Back many months ago I wrote in Scenario about a call where I intubated a patient who was a DNR, but not a DNI. In the comments section there was discussion about the categories of DNR. In this state we have several different forms. The other day from the same nursing home where the DNR, but not DNI occurred, I had a patient with an advance directives sheet that listed Do CPR, Hospitalize, artificial nutrition, medicine, but Do NOT intubate. I think often people don’t know what they are signing. On one hand you have the intubate but no compressions, on the other, do compressions but don’t intubate.
I gave morphine twice in a row the other day. One to an eighty year old with a possible broken hip, who fell right to sleep. The other a seventeen year old football player with a possible dislocated shoulder. It knocked his pain down from an 8 to a 3. The x-rays showed no break or dislocation and he was sent home with Motrin. Should I have given him the morphine even though he had no eventual break or dislocation. Yes. He was in pain.
I was driving back from a call in the rain. I came up over a rose, and there was a line of cars stopped in the road. I hit the brakes and went into a controlled skid. I kept getting closer to the car in front of me. I tried to steer to avoid it, and fortunately after about a five second skid, stopped ten feet short. I looked in the rear-view mirror and saw the car behind me go skidding off the road to avoid me. No impacts thankfully.
I didn’t write about it at the time, but a week ago Tuesday at our monthly MAC meeting, the issue of morphine for abdominal pain came up again, and even though we had already passed it, we backed off. We are still permitting it specifically in the protocols, but are requiring medical control. We try to operate by consensus so if even one doctor insisits, we tend to back off. One of the arguments against morphine was that because ERs are so busy, and the loudest most complaining patients often get the most attention, calming down a patient with abdominal pain prehospitally may enable them to slip through the cracks in the ED. I didn’t say at the time because I was argued out about how there was never any research in the first place that morphine hindered diagnosis along with all the damage pain can to do a person, but what I wished I’d said was paramedics shouldn’t have to lower their standard of care just because the ED can’t provide it.
The new issue of JEMS has some good articles, including one that relates to the story Understand. It describes a county in Washington that came up with a “Compelling Reasons” guideline to prevent futile resuscitations.
The “Compelling Reasons” guidelines allow both EMTs and paramedics to withhold resuscitation if a patient has a preexisting terminal condition and the patient, family or caregivers indicate, in writing or verbally, that the patient did not want resuscitation. – October 2006 JEMS
Here’s the link to the article: