Dying on arrival… April 25, 2013

Posted by Andy Jagoda, MD in: Psychiatric and Social Emergencies, Respiratory Emergencies , 30 comments

On a quiet overnight shift, you receive a call from EMS. They are en route to your ED with a 55-year-old woman in respiratory distress. You walk to the resuscitation room and prepare for rapid sequence intubation, wondering what catastrophic event might have precipitated this patient’s respiratory failure. As the patient arrives, you notice that she is cachectic and pale, gasping for breath as she tries to pull off the nonrebreather mask on her face. Her distraught husband walks alongside the stretcher, stroking her hair and crying. The patient appears to be terminally ill, and when you ask her husband what’s going on, he says, “She has lung cancer. We just stopped chemo because it wasn’t working anymore. We’re supposed to get hospice, but it hasn’t been set up yet.” Meanwhile, the paramedics read her vital signs out loud: “temp 99°, heart rate 120, respiratory rate 40, pulse ox 90%, blood pressure 100/50.” You briefly wish that it was the middle of the day so your hospital’s newly formed palliative care service would be available. Faced with this clearly uncomfortable, dying patient, the traditional emergency medicine tools of endotracheal intubation and mechanical ventilation are clearly inappropriate? You have read that patients often receive morphine at the end of life, but you don’t want to be accused of .hastening anyone’s death. Her husband pleads, “Please help her, doctor. I can’t watch her suffer like this.” Despite your desire to do everything possible to make this patient comfortable, you reflect on the unique legal and ethical framework that surrounds care of the dying patient and want to ensure that you are doing the right thing.

What other medical strategies exist to help this distressed, symptomatic patient?

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“Trauma In Pregnancy…” Case Conclusion April 5, 2013

Posted by Andy Jagoda, MD in: Obstetric Emergencies, Radiology, Trauma , add a comment

Case re-cap:

Your radio going off as a very distraught paramedic hurriedly relates that they’re about 2 minutes out with a motor vehicle collision victim who looks sick and is tachycardic, hypotensive, and having agonal respirations. He relates that the husband is frantically screaming that she’s due next month to have a baby girl. As your team gears up for the patient about to enter your trauma room, you realize that the ambulance is going to arrive much faster than your obstetrician on call (who is coming from home). You fully appreciate that the opening moves of this drama are going to be entirely up to you.

Case conclusion:

The patient arrived to the ED with a barely palpable pulse and a fundus that was well above the umbilicus. Because she was nonresponsive to pain upon arrival, you placed a wedge under the spine board, which improved her pulse, but you decided to intubate for airway protection. This went uneventfully, and you began rapid infusion of crystalloid and called for O-negative blood. As you performed a FAST exam, you anticipated the worst and had a knife and chlorhexidine at the bedside “just in case.” With volume, her vitals improved, and she was stabilized and placed on electronic fetal monitoring, with some variable decelerations. In consultation with the surgeons, she was taken to the CT scanner, where several intra-abdominal injuries were noted, including a splenic laceration and left kidney laceration, but no evidence of placental abruption or uterine trauma was seen. She was taken to the surgical ICU, where over the next 3 weeks she had a rocky course, but ultimately she underwent a cesarean section and delivery of a healthy baby girl.

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