Your first day as a doctor

Now that's an interesting thought. Would they not be discriminating against the patient unless they found another surgeon to do the operation assuming the operation is in the patients best interests?

How do you know it is due to the effects of the sedatives and not the brain injury?

However, if you were every in a situation where it was entirely unclear whether CPR was appropriate (such as validity of a DNAR or advanced directive) then you always start CPR anyway whilst calling the cavalry including some senior people.

The fact that she still has sedative drugs in her system doesn't change any of the above.

...then she should not be resuscitated.

Because the brain scan is not consistent with a sudden death. She would die eventually over a couple of hours, but her sudden apnoea can only be explained by the sedative drugs not having worn off yet.

You are asked to see an elderly lady brought in unconscious having fallen and sustained a head injury. She is promptly intubated and placed on a ventilator, before being rushed to CT for a brain scan. It shows a massive brain haemorrhage, clearly non-survivable.

The family are told and all agree that she should be extubated and allowed to die peacefully over the next couple of hours. As the family wait outside, the intensivist switches off the infusion pumps keeping her asleep and removes the tube. She is now breathing spontaneously and appears stable. The intensivist tells you “I’ll be right back” and leaves the department.

The family are called back in to her side. After a few seconds she suddenly stops breathing and her oxygen levels start to plummet. You realise that this is due to the effects of the sedative drugs still in her system and nothing to do with the non-survivable brain injury. The family look at you anxiously.

What would you do?

Run out of ratings today, but would say thanks!

So essentially if you don't intubate now, her death will be as a result of the sedatives? If you do intubate and resus, then she will die anyway?

I personally would rather intubate and resus, bring her back and let her die of the brain injury later please- preferably with someone a lot more senior around, just to be certain! If she is making respiratory effort on her own, then her brain has not gone yet? Hence, why I would make that decision?

Usher the family outside whilst doing this however. Then have a chat with them over the next couple of hours so they do know what to expect.

PS Medical student-to-be and current army medic

Administer saline IV, keep a close eye on her BP, any improvement in condition?

Obviously a good idea to re-intubate.

The family want to stay. How long would you continue CPR for?

Tough luck- family out. Nobody needs to see that thank you. Friendly matron please usher them out.

The family refuse to leave. They are aware that she is dying but they insist on being there during her dying moments. They don't want to come back in later to see a lifeless corpse.

Tough luck- family out. Nobody needs to see that thank you. Friendly matron please usher them out.

(Run out of medical knowledge here) but continue CPR until it is clear there is no response, or she comes back- crash call required I think. Then senior crash doc/registra calls it (even if that is you).

Ok, I get that the form wasn't done, but just as a randome musing - why on earth wasn't a DNACPR form done before extubation in a patient who is absolutely expected to die within the next 2 hours? Plenty of time to do it before pulling the tube out!

I'm a bit confused by you refering to the drugs "keeping her asleep" though. It says she came in unconscious.

CPR for the sake of CPR, 20mins probably and then reasess with seniors present. Family could be present..the friendly matron would be too busy in her office to deal with them.

Is this where I get silly and suggest I am bigger than they are and rugby tackle them out?

As a doctor you shouldn't do anything that you don't feel comfortable with, even if it is in the patient's best interests. In practice, few doctors would actually deny such a patient treatment, but they do have the right to refuse it if personal health and safety are at risk.