might be helpful to control extreme agitation. Next time I get asked to see a patient with “respiratory failure from being obnoxious” I will suggest it to the surgeon.

When I was called to see the patient after a motorcycle accident I expected the worst. The patient sustained a thoracic spine injury with cord transsection at T5 level as well as significant chest wall injury on the right side.

Multiple ribs were broken; some with a significant displacement (see the upper image above). Managing patients with a significant chest wall trauma could be a nightmare. Pain control is only one of the challenges.

Mechanics of the respiratory mechanism is impaired. Patients often are unable to take a deep breath and fully expand their lungs. Clearance of the secretions is a concern as well. Many patients with severe chest wall injury succumb to pneumonia and respiratory failure.

To facilitate pulmonary clearance, improve pain control and pulmonary mechanics chest wall stabilization has become a practical option. The technique of realigning and stabilizing ribs with metal plates is yet to be widely adopted. I have witnessed on multiple occasions that the patients with a stabilized chest do better and recover faster then the patients treated conservatively.

I was surprised to see that the patient was, actually, doing Ok from the respiratory standpoint. He was describing that he could feel his whole right side of the chest shifting when he was being moved. Besides that, pain was not a major issue and his respiratory status, otherwise, was stable.

The explanation for this surprising “wellness” was not in any way satisfying. He also sustained a severe spine injury with cord transsection at T5 level. His sensory level was just below his nipples. The patient simply could not feel the pain from the chest injury.

In no way I can call it even a mixed blessing. Most of us would likely take severe pain over being paralyzed.

It did make me think, nevertheless, about the importance of pain control in these trauma patients. Huge doses of narcotics are often unable to control the discomfort. Epidural analgesia is frequently employed to alleviate the pain. Some centers even utilize pain control techniques like intercostal blocks to achieve analgesia.

Currently more than 100,000 patients are on the organ transplant list in the US alone. Many patients die each year without receiving a life saving organ. Increasing organ donation rates will improve this situation and will save many lives.

One of the biggest sources for organ donation are the patients with severe traumatic brain injuries who progress to brain death. Even after the patient is pronounced brain dead there is often a delay in time until organ procurement takes palce. Obtaining consent for organ donation from the family is one of the biggest obstacles towards a successful donation.

Does it matter how soon the organs are taken after the patient is declared brain dead? Does it decrease the viability of organs and reduce the number of organs harvested if the waiting time is prolonged?

Currently there is no maximum established waiting time from the onset of brain death to when a successful donation is possible. A study published in the June issue of the Trauma Journal attempts to answer those questions. The study was conducted in Southern California.

The authors of this study found no decrease in the proportion of organ procurement with a longer waiting time. Indeed, according to this publication, a successful organ donation is possible even more than 60 hours after brain death.

Furthermore, the rate of heart and pancreas procurement increased with a longer delay after the diagnosis of brain death was made. The exact reasons for this finding are unclear. The authors suggested that many more patients were hemodynamically stable for organ procurement with a longer time delay.

These findings are supported by previous studies. It was shown that the graft viability might improve after kidney donation with a longer time allowed to pass after the brain death. Better hemodynamic status and attenuated inflammatory response with longer waiting times were attributed to a better kidney graft function in the recipient.

Of course, better organ procurement rates do not guarantee better organ graft survival in the recipient over time. The findings of this study are encouraging, nevertheless. So far there is no established maximum time between the diagnosis of brain death and organ donation. After all, sooner or later is better than never at all.

This is the most unusual and bizarre cancer case I have ever seen.

69 year old female with no previous medical history presented to her gynecologist with vaginal bleeding. Pelvic ultrasound reveled an abnormal endometrial thickening. Endometrial biopsy confirmed the diagnosis of endometrial cancer.

The patient underwent uneventful laparoscopic hysterectomy and salpingo-oophorectomy. The post-op pathology revealed a surprise – in addition to the endometrial cancer the patient also had grade 1 ovarian papillary serous carcinoma.

A PET scan revealed areas of increased intake in the pelvis. Very shortly after the first surgery she underwent exploratory laparotomy and restaging including pelvic/periaortic lymphadenectomy, omentectomy and multiple biopsies. The final pathology – no cancer, just reactive changes after the first procedure.

