POTD: To intubate or not?

Happy Thursday!

Today, we will be discussing an interesting ethical topic that is based on a patient that presented to the ED a few months ago. To set the scene, imagine you are working resus and you get a notification by EMS that there is an unresponsive patient coming in who is currently being bagged. Upon arrival, EMS informs you that they were found on the floor of their home surrounded by multiple pill bottles that contain opioids and benzos. As you get ready to intubate, you find out this patient has a DNI/DNR order. What do you do in this situation if you are concern this was a possible suicidal attempt? Do you honor the DNI/DNR that the patient made while they had capacity or do you disregard it because this patient had a possible suicide attempt? Lets dive deep into this discussion. 

Lets start with DNR/DNI, when you decide to make yourself DNR/DNI, DNI or DNR, at that time you have been determined to have medical capacity and able to make an informed decision about your medical care. First point, a MOLST form is different from a DNR/DNI order. A Medical-Orders for Life Sustaining Treatment (MOLST) form can only be filled out by physician, NP or PA and is intended for patients with serious health conditions who want to avoid/ receive any or all life-sustaining treatment, reside in a long-term care facility or require long-term care services and /or might die within the next year. A DNI or DNR is a medical order written by a healthcare provider stating either do-not intubate, do-not-resuscitate, or both. Under NY state law, the MOLST form is the only authorized form in New York State for documenting both non-hospital DNR and Do Not Intubate (DNI) orders. 

In New York, a DNR order only refers to withholding CPR during respiratory or cardiac arrest; it does not make any determinations on other medical treatments or the withdrawal of medical care. What do you do in the setting of suicide as the emergency medicine physician when you may have limited time and information when this type of patient comes to your ER? 

When researching this, it seems to be split 50/50. Some physicians believe that regardless of how if a patient has a DNI/DNR then they will respect it even in the setting of suicide while other physicians believe that suicide may have a possible reversible cause / good outcome. When I asked some of our ED attendings, there were some split points of views, one said each scenario would be different but it would be important to involve our ethics committee because each situation may not be so clear-cut. 

Something to note is that immunity for physicians who disregard a DNR is provided in situations where, in good faith, the physician had reason to believe the DNR was revoked or canceled, or they were unaware of the DNR, there is not a clear answer when it comes to a suicidal patient. 

When reviewing some case reports written about DNR/DNI in a suicidal patients, both courses of actions have been taken: upholding the order and disregarding it. There is no legal precedent on what to do in this situation. One case reported involved a middle aged female with a medical history of Major depressive disorder who was found unresponsive during this inpatient psych admission after presumed opioid overdose, at that time she was found holding her DNR document, in this situation the medical team and on-call psychiatrist decided to resuscitate the patient. This case was referred to the ethical board and they agreed with the psychiatrist decision of suspending that patient’s DNR during that situation because suicide represents disordered thinking and the patient had no capacity to make medical decisions and the patient had no life-threatening or terminal illnesses. There are other cases where an ethics committee has decided that the DNR order should be upheld. Many institutions don’t have set guidelines in place regarding overriding DNR /DNI orders in the context of a suicide attempt. 

One of the first things we may think about when overriding a DNR is the legality of it. If we disregard it then technically we are going against a patient’s autonomy since when they made their DNR/DNI they had medical capacity… but then does the patient have medical decision-making capacity and autonomy at the time of a suicide attempt?

Key Takeaways for Decision-Making in DNR/DNI Situations with Suspected Suicide Attempts:

1. Start with the Basics: Verify the validity of the DNR/DNI or MOLST form. Understand what treatments it explicitly prohibits and what it permits.

2. Assess Capacity: Suicide attempts often suggest temporary mental incapacity, which may invalidate prior autonomous decisions.

3. Err on the Side of Life: When in doubt, prioritize interventions that preserve life, especially if the situation seems reversible (possibly the most controversial point but do what you believe is right for your patient, like I said, each situation is unique) 

   1. If you are truly unsure on what to do, you may err on the side of life 

   2. Take note, that some physicians will honor the DNR/DNI or MOLST form regardless of the situation, make sure to document your actions/ reasoning well

4. Consult and Collaborate: If time permits, involve ethics, psychiatry, and legal teams to guide complex decisions.

5. Document Thoroughly: Always clearly document your reasoning and actions, particularly if you decide to override a DNR/DNI order. Good faith actions are legally protected in NY State.

6. No Perfect Answers: Acknowledge that every case is unique and requires individualized clinical, ethical, and legal considerations.

