Are Community Standards for When to Resuscitate Valid?

A 24-year-old man is involved in a motorcycle accident one block from the com­munity hospital. An empty ambulance passes by, scoops him up, and brings him into the emergency department. The patient, who initially has minimal vital signs (pulse 140 / minute and weak, blood pressure 40 palpable systolic) goes into cardiac arrest after about five minutes and resuscitative efforts begin.

The two staff surgeons who are on call that day are observing the efforts of the emergency team, although they do not actively participate in the resuscitation. But when the emergency physician prepares to open the patient's chest for further resuscitation efforts, the surgeons intervene and demand that he cease.


They argue that taking the patient to the operating room would disrupt a busy operating room schedule for what is most probably a lost cause. The emergency physician hesitates to do as they ask, since he realizes that the patient would be taken to the operating room in most of the other hospitals in town and, if other surgeons were on call, even in this hospital. What should he do?

Commentary

Before deciding upon a response, the emergency physician must decide some important aspects of the situation, answering the questions listed in Table. First, what is the real likelihood of success in reestablishing a heartbeat?

Young age and rapid emergency attention would be auspicious, but trauma leading to hypotension that does not readily reverse with initial emergency care would militate against optimism. The emergency physician would know which diagnostic possibilities have been eliminated or established or still are likely and what impact they have upon the likelihood of successful resuscitation.


Then the emergency physician will have to assess the likely eventual outcomes if heartbeat is reestablished. Again, the patient is young and acutely injured, so some reasons to hope for neurologic recovery are present. However, the patient has probably had more than five minutes of severe hypotension (without protective hypothermia or barbiturates).

The emergency physician will by this time know a great deal about the severity of associated injuries; for example, the likelihood of spinal cord injury, the presence of fractures of long bones, the degree of direct brain injury, and the presence of brain stem reflex response. The emergency physician should then have a realistic assessment of the range of potential outcomes and the general likelihood of each.

Then, the emergency physician must decide whether further treatment is likely to benefit the patient. If the chances of restoring heartbeat are extremely small or nonexistent, the emergency physician is under no obligation to provide useless efforts. If the prospects for recovery are very grim — for example, if the brain was extensively ablated and the spinal cord ruptured in the neck — the physician might well reason that extensive efforts are not warranted when the best that can be achieved is a vegetative or severely brain damaged and permanently dependent existence.


However, unless the emergency physician is fairly certain of short-term or eventual failure, treatment should proceed, if possible. If the best treatment involves emergency thoracotomy, the emergency physician should proceed to do this.

Of course, the same evaluation will have to be repeated frequently as response to treatment indicates changes in the likelihood of various outcomes. Especially if thora­cotomy and direct examination of the heart and great vessels do not disclose a remediable lesion and cardiac rhythm cannot be reestablished with maximal therapy, prospects for success will have been shown to have vanished and therapeutic intervention can cease.

If the justified thoractomy allows reestablishment of effective heatbeat, further surgery and other treatments very likely would be warranted.


Table. Questions Affecting Treatment Decision.

1. What is the likelihood that a heartbeat will be reestablished?

2. What are the likely outcomes if a heartbeat is established?

3. Will further treatment benefit the patient?

EFFECT ON OPERATING ROOM SCHEDULE


What of the disruption to the operating room schedule? Clearly, this inconvenience and possible risk to other patients should not be caused when no gain is expected for the patient.

Reasonable efforts should have been made to assure that the emergency department can provide enough initial treatment for most patients that only those with a substantial chance for satisfactory outcomes must be sent to the operating room as emergencies. Perhaps thoracotomy and direct cardiac resuscitation should be able to be done in the department.


The onlooking surgeons may certainly remind the emergency physician to assess the likelihood of benefit for the patient and could even suggest ways to limit the disruption of the operating room schedule (like doing the thoracotomy in the emergency department and, only if it is successful, taking the patient to the operating room).

However, the onlooking surgeons should not encourage the emergency physician to compromise the prospects for his patient in order to avoid inconvenience to others. In fact, to suggest nontreatment without having all the facts would seem quite improper.

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