whenever someone gets a breathing tube with mechanical ventilation it can unfold in a number
of ways it doesn't matter if it's a breathing tube for COPD emphysema asthma ARDS Covid 19 with ARDS
no matter the reason when someone gets a breathing tube it's gonna unfold in a number of ways one the
patient ends up getting better we were able to fix the underlying problem that caused them to
be intubated and they get better and then we take out that breathing tube the second
scenario is we put the breathing tube in we have them on mechanical ventilation and despite all
their efforts they still decline and they are not able to come off the ventilator and they die the
third scenario is when we put that breathing tube in and they're on mechanical ventilation
they may not get better or they may not get worse or maybe it's only a little bit of either one but
eventually it comes to a point where we need to do a tracheostomy meaning we put a hole in the neck
here and it's a very very short tube that goes in here that reduces the complications of mechanical
ventilation that you have with a breathing tube because the breathing tube can only stay in for
so long typically it's only 7 to 14 days before we have to do a tracheotomy okay the fourth scenario
is where the patient and/or the family decide you know what we gave the breathing tube a try we gave
mechanical ventilation a try but you know what we don't want a tracheostomy so let's take out
their breathing tube and let's let our loved one go in peace and comfort in their final moments now
there is a fifth scenario that sometimes unfolds and that's something called ECMO extra corporal
membranous oxygenation and that's a fancy way of saying we take out blood from the body and then
we oxygenate that blood and remove co2 from that blood and put it back into the body essentially
taking over the function of the lungs now that's called veno-venous ECMO sometimes we do venous art
ekam Oh where we bring it out of the vein bring it back to the artery so not only do we oxygenate the
blood and remove co2 from that blood but also it's taken over the function of a heart with a
circulation so there's actually two types of ECMO ECMO is a very serious procedure that comes with a
lot of risks and it's reserved for people who have certain criteria for it usually it's reserved for
someone who has life-threatening hypoxemia that does not get better with mechanical ventilation
so in other words they're on the ventilator and their oxygen levels are still too low despite
the ventilator and whatever condition they have has the potential to be reversible so if we can
if you can temporarily take over the function of the lungs with the ECMO and their underlying
condition will improve during that time that would be an indication the downside of doing
ECMO is that there's a 30% risk of bleeding with that and that bleeding could be life-threatening
because when you're doing the ECMO and you've taken out of the body you have to put in huge
catheters into the body and with these huge catheters you can't have clot forming on those
catheters so you have to give a blood thinner in order to keep that blood thin so you don't
get those clots with that said the clots still develop in about 5% of patients who get ECMO so
ECMO is a big deal and there's only about 250 hospitals in this country who do ECMO now for
the final topic in this video I'm going to talk about D&I DNR meaning code status so D&I means do
not intubate DNR means do not resuscitate now when someone comes to the hospital especially if they
come to the intensive care unit we typically have a conversation about the patient's wishes about
their goals of care some patients say you know what do everything no matter what if my heart
were to stop do everything no matter what you try you keep trying till the end no matter what other
patients say you know what treat me medically do everything you can short of putting a breathing
tube in short of doing compressions on my chest short of getting electrical shocks to my chest
so don't do those things but do everything else medically speaking sometimes patients
say you know what I don't want anymore medical treatment I just want to spend my last moments
in peace and comfort so just give me medications just for that nothing else so lots of times that
entails giving morphine because morphine not only does it treat pain but it also treats shortness
of breath so patients who are having shortness of breath endure pain we often give them morphine in
their final moments of life that way we ensure that they're comfortable and peaceful in their
final moments now the question about denied in our status code status for patients who
have covid 19 let's say someone comes to the hospital and they have covid 19 the question
becomes should they be a full code meaning you do everything possible to save their
life no matter what even if their heart were to stop you do compressions on their chest you
do electrical shocks to the chest you put that breathing tube in and have them on mechanical
ventilation you do everything you can to save their life now this is a very controversial area
for a number of reasons for one the chances of someone who dies from Covid 19 to the point