I hope you made it til the end of this long POTD. 

Resources:

https://pmc.ncbi.nlm.nih.gov/articles/PMC7805523/

https://www.researchgate.net/publication/309214885_Suicidal_Patients_with_a_Do-Not-Resuscitate_Order#:~:text=Background%3A%20A%20suicidal%20person%20with,setting%20of%20a%20suicide%20attempt.

https://blog.clinicalmonster.com/2022/09/22/dnr-orders-in-the-suicidal-patient/

chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.corpuspublishers.com/assets/articles/crpbs-v4-23-10102.pdf 

https://www.cambridge.org/core/journals/bjpsych-open/article/advance-decisions-to-refuse-treatment-and-suicidal-behaviour-in-emergency-care-its-very-much-a-step-into-the-unknown/3365ABDAD49526E22073A5B8F801CD6F

Thanks everyone, 

Caroline Paz

Sep-tacular Views of Ascites

HPI: This is a 72-year-old male with a PMH of cirrhosis and multiple other medical comorbidities who presented from his nursing home with vomiting and abdominal pain and distention.

POCUS revealed loculated ascites, which was confirmed on CT abdomen.

The patient underwent diagnostic paracentesis under dynamic ultrasound guidance, which yielded 50mL of serosanguinous fluid.

Ascites on Ultrasound

• Ultrasound is a useful tool for diagnosing ascites because it can detect small amounts of abdominal free fluid not otherwise felt on physical exam and help estimate volume

• It can guide safe paracentesis by helping visualize bowel and other organs to avoid

• Simple ascites appears anechoic while hemorrhagic or exudative ascites will often contain floating debris

• Septations (aka loculations) suggest an inflammatory or neoplastic cause
  

Clip 1 shows complex abdominal free fluid with loops of bowel floating within it.

Clip 2 shows an ultrasound-guided paracentesis. Note the needle being introduced into the ascitic fluid from the right side of the screen. The linear probe is used for better resolution of the superficial structures. Color flow can be used to identify the inferior epigastric artery and other vasculature to avoid puncturing in the abdominal wall.

This Core Ultrasound video gives a helpful rundown on how to perform an ultrasound-guided paracentesis.

Case conclusion: Spontaneous bacterial peritonitis was diagnosed based on the ascitic fluid containing >8000 neutrophils, and antibiotics were initiated. The patient was admitted. His hospital course was complicated by acute renal failure and an acute duodenal ulcer bleed, and he remains admitted 1 month later.

References:

• https://radiopaedia.org/articles/ascites?lang=us

• https://www.thelandofem.com/blog/2022/7/8/iusotm-ascites-evaluation-and-management

POTD: Anchor North Wall

Hi Maimo Family,

Today's POTD is dedicated to our lovely, kind, hardworking, powerful, competent, reliable, wicked smart interns. 

It's December now, which means we are exactly one month away from the 18 of you making your biggest transition of residency thus far: becoming the anchor North Wall residents on the 7a-7p and 7p-7a shifts. 

This means that, for at least part of these shifts, you will be the sole resident covering all of the patients on the North Wall. I know what you must be thinking: exciting! Exhilarating! Expletives! This is always a big change for the interns, and it’s Maimo tradition to send a list of recommendations on how to succeed on these shifts from anchor North Wall residents come and gone. As a senior resident of mine passed along to us, “being the anchor is more than learning and knowing the medicine. It’s identifying sick patients, working with your team, and having a birds-eye view of the department.” So without further ado, below are tips on how to conquer the anchor North Wall shift.

1. Try to see new patients within the first 20 minutes of their arrival. Assume these patients are on death’s door until proven otherwise.

2. If multiple patients arrive, do a few things quickly: put your name on them, check triage vitals, quickly eyeball them, and make sure initial orders are in to get the workup started. (Some example workups to throw in…Chest pain? EKG, CXR, trop. Fever? Labs, blood cx, urine, CXR. Old person with AMS? Labs, urine, CTH.) Once you have a moment, return back to the patient to get more of the story.

3. Review triage orders if they have been placed. Since most of North Side patients will get labs and imaging, it is easy to assume that all the orders were placed in triage. It’s best practice to review the orders placed and make sure it aligns with what you want after getting a more thorough history and physical from the patient. The triage doc is an insanely busy role and already helping us out by starting the workup, but it’s our responsibility to ensure it’s complete.

