DNR, DNI..where do we draw the line?? DNT?

Ok i understand most people have no idea what the title of this post is all about, just one year ago I had the same perplexed confused look upon my face. This post will explain a the title and go into more of what I have been experiencing the past few weeks on my rotation. Currently I am completing a medicine rotation in the Intensive Care Unit, during my surgery rotation I had one month in the SICU (surgical ICU) and now i am in the CCU/MICU and on the code blue team. At the start I envisioned learning medicine and the care of the critically ill patient, fortunately I have learned so much more, focusing more on the ethical medical decision making, how to address family in times of critical illness and how to effectively manage all aspects of patient care.

A little background, i currently work in a 'closed unit' - this means that all patients in the intensive care unit are cared for by an intensivist, not their regular PCP. All orders and care is over seen by one doctor, who is board certified in critical care.

First learning point - not all hospitals have closed units with 24hr intensivist on duty to manage critically ill patients. According the Critical Care Medicine (journal) in order to achieve a better outcome for patients in a critical care setting the management should be overseen by a single doctor who is trained in the management of critical care.

That seems like a stupid obvious point, but one that is just starting to catch on throughout the country. Recall back to High School or even college when you had to work on group projects, or function on a team. Didn't everything run smoother when there is a single leader? project manager? chief? The idea of too many cooks in the kitchen, actually makes sense and applies to medicine. So many times the continuity of care is fumbled by too many doctors taking care of a patient without a central communication. I am only a 3rd year medical student, and have been in a hospital setting for 7 months, so i know i have a lot to learn. But has the 3rd medical student, I am generally the person who reads the CHART, the WHOLE CHART, including all recent orders for the previous 24hours. Countless times i have seen orders reversed, overlooked, recommendations by specialist ignored or contradicted. Most of the doctors taking care of the patient never speak to one another....even a medical student can see the possible problems here..every patient needs a captain, a quarterback, a single person that manages all the specialist. This is supposed to be the hospitalist/ internist or primary care doctor, but when it comes to the critically ill, I would want an intensivist looking after me.

Anyways, for the past 4 days i have been working the night shift, 7pm-7am. It def seems that if you are going to code, its going to be during that shift...basically my nights have been busy and a little on the crazy side...before continuing let me give some definitions to the title.
DNR - do not resuscitate
DNI - do not intubate
DNT - do not treat (not a realistic option)

If a patient does not have a DNR on file we are required to code the person, that means pump on their chest, breaking ribs, shocking the body, putting a tube down their throat and administering drugs...realistically we code people for (100-age)min. Ex: 80y/o man codes, we will work on him (coding) for 20min before the doctor will call it (pronounce death)

Over the last few nights there have been some interesting train wrecks that have come into the unit, some will hopefully leave and others are hear to stay. Some of them are interesting to say the least...

case #1: 61y/o female chronic hep B, end-stage HIV, and COPD. She arrived to the hosp 5 days earlier for COPD exacerbation, on admission tested positive for opiates, cocaine and THC. She had been admitted to the ICU on admission, and is ready to transfer out when the nurse calls to say she is having difficulty breathing, they want us to intubate her (ie keep her in the unit longer). She is on full contact precautions, including airborne, so it takes us a few extra minutes to put on gowns, masks, gloves before entering the room. Her pulse is elevated, breathing fast with a good blood pressure. My doctor asks me what indication for intubating the patient are present, after a quick listen, i reply with "none!" "Correct, this is an example of nurse panic! there is no reason to tube this woman, intubating this patient is futile and will not help her recover." the doctor decides to get a new urine drug screen, and it comes back positive for cocaine, meaning someone brought her drugs into the ICU and she took them while under the close watch of her nurse!! no wonder the nurse panicked and wanted the patient ventilated and sedated.

case #2: 81 y/o female came to hospital from nursing home facility 5 days s/p (status post) AAA repair with graft, with bilateral cold, pulseless lower extremities. It turns out while at the nursing facility the patient had been neglected and had developed a clot occluding all blood flow to her legs. Both of the legs were mottled and the feet where both black. These legs were both dead! they took her to the OR in an attempt to remove the clot and restore perfusion, completely unsuccessful. There was nothing left to do, amputation is not an option, the dr said she would need a hemicorpectomy (cutting her in half at the waist) and at 81 years with a list of complicating other conditions no other surgical options. The husband is crying in the hallway, there is no other family left, and its one of the hardest things to watch. The husband mentioned she was awake and walking 2 days prior and now she on a ventilator with two legs that are rotting. We convinced the husband to make her a DNR. She is going to die, and it will probably be tonight or tomorrow...that conversation is a difficult one to watch, i dont know how i am going to be able to tell a family, your father/brother/mother/sister is going to die...

case #3:
47 y/o male had been in and out emergency rooms for the last few months complaining of difficulty swallowing and burring in his chest. he had been told be the ER he had gastric reflux and to change his diet and try prilosec. no imaging studies ordered. came into the hospital on this occasion with new onset of cough, producing pink stained mucus. He got a CT of the chest, to reveal a mass the size of a grapefruit at the base of his esophagus, wrapping around the pulmonary arteries and into the left lung. He actually had stage 4 esophageal cancer. This is beyond surgical intervention. I watched my doctor tell his wife, and 3 kids (range from 7yr-25yr) that their father is going to die. The ventilator is keeping him alive, but the mass is surrounding major blood vessels that when infiltrated will cause him to bleed to death (meaning if we ever had to perform CPR the act of chest compressions may actually kill him).
Having a 7yr ask, "if the tube in his mouth is keeping him alive, can we keep it forever?"

heartbreaking. truly heartbreaking.

