Buying Time: Making the case for pacing a hypoperfusive DNR patient


 
 

Keith Wesley, MD, FACEP | Tyrel Steines, EMT-P, NREMT | From the April 2009 Issue | Tuesday, March 31, 2009


Your ALS crew is dispatched at 16:06 to a local nursing home for an 85-year-old male patient. He's diabetic, with a blood sugar of 65, and "having problems." On arrival, an RN guides you into the room, where you find a morbidly obese man who's responsive to only painful stimuli but maintaining his airway. His radial pulse is absent, and there's a weak carotid pulse rate of 56.

The nurse explains to you that the patient went out with his family for lunch but didn't eat anything, and now his blood sugar has been steadily declining -- his last reading was 55. Nursing home staff administered two tubes of oral glucose and then one dose of glucagon IM, but the patient continued to deteriorate. The nurse says the patient has a history of cardiac issues, hypertension, peripheral vascular disease and diabetes.

Your partner tells you the BP can't be obtained through auscultation or palpation. HR is 56, RR 36, pulse ox 87%, lung sounds reveal crackles bilaterally, and blood sugar is now 29 mg/dcl. You apply a non-rebreather mask at 15 lpm, and the patient's O sat rises to 92%.

Your next step is to secure IV access and administer 25 g of D50. Your partner makes an attempt to secure an IV but is unsuccessful. You make two unsuccessful follow-up attempts to secure an IV. What other options are available to gain vascular access? You turn to the IO to administer the medicine your patient desperately needs. You assess the patient's tibial tuberosities to find more adipose tissue than your current adult IO needle will penetrate.

Quickly assessing the patient's deltoid, you find large amounts of adipose tissue, and you wonder if the nurse used a large IM needle. You then administer a second dose of glucagon IM in the opposite arm with a large needle, thinking maybe the nurse inadvertently injected the glucagon into the adipose tissue instead of the muscle.

You reassess the patient: His BP is still unobtainable through auscultation or palpation, the cardiac monitor shows an idioventricular rate, and lung auscultation reveals crackles. His HR is 48, RR 32, pulse ox 89% on 15 lpm with a non-rebreather mask, GCS 6.

What can you do? You can't administer the medication he needs, and his heart rate is slowing down along with his BP and perfusion. The glucagon and oral glucose won't have a chance to take action while his cardiovascular system is failing due to hypoglycemia. How can you support the cardiovascular system long enough without vascular access?

Then it dawns on you: You have the milk and the chocolate syrup; now all you need to do is stir. You need to buy time to let the medications work, a way in which you can support BP and increase perfusionƒtranscutaneous pacing. If you can increase the heart rate, it will increase the BP, thus increasing perfusion and giving time for the medications to work. Increasing the BP will also give you a better chance to get an IV line.

So, you apply the cardiac pads. You know the patient has a significant cardiac history, so you set the rate to 60 and titrate the mA until you obtain capture. The patient begins to make noises and slowly regains consciousness. On arrival at the hospital eight minutes later, his GCS is 14, he's experiencing mild dyspnea but no pain, his BP has risen, the manual pulse taken matches the cardiac monitor, pacing at 60 ppm at 75 mA, RR 30, and SpO at 97% on a non-rebreather at 15 lpm.

You did it! You bought the time necessary for the medications to work, and the patient's blood sugar has risen, responding to the medications. But upon entering the emergency department (ED), the staff immediately challenges your treatment of the patient, demanding, "Why are you pacing this patient? Don't you know that he's a DNR?" You respond, "Negative. He has no DNR bracelet and the RN at the nursing home didn't mention anything." Uh oh. Now you have a problem on your hands.

Discussion
In EMS, we're often faced with difficult choices. Sometimes, these choices are seemingly impossible to make. Sometimes, we don't have all the facts. Sometimes, the dilemma is between our duty to save lives and the legal and moral issues that complicate it.

Here's a very important question for any EMS crew: Is pacing a DNR patient wrong? This patient had one main medical issue that was causing his problem: low blood sugar due to diabetes -- a simple problem with a simple solution. So, is it wrong to use transcutaneous pacing on a DNR patient if it's used only as a means to maintain the patient long enough for the medications in his body to work? This is a tough question. Later evaluation of the 1.5'' stack of paperwork revealed that the patient did have DNR orders and advanced directives, but no bracelet (as required by Wisconsin law).

However, transcutaneous pacing wasn't in the "provide" or "do not provide" column of his advanced directives. Had venous access been obtainable, the crew would have simply administered 25 g of D50 and possibly signed the patient off to the RN without transporting. But that wasn't the case, and the question remains: Is transcutaneous pacing right or wrong in a DNR patient?

The patient recovered and returned to the nursing home. The same service actually transported him a couple of weeks later to a higher-level-care hospital for pacemaker implant surgery. Maybe a better question would be, Why don't all DNR orders come with advanced directives and a checklist of do's and don'ts, predetermined by the state, that a person could add to if they desired?

Dr. Wesley's Opinion
This case presents several interesting challenges, mainly the validity of using pacing to support a patient's vascular status not for a cardiac rhythm disturbance but for hypoperfusion, so as to provide time to obtain vascular support. By the time the patient regained consciousness, his perfusion status had improved to the point where a peripheral IV could be easily inserted in the ED, allowing the patient to receive D50 and be discharged the following day. Unquestionably, pacing this patient improved his perfusion and led to his positive outcome.

Now, for the issue of pacing in DNR patients. DNR is interpreted differently across the nation. There's no national standard, and nursing homes are notorious for failing to notify EMS of patient status. We must be driven by our goal to provide care in the best interest of the patient. With that said, pacing is generally considered a therapy for brady/asystolic arrest.

Most agree that we don't do CPR or BVM on a DNR patient. But DNR patients develop third-degree heart block and have pacemakers inserted all the time. To undergo this therapy, they have their DNR temporarily suspended during the procedure to allow anesthesiology to intubate them.

The question in this case is, What would you have done if you had known the patient was DNR? Would you have allowed a hypoglycemic patient to die when the cause of their demise was not a respiratory or cardiac event?

Cases like this raise many ethical issues that should spur serious discussions among services and their medical directors, the nursing homes they serve, and the hospitals where they deliver patients. --JEMS

Tyrel Steines, EMT-P, NREMT, is a paramedic with the Higgins Ambulance Service in Wisconsin Rapids, Wisc. He's active in Wilderness EMS and can be contacted at wildernessfiremedic@yahoo.com.

Keith Wesley, MD, FACEP, is the medical director for Higgins Ambulance Service and the Minnesota State EMS Medical Director and Operational Medical Director for HealthEast Medical Transportation in St. Paul, Minn. He can be contacted at drwesley@emsconsulting.net.




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Related Topics: Patient Care, Cardiac and Circulation, Medical Emergencies, Jems Case of the Month

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Keith Wesley, MD, FACEP

Keith Wesley, MD, FACEP, is the Minnesota State EMS medical director and the EMS medical director for HealthEast Ambulance in St. Paul, Minn. and and can be reached at drwesley@emsconsulting.net.

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Tyrel Steines, EMT-P, NREMTTyrel Steines, EMT-P, NREMT, is a paramedic with the Higgins Ambulance Service in Wisconsin Rapids, Wisc. He_s active in Wilderness EMS and can be contacted at wildernessfiremedic@yahoo.com.

BROWSE FULL BIO & ARTICLES >

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