Five weeks later the patient gets readmitted with abdominal distention and a sepsis like picture. CT abdomen/pelvis showed multiple abdominal and pelvic masses. CT chest shows multiple pulmonary nodules (see the images above). Broad spectrum IV antibiotics started. The patient was getting progressively worse.

The biggest question was: what were we dealing with? It would be unlikely for stage 1 endometrial or ovarian cancer to progress so rapidly just a few weeks after a complete restaging.

Some reports in the medical literature indicate that a laparoscopic approach for hysterectomy could promote retrograde dissemination of the cancer cells through the fallopian tubes into the peritoneal cavity. These concerns were not substantiated in the bigger studies.

The patient was taken back to OR for an exploratory laparotomy. Intraoperative findings – abdomen and pelvis are packed with cancer. The preliminary pathology – high grade sarcoma. The biopsy specimens were sent to New York to a sarcoma specialist.

The patient continued to deteriorate and Hospice care was initiated.

All the pathology slides beginning with the first surgery are going to be re-looked at and reviewed again. Regardless of what the final pathological diagnosis is, this is the most explosive presentation of cancer I have ever seen.

There are very few oncologic emergencies. Neoplastic epidural spinal cord compression is one of them. The delay in diagnosis and treatment is often explained by the non-specific nature of the presenting signs and symptoms.

The patient developed urinary retention a couple of weeks prior to presentation. On the morning of admission he was fully functional. Later he sat down to have a cup of coffee and boom – he couldn’t feel his legs. He couldn’t get up either.

Ideally, this patient should be rushed to the Hospital with an emergent neurosurgery consult. Prompt surgical decompression of the spinal cord or radiation treatment could improve his chances for functional recovery.

The patient lives on a 500 acre farm in a remote part of the country and getting to the closest ER took some time. It did not take the ER physician a long time to recognize the potential problem. Intravenous steroids were administered. MRI of the spine clearly showed an epidural mass with spinal cord compression at T6 level (see the image above).

No neurosurgeon was available in the small outlying hospital. That means that the patient had to be transferred to a bigger hospital. More time spent on arranging the transfer and getting the patient to the neurosurgeon.

All in all, it took 12 hours from the onset of symptoms to the neurosurgical evaluation. The patient had an urgent laminectomy with spinal cord decompression. The likely diagnosis is metastatic prostate cancer with T6 epidural metastasis and spinal cord compromise.

Despite the treatment with steroids and an “emergent” surgical decompression the patient remains paraplegic. His PSA is > 300. The final pathology is yet pending.

This is an unfortunate case. Despite appropriate actions and management, the patient did not receive the needed care for 12 hours after the onset of symptoms. Had he lived closer to an urban area and a bigger hospital, he might have been able to walk.

This is true not only for trauma and oncology patients. Same goes for the patients with coronary conditions and other emergencies. The unfortunate truth is that access to medical care often decreases the further you go from a major urban center.

We have come a long way since the old days when ground ambulance was the only way to transport critically ill patients. Helicopters and fixed-wing aircrafts are readily available now for transfer.

Everything takes time, though. Packing the patient for the ambulance ride or even picking up the phone and waiting for the answer on the other end wastes the precious time that could make a big difference in the patient’s outcome. The bottom line is - in the case of a medical emergency the distance from the Hospital could be a deciding factor between life and death.

Dealing with an incurable illness or terminal condition is an inevitable reality of the practice of Medicine. Not uncommonly, especially in the Intensive Care Unit, we care for the patient with no chance for recovery and survival. Keeping that patient comfortable and allowing him or her to die with dignity becomes the priority of care.

Occasionally, I hear requests from the family members of the dying patient – “Can you give her a little something to…you know…make her comfortable and let her pass away quickly?”

Keeping the terminal patient comfortable is the purpose of comfort care. Facilitating or hastening death is considered unethical or even illegal. Physician assisted suicide or euthanasia is illegal in most states.

In theory, comfort care is quite different from euthanasia. Keeping the patient comfortable and letting the nature take its course is at the core of palliative care approach. Yet, the line between keeping comfortable and facilitating death is often blurry.

The same medications used to control pain and discomfort, primarily opioid analgesics and sedatives, could be used to “help” the patient to stop breathing. The concept of terminal sedation assumes death as an outcome of the intervention.

There are no standards regarding the amounts of medication that could be given for the purpose of comfort before it could be considered a “lethal dose”. Patients on chronic opioids, like many cancer patients, may develop tolerance to the medication and require very significant doses just to control the pain. In contrast, it might not require a lot to stop the breathing of an 89 year old with bad kidneys.

As one transplant surgeon in California found out, it is possible to get in trouble for trying to keep the patient comfortable before death.

Dr. Hootan Roozrokh was accused of hastening the patient’s death by administering large amounts of Morphine and Ativan. The incident took place in November of 2006. The prosecutors alleged that Dr. Roozrokh was hastening the patient’s death to harvest his organs for donation. Subsequently the doctor was acquitted of all charges. His defense was able to prove to the jury that the medications were administered to keep the patient comfortable.

The patient in the above incident had been on opioid analgesics and likely was tolerant to the effects of those drugs. It was very reasonable to assume that he required seemingly exuberant doses of Morphine just to control his pain and discomfort.

This case indicates that there could be a very thin line between what we consider terminal sedation and euthanasia. The purpose is clearly different – keeping comfortable vs. hastening death. Yet, in clinical practice, it is more of a continuum or spectrum of actions and outcomes. Often, it’s not all that difficult to cross that line.

This is Part 2 of the post on the motorcycle helmet law.

Click Here to read Part 1

So, if there is overwhelming evidence that helmets do save lives, why is there so much controversy about it? Why do only a handful of states have mandatory helmet laws?

Obviously, the law would not have been repealed without strong support from the anti-helmet advocacy groups. There are several arguments that have been presented as a reason for why not to wear a helmet.

Helmets can decrease peripheral vision and hearing. Helmets can exacerbate cervical injuries due to the added weight of the helmet. And the most important one – helmet laws violate individual rights and infringe on personal freedom.

Several studies have shown that helmets do, indeed, decrease peripheral vision by approximately 20%. This reduction, however, is small and was shown to have no impact on motorcycle safety or collision rates.

In terms of the increased rate of cervical spine injury the evidence is somewhat contradictory. Some studies found no increased rate of spine injury. Other studies have shown an increased rate of cervical spine injury, yet there was no difference of the spinal cord injury. As far as I am concerned, cervical spine injury is a fixable problem as long as the brain and the spinal cord are intact.

So, if there are proven benefits of wearing a helmet and no real reasons to not to, why there is still so much disagreement about it? At the end of the day it all comes down to individual rights and personal freedom. If somebody prefers to live on the edge and take the chance of a severe head injury in a motorcycle wreck – why not let them?

And that is where the quandary begins. It is an individual right to not wear a helmet that becomes a burden to society of caring for this individual after the accident. A study conducted by the American College of Surgeons showed that more unhelmeted trauma patients have no medical insurance than trauma patients wearing a helmet (29% vs. 21%).

The same study showed a significantly higher resource utilization use with the unhelmeted trauma patients. And this is just the tip of the iceberg. Most healthcare expenses for the head injured patients occur later during the rehabilitation and placement phases of their recovery. Many patients remain permanently disabled and never return to gainful employment.

If the patient has no insurance, it becomes the taxpayer’s responsibility to provide funding for the long term medical care. Even for insured patients, the tremendous cost of caring for the chronically disabled head injured patient reflects in higher insurance premiums and overall healthcare costs. The individual choice of ignoring personal safety becomes a burden for society.

There is a flip side of this issue, though. If I was a lobbyist for the helmet-free group, I would focus not on the technical reasons for not wearing a helmet but on the social ones. The healthcare expenses for providing care for the head injured patients after motorcycle accidents is a drop in a bucket when compared to more common “lifestyle related” conditions.

You can easily enforce the helmet law, yet you cannot write a ticket for smoking, fast food binging, not exercising or not taking your medications.

Conditions like COPD (chronic obstructive pulmonary disease), congestive heart failure, and heart diseases are the big ticket items on the healthcare spending menu. Those are the things that could bankrupt Medicare. If smoking and abusing one’s body is considered a personal freedom, not wearing a helmet might not be much different…