My doctor actually walked out and shed a single tear. A nurse said, "Dr B, you have a heart!"

she replied, "yes, but it normally pumps ice cold blood." then walked away.

I stood there in disbelief of the comment. My attending is an amazing doctor. She is triple board certified in general surgery, transplant surgery and critical care medicine. Has 2 kids, a husband and is one of the smartest people i have ever spoken with....it is possible to have it all!

anyways, i am going to leave the post for now....i will try and give another update this week when i am back on days, working nights is rough. I come home and sleep for 6 hours, wake up, shower eat and have to be back at work 4 hours later....

how come when you work early in the morning there seems to be more time to the day...this night shift is just crazy and messing with my clock...

peds...at least the kids are cute

The month of December i spent working in a Peds office, in theory it sounds like a chill vacation of a month, the hours are great 9-5 M-F and 9-12 every other sat. Fortunately for me i have learned what i do not like in medicine and working 9-5 is one of them, especially in a field like Peds. The best description of a pediatrician is a veterinarian. In Peds you cannot talk directly with the patient and have to spend a lot of time counseling the parents or dealing with screaming siblings, over bearing grandparents or new parents that think every fever and runny nose is a reason to see your doctor. The other part of the rotation particular difficult for me involved working with the ancillary staff, that at times could be more of hassle then assistance.

For the most part i saw healthy kids ranging in ages from newborns to 20yr, and in terms of sick kids here is my top ten complaints
1. cough
2. runny nose
3. fever
4. diarrhea
5. rash
6. rash
7. runny nose
8. constipation
9. reflux
10. runny nose, runny nose, runny nose

if you can get the hint, every kid came in complaining of cough with a runny nose, sometimes with fever and most of the time without fever...on a happy note, the doctors i worked with had great personality and a quirky sense of humor that kept the craziness of crying, screaming and vomiting kids to a tolerable level.

Unfortunately i seem to lack fun and exciting stories from my time on peds, most of what happened is very boring day to day stuff....here are some of my highlights-

Story: "parenting 101"
it was a Friday afternoon, the doctor left to attend a meeting and the medical assistant, receptionist and I were staying until 5pm to administer vaccines, return phone calls and follow up on labs. A mother calls at 2:45pm to ask if she can bring in her 12 year old son for some vaccines. Not being terribly busy, she had been told to come in as soon as she had the time. I am in the lab working on the computer and hear some screaming/ yelling from the front, its 3:02pm and a mother is becoming irate because she got there at 3pm for vaccines and she has to leave...the woman had literally been there for 2 minutes. I checked the computer for the vaccines her son needed, and started mixing the dilutants to prepare for administration. I am working on drawing up 4 different injections and preparing the tray, by 3:14pm i walk out to the front to call her son back, and all i hear is her yelling, "i have to go, i have 2 kids in the car, this is supposed to be a fast process all i need is some vaccines!"

at this point i happen to mention, "why did you leave 2 kids in the car?"

the mother freaks out and invokes the 'head motion' to proceed to yell, "how dare you tell me how to raise my kids!"

I think she obviously misunderstood my comment....basically i wanted to know why a mother would leave 2 kids in a car alone, in a parking lot at a pediatrician's office. The waiting room is kid friendly and the staff are willing to play with kids, that there is literally no reason to leave children unattended in a car.

clearly, it makes more sense to yell at me for inquiring about the location of her two other children....on the bright side, at least she is taking responsibility and vaccinating her children.


(I take issue with the parents who dont want to vaccinate their kids, if i hear one more parent tell me it causes autism i will scream! the medical literature actually states that there is no link!!! I should just get mad at CNN or MSNBC for bringing it up in the first place, just like 2 months ago when they had headlines about a NEW super bug, MRSA!! MRSA has been around for more than 10years, its not new and 50% of the population have already been colonized anyway)



Story: "what is the jugular?"
So the office has a medical assistant student, who is also a certified phlebotomist (ie the person who draws blood from a vein). While in the back, the office manager told a story about how they had to draw blood from a childs jugular. The MA looked confused and then asked,
"what is the jugular"
we all starred in disbelief, astonished by the comment, since its almost a term that is in normal vernacular. After we educated her about the major veins of the head, she asked, "oh, so its the carotid!" Again, stunned in complete disgust, trying to explain the difference between a vein and artery, something most junior high students understand, to a soon to be medical assistant.

I tried to look past this, she is still learning, maybe others dont pick up science concepts as quickly as others....but this girl is 21years old, has a 2 year old son and is studying to be a medical assistant, she has a lot on her plate and i tried to give her a break. Until her next comment...

while discussing travel, citizenship and passports, she asked, "do i need a passport to travel to Palestine?"

i responded, "a passport and a time machine back to 1947."

"why do i need a time machine??"

"Because Palestine has not existed since Israel declared its independence in 1948, then fought a war to secure itself as a state."

"What are you talking about? Palestine exists and dont you dare tell an Arab, that Palestine doesnt exist!"

"First, i think Arabs know that Palestine doesnt exist, its part of the reason for all the fighting in that region. Secondly, you need a passport to travel anywhere outside the US, not to get out necessarily but more importantly to get back into the country."

After this conversation, i decided to not take anything she states seriously, and to not discuss certain topics due to limited education on the subject.


Overall- my peds rotation went well, until the last day when i became super sick sleeping for almost 20hrs, and finishing a box of advil cold and sinus, a bottle of cough syrup and 2 boxes of tissues. Stinky petri dish kids carrying disease!!