where their heart stops the chances of you getting them to survive is essentially zero
if that infection caused them to stop breathing to the point where it caused their heart to stop
the chances of them recovering by you doing CPR is essentially zero when you have a co team in there
where you're gonna have at least one doctor you're gonna have at least one respiratory therapist
you're gonna have at least three or four nurses so you're talking about a code team of at least
five people to try and resuscitate that patient who has a chance of recovery of essentially zero
that's bad for two reasons not only do you expose those healthcare workers to the virus not only
do you risk that but also you're using more PPE you're using a lot of personal protective
equipment during a code you imagine at least five people all gowning up the whole nine yards with
the gown and the goggles and n95 and probably surgical masks over that n95 may be a pepper as
well so that's a lot of PPE to use that's just one person and you multiply that however many people
are in that room we're sedating that patient for a patient that essentially has a prognosis of zero
at that point it doesn't make sense I can confirm that there are hospitals in this country who have
designated teams that are determining code status for patients who come in with covid 19 and some of
them are doing it even for patients who don't have Covid 19 because not only are the resources limited
with a number of healthcare workers but also you're exposing healthcare workers and also you're
burning through PPE so there has to be a selection of who is full code and who is not full code and
the way that's being the and at least some places as there is a team that designates based on sofa
score which essentially is predicting prognosis based on that sofa score they're getting a
determination of what their code status will be based on that sofa score so I know it's a very
controversial area but you have to realize it doesn't make sense to risk health care workers
lives multiple based on the attempt to save someone who has essentially a zero prognosis but
these are the times we live in everyone in this country and most people in this world is affected
by this pandemic in one way or another whether it's direct or indirect I can give you an example
I've had two cases of this happen already where patients who did not have Covid 19 were directly
impacted by this pandemic for example one of them came to the hospital with he was denied nr meaning
he did not want the breathing tube and he did not want resuscitation on his heart if his heart were
to stop so the reason why he was essentially dying at that point when he first came was because he
had about ten different lung issues 10 different lung diseases over the course of previous 5 10
years including lung cancer including different infections with different pneumonias so he already
knew that coming in his prognosis was bad and so when we spoke to him he said you know what
try to do everything you can to get me better with antibiotics medications and so forth and
the BiPAP mask tried doing all that stuff try doing everything short of putting the breathing
tube in short of doing compressions and electrical shocks to my heart so that was the decision about
24 hours later he did not get better he continued to get worse he was working very hard to breathe
even with the pipet mask and he's breathing at a rate about 30 times per minute he was struggling
and it was very uncomfortable for him because he was having a very difficult time breathing what he
decided was that you know what doc I just want to be comfort I just want to be comfortable in
my final moments not gonna survive I just want to be comfortable and we said of course you'll want
to comply with your wishes but what do you want to do in terms of your wife because she can't be here
because you're a Covid 19 rule out in other words we were waiting for the Covid 19 test to come back
before we could allow any visitors to go see him in the room now I knew the test was gonna come
back negative but the test was already sent before he got to the intensive care unit the reason why
I knew it was gonna come back negative is because his risk factors were very low he didn't have any
travel he didn't have an exposure and he had other reasons to explain his long illness and I knew it
was gonna come back negative so that was that was the hard part because I knew this guy doesn't have
covid 19 I knew because of that really I wish that his his wife could come and see him in his
final moments of him living unfortunately because the test had to come back the wife wasn't able to
come in the room so he didn't have any family with him in his final moments and at the very
least I'm glad they were at least able to face time in his final moments and so that was just
one case there's also another case that's very similar to that so even people who don't have
Covid 19 are being directly impacted by this pandemic but anyway I know this is kind of a
depressing video but try to stay positive and you know that's what I'm doing is staying positive
and I know we're gonna get through this I know we will come together as a country as people we
will come together and we will pull through this pandemic we will do it it's just a matter of time