When to stop CPR

When to cease resuscitative efforts is a constant topic in the medical education and medical ethics communities. While certain scenarios are usually cut and dry, such as mortal wounds with significant destruction to vital organs, other scenarios such as end-stage disease generate uncertainty to the providers medical judgement. So here we go, the question and background presented to me:

85 year old female patient in cardiac arrest with comorbidity (simultaneous presence of two or more chronic diseases/conditions in a patient) of HCC (Hepatocellular Carcinoma, aka liver cancer), HCV (Hepatitis C Virus, author note: assumed to be the cause of HCC), and “large amounts” [exact volume unknown] of hematemesis (vomiting blood).

It was reported that CPR [Cardiopulmonary Resuscitation] and ALS [Advanced Life Support] measures were immediately started. Progress the “code” for an unknown amount of time and the patient converts into ROSC [Return of Spontaneous Circulation, the goal of CPR] and re-arrested a reported four times. Secondary [assumed] to the hematemesis, two units of packed RBC [red blood cell] were transfused to the patient without additional units being available per the blood center. Also note that the relative (relation degree unknown) of the patient asked for efforts to stop and “let her die in peace”.

 On the fifth presentation of cardiac arrest the senor physician called for a vote to either continue or cease resuscitative efforts. The vote resulted in the cessation of resuscitative efforts and the patient terminated. 

 Several questions are asked, as followed;
What are the guidelines for stopping CPR in cardiac arrest? 
At this time (2018), the American Heart Association, DOES offer guidelines to cease [AHA ACLS 2015 manual, page 117 “Terminating Resuscitative Efforts”] resuscitative efforts for in-hospital providers but no current algorithm exists, that I know of currently. Specifically to this event, the presentation of hematemesis requiring two units of RBC without additional units available from the network [as questioned, it was assumed the patient needed additional units], the repeated arrests, the almost certainty of severe secondary hypoxic brain injury, and wishes of the family should be a strong indicator to lead a provider to cease resuscitative efforts. It should be noted that the author is assuming that cardiac arrest means PEA/Asystole over the wording of arrhythmia, a poor prognosis on its own standing. It is also assumed that PETO2 is less than 10mmHg related to poor pulmonary perfusion secondary to hypovolemia, also a cited reason is cease resuscitative efforts [AHA ACLS 2015 manual, page 117 “Terminating Resuscitative Efforts”].

 Is it right to exhaust all efforts to resuscitate without consideration of quality of life post-event? 
 If this is the only aspect of the question without any consideration to other patients in the network, without prior wishes from the patient, and assumed resources at unlimited supply then we have to say “yes”. However we do not provide in a vacuum and we do have to consider other patients as well as the resources dedicated as part of you care plan. We also direct our efforts with the finite resources available. I might suggest reading the AHA journal article “Part 2: Ethical Aspects of CPR and ECC”; 2000 which I will link at the bottom. I will say that for this scenario everything appears to be checked off on the list for ceasing supportive efforts. Also consult your bioethics office at your establishment for additional guidance.

What is the medicological response of the efforts for this patient? 
 I cannot speak to a full physician provider level but I can speak to the paramedic level and as an ACLS instructor. Immediate CPR is given followed in tandem to aggressive airway suctioning with efforts to ultimately provide an advanced airway. I am applying a heightened focus on prevention of foreign substance aspiration given the ejection of total body blood volume, route of exit, and assumed subsequent drop in pulmonary perfusion. To simplify the statement, what is the point of making blood go round-and-round if I cannot get air to go in-and-out. At the physician level I would suggest chest tubes if not already in place.

  I need to note that I would require my team to place an IV/IO to provide large volume fluid bolus or ideally blood units if available. I would continue to follow the established ACLS algorithm with two minutes of CPR cycles with 1mg of Epi 1:10,000, each other two minute cycle I would withhold Epi. Consider your H&T’s (try not to eye roll), which in this case should be going off like a billboard light in the dark. Hypoxia, Hypovolemia, Hemothorax (I added that one), and Toxins (suspect because of your lab statement comment) secondary to the liver cancer.

   If these supportive measure are not maintainable (Hypovolemia) then working the arrest to the 20 minute mark with noted levels of your PETCO2 leads to the reasonable decision to cease CPR. I hope this answers the questions you presented and I am happy to answer more.

 If I cannot answer your question(s) I know which resources to contact to deliver appropriate answers.

American Heart Association - 2015 Guidelines (2018). “Terminating Resuscitative Efforts”, 117,

American Heart Association (2000) “Part 2: Ethical Aspects of CPR and ECC”, Retrieved 2018, http://circ.ahajournals.org/content/102/suppl_1/I-12

American Thoracic Society Journal (2015). “CEASE: A Guide for Clinicians on How to Stop Resuscitation Efforts”, Retrieved 2018, https://www.atsjournals.org/doi/full/10.1513/AnnalsATS.201412-552PS

 #WhentostopCPR
#CPR
#AHA

Thanks Russia

Thanks Russia for making up 90% of my site traffic.