4. Nurses and PCTs will be your best friends. If it’s the first time interacting with someone, introduce yourself and try to remember their name. They are the difference makers in patients getting stabilized on the North Side, and also they are just amazing people. Get them in your corner, and be in theirs.

5. Dispo ASAP. The more patients you can cognitively offload by admitting or discharging, the better your brain will feel.

6. Call the consultant even more ASAP. Get in the practice of asking every patient you see on North Wall for their PMD, and, once you’re back to your computer, immediately put in the call to the PMD via the Contact Center. Usually the two questions you’ll be asking are 1) any clarifying history and 2) who you would admit to. Even if you don’t end up admitting the patient, get the information right off the bat to save you the hassle down the road. Same goes for consultants; get them on board early.

7. Attend the codes and traumas when you can. Not only is it good practice to be a part of these cases, but helping out your resus resident with the FAST, primary/secondary survey, and putting in trauma orders can be a huge help when the resus bay is packed. These shifts especially rely on teamwork. Which leads me to…

8. You may become the resus resident if things get bonkers with multiple sick patients in the resus bay! Don’t panic. Just start the initial stabilization: speak with patient/family/EMS for the story, ensure IV/O2/monitor, get orders in.

9. Learn the extra stuff. Putting patients on cardiac monitors, hanging fluids, drawing labs, setting up BIPAP; these seemingly non-physician tasks can often be the most emergent, and knowing how to do them yourself can be a huge stress relief and time saver.

10. Have a system of keeping track of your list of patients. I use a sheet of paper with name, age, one-word chief complaint, abnormal vitals in triage, then leave space right below that for any weird details about the patient that I pick up from the history (e.g. PMD name, phone number of family, date of recent surgery, etc.). Next to that I jot down the general to-dos for the patient (e.g. labs, urine, CT, MICU, call family, etc.). And finally across from the name I make two check marks: one check mark once I wrote the note, and one check mark once I dispo’ed the patient. I think we all have a variation of this that works for us, with some people scribbling entire histories and some people just writing down PMDs. Try to figure out the system that works best for you.

11. Run your list over, and over, and over, and over. And over. If you don’t know what to do, run your list. If you and your attending happen to both be on your computers at the same time, run your list. If you just got done running your list, eat then run your list. Identify what’s pending and keeping you from accomplishing tip #5. 

12. Run the board, too. This is the leveling up part of anchor shifts. Not only is it important to know your own active patients, but it’s helpful to have a general idea of the North Wall patients admitted, discharged, or coming your way from ambulance triage. Sometimes ambulance triage patients can sneak onto North Wall without you knowing, though usually you will get inkling based on the triage note, the vitals, or the name of the nurse assigned to the patient (making tip #4 all the more important). Run the board by yourself to make sure everyone has a dispo, and if they don’t, you’re working on it. Having this bird's-eye view will really help you achieve self-actualization as an EM resident and future attending.

13. Document on the go. This will be very different from South Side documenting flow, during which you can usually sit down, finish multiple notes, and see new patients when the chart documentation is all wrapped up in a bow. On anchor North Wall shifts, your documenting is going to be interrupted annoyingly often, but, unlike the South Side, it’s usually for something that does actually need to be addressed immediately (e.g. new patient, unstable vitals, agitated patient ripping out his only IV access, etc.) You’ll have to be flexible, and this means you’ll want to use F7 liberally. Document in F7 what you can, go fight the fire, and then return to finish your documenting when things calm down. Also utilize the ED Diagnoses portion of F7 to keep track of any labs, vitals, or workup that comes back abnormal. Adding diagnoses in there will help you on hour 12 of your shift when you’re trying to remember what the heck is going on.

14. You are truly never alone. The resus resident, the attending, the team triage doc, the South Side team, the Peds team, the charge nurses, any of us via phone…do not hesitate to grab us if you need help. Whether you’re worried, scared, overwhelmed, or just wondering where the best place to cry for a second is, we’ve been there. We get it. And we are here for you for whatever you need.

It sounds scary, I know. I can remember nearly hyperventilating while walking into my first North Wall overnight shift. But deep breaths. Because here’s the thing: you can do this. I know it might be terrifying, I know it might be hard, and I can promise that you will walk out of some of these shifts feeling more stupider than when you walked in. But you can do this. You got this. And we’ve got you, we promise.

You have spent the last 5 months showing us just how incredibly intelligent, curious, and driven you are; meet this challenge with that same energy and you will be the kick ass doctors we already know you to be.

Happy leveling up!

Kelsey