David A. Greene

Published Writing - Winter 2009

To Work or Not to Work – That is the Question

Last issue, we reviewed a “theoretical” building fire.  This issue, let’s look at a “theoretical” medical call. It is a sunny Wednesday morning, and you are dispatched to a 60ish year old patient not breathing in a very remote area. You anticipate that the drive to the scene will be at least fifteen minutes and transport to the closest hospital from the scene will take probably thirty. During your response, dispatch advises that the caller states his wife fell over, is not breathing, turning blue, and CPR is in progress. You arrive to the scene in nineteen minutes to find a female patient that is pulseless and apneic with what appears to be some fairly decent chest compressions being performed as her husband looks on in terror. Your first EKG interpretation is asystole; your patient has no medications or history, and is warm to the touch.  It presents a question, to work or not to work?

This timeless question has resulted in an interesting debate over the years.  Some say that to work the above patient is to give the terror-filled husband false hope.  The idea is that the husband need not have the “inevitable” be delayed any longer and should be spared the trauma of witnessing intravenous therapy, endotracheal intubation, continued chest compressions, and in some cases defibrillation.  In our scenario, it is safe to assume that it took at least a minute to process the call, another minute for us to react and respond, and then 19 minutes to reach the scene. This means if our patient was in fact not breathing at the time of the call, she has been without adequate perfusion for over 20 minutes.  We all know that CPR never provides one-hundred percent of the perfusion that a normal heart and set of lungs does.  Depending on what study you are reading, you may find that the rolling emergency room that we deliver to the patient still does not provide what the brain demands from the heart and lungs.  Most studies indicate that on average, 5-10% of people who receive CPR survive.  Many of these studies include witnessed in-hospital cardiac arrest cases, which hold, by far, the highest survival rate.  With all this written, is there anyone out there who would work the above patient?  The answer is…absolutely.

While there are some that say we may be projecting a false hope to the family, others will counter with the desire to be able to tell the family that we did everything that could have been done.  Although the outcome will likely be the same when faced with a 20 minute down time, the need to provide that perception may outweigh any overriding thoughts of sparing the family from any false hopes.  However stacked the odds are against us, it’s easy to equate this decision to playing the lottery.  If you go buy a single Powerball ticket, your odds of winning the grand prize are 1 in 146,107,962 (or something like that). Despite the long shot with which you are faced, the odds are much more in your favor than if you decide not to buy a ticket. Although beginning or continuing resuscitative efforts on someone that has been down a while is a long shot, our odds that a return of spontaneous circulation will occur are higher than if we don’t buy a ticket.

Let’s assume in our scenario that we proceed with resuscitative efforts.  We start towards the hospital with our patient’s husband in the front seat of the ambulance.  Have we already begun our false hope?  Well, chances are if we have not properly briefed our family, then that is a real possibility.  It is sometimes easy to get wrapped up in the technical parts of our job and forget that our average customer doesn’t know the difference between interior and exterior attacks, level A and level B suits, or Epinephrine and Atropine.  Therefore, we have to talk to the customer on a level that they can understand.  In our scenario, someone needs to tell the husband that the condition of his wife could not be any more critical.  Be careful not to include confusing medical terminology.  For example, if we tell the family that their wife, mother, or sister is asystolic, apneic and cyanotic, they will likely not understand.  However, if we explain that right now their heart is not beating and they are not breathing but we are going to do everything we can to get it restarted; however, their condition is extremely critical.  Remember the ninth commandment (Thou shalt not bear false witness) when faced with the question, “Is he/she going to die?”  A family member that asks this question has already considered the possibility; otherwise they wouldn’t be asking the question.  There are many that think the best way to answer that question is, “It is a possibility that he/she could die, but we are going to do everything we can for them.”

This would be the point where many argue that beginning or continuing resuscitative efforts on a patient that has been “down a while” is, in a sense, lying by creating false hope for the family.  While a valid point to the argument, it does not clearly answer our question.  So what are some of the things out there that can help us determine the appropriate path to take?  First (after ensuring there is no Do Not Resuscitate Order), we should determine if this was a witnessed arrest.  If it wasn’t, the patient’s down time can only be approximated.  Second, what are the patient’s pupil reaction, relative body temperature, and a “quick look” electrocardiogram?  Fixed, dilated pupils, cold body temperature (relative to patient’s environment – and keeping in mind that you aren’t dead until you’re warm and dead), and asystole that doesn’t respond to medications are all bad signs for the patient.  Next, what are the patient’s medications?  If the patient is taking Lopressor, Propranolol, Labetalol or perhaps all three, then most likely all of the epinephrine we carry on the truck is not going to be enough to overcome the effects that these medications have by “blocking” the “beta” receptors we use to stimulate cardiac tone and automaticity.  These beta-blockers are designed to have a negative chronotropic and inotropic effect, which decreases oxygen demand and cardiac workload.  With the presence of a long list of medications, we may be fighting an uphill battle by continuing resuscitative efforts.  Likewise, we need to identify any recreational drugs that the patient may have used.  This may be the cause of the cardiac arrest and may be reversed with the administration of narcan and aggressive advanced cardiac life support.  Finally, let’s examine what our interventions are doing for the patient.  If we’ve given our patient enough epinephrine to resurrect a small horse and we have no changes to the monitor, then we are probably behind the curve.  If we have intubated our patient and are only reading 2 to 3 on our end tidal carbon dioxide monitor, then directly we have virtually no elimination of carbon dioxide by the lungs; which indirectly means, we have virtually no production of carbon dioxide by the tissues. This again means we have a patient who has not exchanged oxygen for carbon dioxide at the cellular level for “a while” and resuscitation is unlikely.  It should not be our intent to use these items to avoid having to work the arrest; rather they should be clues which we can translate into layman’s terms to help keep the family informed. 

The decision to continue or begin resuscitative efforts is always a tough one.  However, keep in mind that we are there not only to serve the patient but to serve the patient’s family.  Although we don’t want to create false hopes for the family, we do want them to know that we did everything that could possibly have been done for their loved one.  Be safe and do good.