Not sure how I feel about that? International blogger or cyber ragdoll?

#Nopeski

Buying a new old bike

   Ugh! Time to buy a bike again. I always get so overwhelmed with buying anything new. I always want to buy everything at once in some vain attempt to show that I know I am doing. Let's be clear... I don't.

   I don't know what all the bike parts are or the add-ons. Heck I was calling it the handle bar covers until some 9 year old at the store told me it was called "grips". #Facepalm

   We know I don't have a clue about bikes but I do know a deal when I see one. I figure the bike market is split into two markets. Knuckle draggers like me and the Lance Armstrong's out there. I don't need a $1,200 bike. What I need is a $50 bike and how did I decide $50.... that's all I had. But seriously on the resell market most stuff loses 2/3 of it's ticket value. So there you go! Now I have a bike.... with brakes and everything. :)

I know it's a boring post but to all you bike newbies out there, let's talk!

#BikeLife

Two wheels

Is anyone else out of shape? I find myself sucking in my stomach A LOT. I shouldn't have to do that, right!? I think I am the heaviest I have ever been and I can tell it is getting in the way of things. Putting on socks, walking to the mailbox, even sex (sssshhhhhh). Things need to change and it start today! ... well yesterday....but today damn it and don't judge me.

I started biking to work, well mostly. We have light rail in central Texas and so I biked to the train station. My goals here are 1) Save money 2) Get healthy 3) Lose weight; on that last goal I would really love to have my six pack back. Baby steps! I would be happy with having flexibility, lower blood pressure, and seeing my toes again.....maybe other things. :p

I wanted to make a smart start so yesterday my girlfriend took me half way to the train station in the morning. I spent a total of 1 hour and 13 minutes biking to and then from work. How many calories is that? Better be a bunch cause I was a soggy mess on the train. I think someone asked me if I was having a heart attack. Felt like I should be having one and I could see the judgement from the skinny people on the train. Honestly there probably wasn't but in my head there was. Damn them all for not-really-thinking-that-but-in-my-head-they-are. Bastages!

Today I am doing the full Monty, I am talking full frontal male nudity. No, kidding, jesus!

No, I started from our house and made the FULL trip to the station this morning. Check back here later today for a report. I'm doing it! Yuuuusssss!

On the topic of losing ... Part Four

   So here I am in my thirties and recreating my career for the third time. Do I finish nursing school? Do I return to programming? Become a project/program manager once more or even freelance? Return to operations?

   Or ... do I need to even pick a third career? I see and hear that more and more people are not setting into a defined role. Instead, "they" hobble several income streams together. Indeed it requires more management but also offers economic flexibility and autonomy.

   I ask myself these questions for a reason. My final big life lesson came from Fire/EMS, what you do for a job almost doesn't matter. For the first time I was able to take a peak under the covers of society and see people for what they were. I learned, and this happens quite a bit, that people start off on their path and just keep moving forward and often blindly. Rich or poor, a question of "how did I get here" or "how did it get this far". I am no exception, mind you.

   So many people place up a facade and that's only what you see. I've walked into houses that would floor you in beauty. When I found my patient I would discover a deeply depressed individual. Or I would talk to another and be told that it was everyone else that was screwing them over. What I saw was often the misery and sadness of people that thought they "made it" only to discover they "missed it".... just like I had done.

   I sit writing again and determine to make my life anew again. In addition to a profession I need to subscribe to the proverbial "Smell the roses". I need to check off those "Wouldn't be nice to learn " or the "I need to do just us much fun stuff as work stuff".

   For me it's writing, playing the guitar, and painting for starts. Expect me to post on this a lot and I've been asked to make videos in the part, which I might do but I am still mulling that over.

   But yeah.......that's it! Kind of what I have been dealing with in a short little nut shell.

#insight

#perspective

#acceptance 

On the topic of losing ... Part Three

   So there I am in life ... sucking at it. I built a successful career and I let it slip away. I ignored the human factor in life, ignored my inner voice, and blamed others for my failures. I was lashing out and not reflecting in. Like.A.Big.Dumb.Idiot!

   Since my entire industry was moving out of the country during the 2008 recession I decided to change careers. I became a Fire Fighter/Paramedic! For those of you in the field you know how hard this is and the dedication it takes to even finish school. Getting onto a department is a stroke of luck in-and-of-itself. Then the second big lesson that came with the injury.... boom! I can no longer move my upper body. The pain is unbearable and the medical care almost criminal, which FYI - don't get injured as a public servant in the State of Texas.

