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Doczilla
02-07-2011, 01:20
41 YO F presents to the ED in status epilepticus due to profound hypoglycemia. She has a history of type I diabetes as well as multiple sclerosis. She functions independently at home, but has maxed out therapy for the MS, which has been progressive.

The patient was last seen normal by her husband about 3 hours ago when he went out to run an errand. When he returned, he found her unconscious. Accucheck read "low", so he gave her 2mg of glucagon IM and called paramedics. Blood sugar done by EMS read 113, though we think this may have been a spurious reading by the meter. Nothing suspicious was found such as a suicide note or empty pill bottles.

She is on an insulin pump, which appears to be functioning well and is not empty. She gets 2mg ativan IV and D50, which stop the seizures. She never regains consciousness in the ER. In fact, she requires multiple doses of D50 and a D10 drip to maintain her blood sugar.

Here's the kicker: she has a DNR order, which the husband produces from 2007 (DNR orders in Ohio do not expire). He, and her father (both at the bedside), state that the patient had explicitly stated that she would not want mechanical ventilation, CPR, or defibrillation at any time, and was quite adamant about it. The DNR form does not specify what treatments can and cannot be performed, simply to not resuscitate in case of arrest. No mention on the standardized form about intubation or any other measures.

I'll tell you later about what happened with her.

I got into a discussion with a couple of the nurses about what to do with her. I did not think that intubation was appropriate, as we had an (albeit old) DNR form and two close family members that said she would not want it. The nurses said that she is young, still very functional and relatively healthy, so why would we not intubate or resuscitate her if needed? I cited two chronic, progressive, debilitating diseases, although I concede she is not bed bound or demented. They brought up the fact that the husband may be stretching the truth for his own purpose, i.e., to rid himself of her. They brought up the possibility that he may have given her an intentional OD of insulin, though at the present time there is no evidence of foul play. She is currently maximized on therapy for the MS, and in fact exceeding typical doses of her medication (not illicitly, but with doctor's order) to try to slow the progression.

So, if it is medically appropriate (i.e., for airway protection, need for ventilation) do you intubate her?

I am not concerned with discussing details of her treatment right now, only the ethical question of intubating or defibrillating her if it becomes necessary.

'zilla

PedOncoDoc
02-07-2011, 05:36
With a DNR order, and both her husband and father stating she would not want rescucitation, I would not intubate her. In fact, once the DNR order was produced, I feel it would be unethical - and possibly illegal - to intubate her.

I feel the nurses were out of line in making accusations of the husband (especially when the woman's father supported the decision as well) and made assumptions about the wife's quality of life.

So what happened?

Red Flag 1
02-07-2011, 09:12
With a DNR order, and both her husband and father stating she would not want rescucitation, I would not intubate her. In fact, once the DNR order was produced, I feel it would be unethical - and possibly illegal - to intubate her.

I feel the nurses were out of line in making accusations of the husband (especially when the woman's father supported the decision as well) and made assumptions about the wife's quality of life.

So what happened?

Agreed. The DNR seems pretty clear regarding mechanical ventilation and defib. Nurses are speculating re: husband, his motives, and alleged actions; that is a matter for law enforcement and the courts, not the nursing staff.

I suppose a case could be made for endotracheal intubation, or trach for that matter, to protect the airway without mechanical support.

So: Follow the DNR. Intubate, do not ventilate..... Thank the nurses for their opinions.

RF 1

swatsurgeon
02-07-2011, 10:03
No intubation for sure, as far as the nurse stating that she's young, etc, have her review the two cases of wrongful life: successful lawsuits against medical personnel that wrongfully resuscitated patients out of a paternalistic need to intervene when there were written advanced directives and orders to do no resuscitative maneuvers. Both were in the 10's of millions against the medical personnel/hospitals, etc., and in my opinion were appropriate lawsuits.

When faced with these issues, as long as no documentation is in evidence, do all appropriate medically indicated treatments, they can always be withdrawn when a durable DNR order is uncovered or an advanced directive is produced. The withholding or withdrawal of artificail medical support are one and the same as per the courts so not starting something or removing an intervention or therapy is viewed as the same and appropriate when orders exist to remove/stop/not initiate said therapy.

