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The Case Files

To Resuscitate or Not

The EP's Dilemma

Mathew, Roshan MD

doi: 10.1097/01.EEM.0000604600.29757.7d
The Case Files

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A 40-year-old man arrived in an unresponsive state, his carotid pulse not palpable. His initial rhythm was asystole, prompting us to start CPR.

Prehospital care is virtually nonexistent in our part of India, so no resuscitative measures were performed before arrival, and we were told that the patient had been unresponsive for 20 minutes.

Five minutes into our resuscitation, we attempted to intubate the patient, but laryngoscopy revealed a mass protruding through the glottis. We decided to do a surgical cricothyrotomy, my first attempt on an actual patient after practicing on manikins about 100 times. Within five minutes of establishing the airway, the patient had return of spontaneous circulation.

The patient's relatives reported that he had been diagnosed with a growth in his larynx two months earlier and had not had any treatment for it. As a last hope, they brought him to our institute, and he became unresponsive on the way. My shift was ending, and the next team took over his care.

I asked about the patient's status on my next shift, and learned that the family had decided to take him home after ENT and neurology said his prognosis was poor. The treating team was not willing to admit the patient because of his grim chances, and said more “deserving” patients should be admitted instead.

The joy of my successful cricothyrotomy vanished in a moment. I may have achieved a personal milestone, but was I helpless. Questions flashed in my mind: Did I do right by the patient or just prolong his misery? Should I be less aggressive in resuscitating based on prognosis? (India has no DNR laws.) Should my satisfaction be limited to a successful resuscitation but not the overall outcome? What is the role of an emergency physician in a country of one billion people where most emergency rooms are overwhelmed and treatment is decided based on how “deserving” the patient is?

Emergency medicine is a relatively new specialty in our country. The emergency departments, commonly called casualty rooms, are staffed mostly by MBBS graduates who have little experience in managing acute emergencies. With the advent of trained emergency physicians came a focus on the golden hour, which can make a difference in long-term outcomes for patients.

Though there is a growing need for specialized acute care, the biggest roadblock is that more established specialties don't accord emergency medicine the respect it needs to grow. When I joined this specialty, I was told never to manage a patient thinking about the disposition, but in a resource-constrained health care system, each day is a mass casualty and suboptimal care is the norm. It is a constant fight between specialties for the sake of the patient.

It is human nature to resist change, so things will change for the better slowly and steadily, with government investing more in health care and putting a focus on emergency care. Each specialty needs to recognize the role of the emergency physician and support us to move forward. But like my mentor says, we have miles to walk before we sleep in the journey from casualty to emergency medicine. Lots of challenges lie ahead in emergency medicine, and this is what makes the specialty exciting. You don't know what is coming at you; neither can you predict what comes after. But time in the resuscitation bay gives you satisfaction. There are a lot of unanswered questions, but for now I can say my first cricothyrotomy was worth remembering.

Dr. Mathewis the senior resident in emergency medicine at the All India Institute of Medical Sciences, a tertiary care hospital in New Delhi, which sees about 600 patients a day in the emergency department.

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