   I spent years trying to rehab, almost all on my own with research from the web. I did well and can mostly move with full range of motion. The pain is still there and I am still weak on one side but I did it almost by myself. *Patting self on the back #SoPunny*

   I then began acquiring knowledge and taking whatever job I could. I worked my way back up the pay scale ladder, yet again. I am not totally there yet but ... what was my second big life lesson?

   My lesson here was that no matter what I can rebuild. No matter what I can push my chest off the dirt, place my knee under myself, and raise my body and soul up. I can lift my head and dust off my chest. I may not like it right away but I can stand. I can stand tall and start walking forward, again. I can do that over and over. I can "never quit"!

On the topic of losing ... Part Two

On the topic of losing ...

I had to learn to first be ok with were I was at my life. My starting life-goals were to be rich and comfortable, I can hear you laughing at this point. Something about me; I was a rock-star in my twenties! I started off as a temporary employee and in a short few years I was in global operations. My peers, most in their 50's, respected and resented my technical and operational acumen. Here I was a cocky 25 year old performing and exceeding people twice my age. Then 2008 happened and I was let go. I began to realize that my layoff from Hell inc. was painful and I could not see that from my veil of anger. I felt like I had been tricked, used even. In truth I was but I wasn't totally innocent. I had a boss that fudged results and claimed my work for their own while pinning failures on me. I was so blind in despair that I didn't listen to myself; letting someone ultimately define me. Eventually defining my career or lack there of.

I learned, years later, that I need to break out of my comfort zone and define my situation and my image before someone else does. It's hard for me, I am a numbers guy. I see logic and patterns, optimization and improvements. I don't do feelings..... well not until they do me. I had to learn a new skill set. A skill set of how to be an emotional human!

My other lesson, again learning years after the event, was to be ok with I had done. I gave Hell Inc. the power to "take away" my success. That power was mine to not give away but in my anger I did. I blamed them for my poverty and for the sad state I was in after my lay-off. I adopted a victim persona and that held me back for many years.

My accomplishments came from my heart and from my head. It didn't come from my badge or the office that I used to call mine. Years later I learn that I am not alone and that many out there hang their hat on their title or company. They, as I, never realize where the true power comes from. In this shadow a hole is created... to be continued

On the topic of losing ... Part One

Speaking of losing, what does one do when they have lost everything? When everything you worked for is gone. When the stress of the effort placed into a task is now made invalid? When the thief of agony replaces the joy of success? I saw darkness

Well actually I didn't lose everything.... it only felt like I did! It's perspective really. When I got hurt and had to leave fire fighting involuntarily the pain physically and emotionally was, at that time, intense. Don't get me wrong it still hurts! My heart sinks when I see emergency lights and I still get a little ping of excitement when I hear sirens. My back continues to hurt to this day. Even typing to you at this moment.

"When the thief of agony replaces the joy of success? I saw darkness"

The question I placed for examination was "Did I lose everything" and the answer is no. It felt like I had everything ripped from me. I could barely interact with my children for years. My ex-partner was going through her own dark period and could not support me. I turned to alcohol and video games. I avoided people and stayed inside my office for days, to months, to years.

I had an afternoon where everything clicked for me and things had to change. I could not see worth in myself, my identity was built on how much I could produce and how much I could provide for my family.... both obliterated in just one day. I had become inflexible; married to an idea of value. In that idea, a flaw really, I had become of no use. I became a depressed, physically disabled drunk.

It was on that afternoon that I died and came back someone else... to be continued

Failing ...... succesfully?

How many times have I tried to pick up writing again and then fall on my face? Should I instead look at the number of times I tried instead of the failure, right?

The last couple of years have been pretty hard. Depression is not something that is talked about when you are injured. It is something you learn about and quickly. I know I did and it took me a long time to accept it but I finally did. Then I was able to start the long road of recovering.

I had to swallow my pride and that took a long time too! I went from an awesome career that made a difference to selling paint at a hardware store. Then I worked in several clinics as a medical assistant and then moved on to teaching healthcare at a local college. Now I teach advanced health care to physicians, nurses, paramedics, etc.

Nothing has been easy and it has been a lot of self discovery. My most painful one so far is learning my relationship with my partner was toxic. Not that she is a bad person but our relationship with each other was toxic. What we needed from each other is not what the other could provide. It didn't take long for that "need" to turn into resentment and the lashing out and fights started. Something was said to me that could not be taken back and clarity hit ...... I filed, it was over and that was the first right thing our relationship needed.

I was able to get out of her way and allow my former partner the room she needs to develop herself. She has had a rocky start and continues to hold on to anger, as I did when I got hurt. I know when the time comes and she reaches the point of self-analysis she will do well. She is smart and can be a driven individual but, like me, blaming others comes first before acceptance.