If she regains consciousness and says stop all Tx's, then make sure her family is at bedside so they see it and then document it and stop all Tx's....we do it all of the time.....and feel good about being able to follow the wishes of the patient, NOT the wishes of the family. It is always a matter between patient and physician, the family is hopefully representing the wishes of the patient, not their own.

ss

Doc Diego
02-07-2011, 10:31
Very unusual. Someone who faces their own mortality and quality of life issues head on and institutes a DNR order. Don't see that enough where I work(on an ambulance). Sounds like the nurses you work with are somewhat inexperienced (or love drama). A DNR is a DNR.

JAGeorgia
02-07-2011, 11:16
Disclaimer: I am not a attorney. This is not legal advice.

An Advance Directive is exactly that! It is not a Power of Attorney for medical treatment so the alleged motives of the husband/father are irrelavant.

Intubation/trach/cric to maintain an airway on a DNR patient? To what end? Find a manequin if you want to practice or spend time saving someone's life who wants to be saved. This lady MADE THE DECISSION. Have enough respect and honor to follow her wishes.

IMHO: It may not always be easy but it's right.

Cynic
02-07-2011, 12:26
Speaking as a nurse, I feel those nurses were out of line. They were not respecting the wishes of the patient. They may have been identifying with the woman and projecting what they would want for themselves or as someone pointed out, they love drama.
In any case I'm glad you did not intubate.

zeromedic
02-07-2011, 13:35
I am in agreement with SS...as long as the DNR is valid (no expiration date is a bit odd, but every state is different) then you have to respect her wishes...as far as the whole intentional OD by the husband theory, it would make a great TV drama but unless there is any evidence of it nothings going to happen...so I say no tube

Brush Okie
02-07-2011, 15:32
Tough call. I would be inclined to tube her to protect the airway until the BG issue could be resolved. The question I have is what is the underlying cause of the coma? Is it BG level or brain damage? It sounds like she got some insulin in a vain or overdosed on it somehow so what are the lasing effects of that?

CSB
02-07-2011, 17:55
Disclaimer: I am not a attorney. This is not legal advice.


I am an attorney. This is legal advice.

A DNR order is a direct order from your boss, the patient.

If you do anything contrary to your patient's express instructions, you are substituting your desire/wants/needs for the free will of your patient.
And that is wrong.


(I realize that the case is probably "over" by now).

JJ_BPK
02-07-2011, 18:06
A Short Story..

My FiL was in for a bi-pass. He was 79 yo and had a 15 yr history of heart problems including a 12 yo pig value that was at end of the trail. He had lost his wife of 59 yrs 6 months earlier and was in decline. He knew it, we knew it, the priest knew it.

He had a DNR prepared at Admittance (hospital spicific, state format). It followed him thru the OR and CICU, no problems.

The day they moved him to semi-private he went into cardiac failure. The wife was there, called me and the priest.

When the monitor beeped for the last, the floor nurse rushes in and wants to re-sus.

We told her there was a DNR and blocked her access.

Nurse starts yelling for security and climbing over the bed to get to Dad...

My wife went hysterical and I went ballistic..

The Super shows just as I am about to pop missy nurse in the nose.

As I stop to explain why I was going to pop the nurse, she starts yelling she didn't care because the order was not in her hands. As if she had the final say..

I cocked back the hammer and the Super said Please Stop, there is no need,, She knew the order was coming up from CICU.

The nurse still didn't want to stop.. Two other floor nurses held her back from getting a good pop..

This was in Florida 18 yrs ago..

It was as close as I ever want to get to going to jail,, But I would have...

End Story..

:mad:

Brush Okie
02-07-2011, 18:22
I am an attorney. This is legal advice.

A DNR order is a direct order from your boss, the patient.

If you do anything contrary to your patient's express instructions, you are substituting your desire/wants/needs for the free will of your patient.
And that is wrong.


(I realize that the case is probably "over" by now).

Its not always that cut and dry. I once had a Pt. with a DNR who was in V-tach but semi concsious. The DNR states he wanted no CPR ok easy, but V-tack will kill him eventually, but he isnt dead yet. Its easy to say in a court of law this or that however when you are at the house with the family screaming for you to do something and they are dying not dead it isnt so clear.

The DNR stated she wanted no CPR or ventilation, an ET tube can be placed to protect the airway without either of those. What if she vomits then aspirates them comes out of it when her blood sugar is restored but dies a week later from pnmonia caused by the vomit she aspirated? Its not always a matter of right and wrong but of choices and actions. It is easy to shap shoot in court but when you are there it is not always so clear.

Saturation
02-07-2011, 20:42
I believe it is quite meaningful to this case that a 41 YO had a signed DNR from several years ago.

