What Would You Do (A Call to the Bedside)?

April 22, 2018
by Mark David Siegel

Hi everyone, 

Here’s a quiz: 

Mr. Brown is a 78-year-old man with oxygen-dependent COPD, admitted with fever, purulent sputum, and worsening dyspnea.  He tells the medical team he doesn’t want to be intubated under any circumstances, nor does he want to be resuscitated if his heart stops.  He’s lived a long life, knows the end is near, and doesn’t want to “die on a machine.”  He won’t accept BiPAP because it makes him claustrophobic. The team enters “Do Not Resuscitate” (DNR), “Do Not Intubate” (DNI), and “No BiPAP” orders, and they place a note in EPIC detailing their code status discussion with the patient.  They start Duo-Nebs, prednisone, and doxycycline and sign out to the night team.












At 1AM, the nurse calls the covering intern and resident, stating that Mr. Brown is short of breath and hypoxemic. They go immediately to his room and find him sitting in a tripod position next to the bed.  He appears frightened and unable to speak.  He is tachypneic, tachycardic, and diaphoretic, and he is using accessory muscles to breathe.  The trachea is midline, neck veins are flat, and there is no peripheral edema.  He is barrel-chested and his thorax is hyper-resonant to percussion.  Breath sounds are nearly absent bilaterally. The oxygen saturation is 78% on a 100% nonrebreather.  A chest x-ray shows hyperinflation, unchanged from previously.  A nebulizer treatment provides no relief and his condition continues to decline.

What would you do?: 

1. Ask Mr. Brown if he’d like to reverse his code status 

2. Call Mrs. Brown to see if she’d like to reverse her husband’s code status 

3. Start morphine for dyspnea and update Mrs. Brown on her husband’s condition 

4. Get an ABG and transfer Mr. Brown to the MICU 

5. Persuade Mr. Brown to try BiPAP

6. Something else 

Let me know this week and enjoy your sunny Sunday, 

Mark

PS I’m admitting in the MICU today with Arjun, Thejal, and Yuki, so if you choose 1, 2, 4, or 5, give us a call.

M


Submitted by Mark David Siegel on April 23, 2018