90-year-old man, unresponsive. The medical dispatch updates us, unresponsive, aides not certain if he is breathing.
As I walk across the dark lawn in the rain I see in the picture window two large police officers lifting an old man out of a wheelchair and starting to lower him toward the floor.
“The aide says he’s a DNR, but they can’t find the bracelet — they took it off a couple days ago,” one officer tells me. The other officer has put a pillow under the old man’s head because of the kifosis in his spine. There is no question he is dead, but he is warm and his jaw is limber.
“Do they have paperwork?” I ask.
“No paperwork,” he says.
“All right, we have to work him then. Start CPR.”
Now until recently I would have handled this differently. I would have said, he’s 90, they say he’s a DNR. Asystole. I’ll just walk out to the ambulance, call medical control and get permission not to resuscitate. I do that, and then walk back in, and tell everyone, and record the time and that’s that. Put a sheet on him, console the family, make a comment about dying at home with dignity, surrounded by loved ones.
I may have mentioned recently a newer medic who tried to do just that. Walked out to the ambulance, called the hospital, said the patient was old, terminal cancer, just returned from hospice with DNR papers signed by the patient, but not the doctor. A slipup. The medical control doctor then told him to immediately commence CPR with full ALS resuscitation, and transport. So he had to walk back into the house and explain this to the horrified family who then had to witness a resuscitation, and transport of their family member, who had wanted to die at home.
The state regs (I have discovered) are clear. Unless a person has a valid DNR or are beheaded, transected, burnt beyond recognition or have dependent lividity with rigor mortis, you must at least begin CPR before calling to get permission to cease resuscitation. But why have to call? What can a doctor miles away bring to the situation that a medic on scene can’t acertain for himself? This person shouldn’t be worked. Some medics say they just do pseudo CPR — pretend CPR — while the call is made. That rubs me wrong too, although I have done it and understand it.
Here’s what I do this time:
I drop a 7.0 tube, put in an IV and hit him with 3 epis and 2 atropines. If I am going to be told I have to work the code, then I am going to work it from the start. The ETCO2 is low and I notice the officer is doing delicate CPR. Like this I say. I do a couple compressions, but then instead of my hand rebounding, the chest gives way and my hand sinks as I feel ribs break off. I wince. “Well, do the best you can,” I say.
An aide hands me the phone. It is the patient’s daughter, who wants to know what is going on. I apologize that we are trying to resuscitate her mother, but the DNR bracelet wasn’t on and there was no paperwork. She tells me they keep the bracelet by the bed in the other room. She is understanding as I explain the law. She wants to know how her father is doing and I say he is not responding and I will soon be presuming him dead, so he won’t be transported to the hospital. She says she will be there in about thirty minutes. I tell her to drive safely.
After our 20 minutes of ACLS is up, the patient is still asystole, I call the time. I extubate him, take out the IV, and pick up all the wrappers and put them in the big plastic bag the ambu-bag came in.
An aide comes into the room now and shows me the DNR bracelet. They had cut it off because his wrists had been swelling in recent days.
We lay a sheet over him.
I wait around with the police officers for the daughter to arrive so I can apologize and explain again why we did what we did.
I keep looking at the sheet. He’s not in his bed or his wheelchair, but it doesn’t look too terrible — him on the floor of his living room beside his wheelchair. I mean at least, he’s still in his house, and aside from his ribs, isn’t too much the worse for the wear and tear of the code. I think well he was after all dead anyway.
The daughter still hasn’t arrived, but it is past crew change and my partner needs to get home, so after ten minutes, we express our condolences to the aides again, shake hands with the cops and wish them Happy New Year, and then carry our stuff back out into the night, across the yard and through the rain to where our truck, its red lights still flashing, waits for us.
I liked the way I used to do it better.