Futility

We're at the nursing home to take a male patient to a doctor's appointment.  He's not terribly old, but is non-verbal at his baseline due to dementia.  He doesn't make eye contact with me when we enter his room.  He doesn't shift his gaze when I call his name, and tell him we're taking him to his appointment with a urologist.  

My partner, the Deer Hunter, and I slide the man onto our stretcher.  As we wheel him down the hall, back to the ambulance, we notice the raspy, gurgling sound issuing from his lungs every time he breathes, and the way his chest heaves with every breath, drawing the flesh between his ribs and collar bone inwards–a sign that he is working hard to breathe.  

At the door, a social worker from the nursing home stops us.  "I think I'm coming with you," he tells us.  "I'm a CNA, we like to have one go with residents to appointments." I tell him okay, and take the opportunity to ask about our patient's condition– "Is this his baseline?"  I ask.  

"I don't know him that well, but he's been steadily declining since he got here a few weeks ago."  The social worker goes off to get his things, and we put the patient in the truck.

"Dude–" DH says to me.

"I know..." I tell him, standing at the back doors.  He presses a stethoscope against the man's chest, listening to his lungs.  "Rales all over," he reports; our patient is having trouble breathing because fluid is filling his lungs.  DH clips the pulse oximeter probe to his finger before wrapping a blood pressure cuff around his arm and pumping it up.  The pulse oximeter reads 77%, a low number even for someone who is not well oxygenated at baseline.  

Shortly, the social worker comes out.  "Uh, he's in a condition we would normally treat..." DH tells him; "He may be in heart failure."

"The family wants him evaluated by this urologist," he tells us.  "He's known to them, and they want to hear about his condition from him.  This was the only time he could see him."  I go inside with the social worker to call the urologist while Deer Hunter puts the patient on oxygen.  I talk to the nursing home administrator.  She explains to me that the family–a son and a daughter– want their father evaluated by this doctor, who will tell them if a miraculous cure is possible, or if they should obtain a DNR for their father, paperwork that withholds the violent, undignified act of CPR if he should slip into cardiac arrest.  She tells me to do what I think is best.  I get the phone number for the doctor's office and dial it on the ambulance's cell phone.  After first talking to a receptionist, then a nurse, I'm connected to the doctor.

"Hi, this is Dan from XXXXX ambulance.  I'm here with a patient of yours, Mr. Roland.  I understand you were supposed to evaluate him in your office today, but we think he's in congestive heart failure."  After describing his condition, the doctor tells me to take him to the hospital:

"I'm a urologist, I can't treat heart failure..."

"I know," I tell him, "We're just–"

"Just trying to appease the family, I understand."  We say goodbye.

"Off to the ER," I tell DH, and get into the back with him.  He has a bag spiked, and has put a non-rebreather mask on our patient, delivering high flow oxygen.  For probably the eighth time in two weeks, I wish we had CPAP on our ambulances.  

"The nurse said she gave him Vicodin for pain, right?" DH asks.  "Check out his pupils, they're pinpoint."  Indeed, his pupils are constricted and unreactive.  "Maybe they accidentally dosed him twice," he suggests.  Accidents like that routinely occur in nursing homes, so it's well within the realm of possibility.  

I start an IV in a large forearm vein.  On the way to the hospital, I give Lasix, which should help the patient eliminate fluid by peeing it out, hopefully making space for the fluid that now fills his lungs to reenter the circulatory system.  Because he is unresponsive and having trouble breathing, I give Narcan–slowly–it will counteract the Vicodin.  If the Vicodin isn't causing any problems, I'll just be bringing back the pain it was meant to alleviate.  

During the twenty minute ride, his color does improve slightly.  His pupils become reactive, although they are still constricted.  He looks around the ambulance, and moves spontaneously now.  Whether his improvement is because we relieved hypoxia or reversed an opiate overdose, I don't know.  I'd probably stake money on some combination of the two.  Either way, he's still very sick.  

At the hospital, the doctor sees him relatively quickly.  Before we leave, he's been put on CPAP.  If Lasix pulls fluid in the lungs out by creating space in the vasculature, CPAP pushes it out of the lungs by filling them with air at higher pressures.  

The call leaves a bad taste in my mouth.  "We did the right thing," I tell DH, who nods in agreement.  "I don't like putting him in the hospital, but that's where they would have sent us if we showed up at a doctor's office with him like that."  We both know that the probability of the man ever coming out of the hospital is grim.  

Later, we drop off another patient at the same ER.  I peek into the corner room where we had left our previous patient.  I wish I could say I was surprised to see him intubated, sedated, and on a ventilator.  I shake my head.

People have different beliefs about death, what happens after death, and whether or not it is right to withhold potentially life saving measures.  TV and the media contribute to the notion that anybody can be saved.  All too often, I see patients who have no interaction with the outside world, with end stage diseases that will kill them, be it today, tomorrow, or a year from now, who are "full codes."  I think the children or spouses who demand that "everything be done" would feel differently if they had seen a working code–watched blood tinged emesis spill out over someone's face as strangers pounded on their chest, felt the pop of ribs breaking underneath the heel of their hands as they compressed the sternum, or, most importantly, experienced the frustration of working against nature, knowing fully that natural forces have already dictated that this person will not survive.

When I went back to the nursing home where we had picked up Mr. Roland two weeks later, I went around the corner to the room we had found him in.  I was surprised to see his name still on the door.  I saw the administrator walking down the hall, and asked after him.  "He's still alive.  His family put him on a ventilator," she told me.  "He was in the ER for 3 days before they had an ICU bed to give him.  It's a shame," she said, reading the disappointment on my face.  

"Let me guess," my partner said, "they visited him once, maybe twice while he was in here?"

"That's right," she said.  "People don't understand what they're holding onto."