I explain and assist people signing DNR's almost every day in my work. It has been my experience that the younger struggle with signing such a form. The more elderly and sickly are quick to sign and sometimes joke/comment "I didn't have this already?!"

She signed the form and she apparently discussed her wishes with the two involved and clearly interested men in her life. Mechanical ventilation/intubation is a routine part of my DNR discussion but you're right - not part of the form. (FL DNR does not expire either).

As an aside- most conflicts that I have been a part of or read about in the take off supportive measures/keep supportive measures have been spouse v. parent. The remainder tend to be sibling v sibling with only a very few parent v. adult child

Saturation
02-07-2011, 20:50
A Short Story..

....

This was in Florida 18 yrs ago..

It was as close as I ever want to get to going to jail,, But I would have...

End Story..

:mad:

DESPICABLE and you had every right to report her to State of FL licensing board (and more :eek:)!

I can't say that would never happen again now 18 years later though. I have witnessed too many 'professionals' placing their values into a situation creating great needless drama. I have in fact threatened bodily harm to a worker that tried to talk a Veteran out of what he wanted for his medical care.

swatsurgeon
02-07-2011, 22:44
IMHO, one of the greatest problems with advanced directives/living wills is how generic they are....."if I have a terminal condition...." I developed one that is scenerio or diagnosis specific and I have given it out to over 600-700+ people. If anyone would like a copy by email just let me know. Most are difficult to interpret as we saw in an above post...DNR comes in many flavors and as the doc reading and trying to understand what the patient wants without the luxury of discussng it with the patient while they are rational, calm, mentally able, I have to read them and try to understand what they meant by their generic DNR or adavanced directive or living will. Usually, families are less than capable or helpful with the interpretation.

There is never an excuse for a health care provider to not know the status (DNR, DNI) of a patient. This is where the wrongful life suit comes into play. They have to know, whether by arm band, chart label/sticker, or what ever means that particular hospital uses, but if a patient is wrongly resuscitated, there should be hell to pay because you have crossed the line of patient trust in their health care providers. We always want to do what is asked of us (if it is reasonable) to fulfill a trust that the patient has in us, we (I) never want to violate that trust, it is too sacred.

ss

Counsel
02-08-2011, 11:46
Here’s your second legal opinion. What CSB is completely correct.

From your first post it looks like the physician would be substituting the patient’s request in the DNR order for that of the nurses and all of their speculations/theories. If you had the time, try to get an “on the spot - first hand” legal opinion by the “in house” counsel or the like. I know that not many have the “timbales” to make such a quick decision as it would be needed, but still, give them a shot. In any case, not following the DNR, base on assumptions, is not recommendable for the treating physician and/or the Hospital if she entered trough the ER. They will be exposing themselves to liability for damages.

Red Flag 1
02-08-2011, 13:09
"There is never an excuse for a health care provider to not know the status (DNR, DNI) of a patient. This is where the wrongful life suit comes into play. They have to know, whether by arm band, chart label/sticker, or what ever means that particular hospital uses, but if a patient is wrongly resuscitated, there should be hell to pay because you have crossed the line of patient trust in their health care providers. We always want to do what is asked of us (if it is reasonable) to fulfill a trust that the patient has in us, we (I) never want to violate that trust, it is too sacred."

A friend of mine has Lung Ca. He is a retired Hospital Administrator, and is now in Hospice care. He went so far as to tattoo "DNR" in bold letters across his chest. This is in addition to clear written orders for DNR.

RF 1

Doczilla
02-08-2011, 13:30
My gut told me there was no foul play, and I thought it unlikely that both the husband and her father were conspiring to off her, although the husband was clearly driving the bus when it came to her care. There was no durable POA; we were just going by the usual OH rules regarding who makes those decisions, i.e., spouse, then parents, then grown children, then siblings, etc. Ethics committee is a good thought, but I'm not sure how we make that happen at 11pm on a weekend.

Ohio currently has two levels of DNR. A DNR-Comfort Care Arrest (DNR-CCA) simply states that no resuscitation will be undertaken in the case of a cardiac arrest. It is frequently interpreted to allow everything else, though we may modify treatment based on discussion with family. A DNR-Comfort Care (DNR-CC) means that no aggressive lifesaving measures will be taken. This is usually taken to exclude intubation, pressors, central lines, defibrillation, but not necessarily IV hydration, artificial nutrition, or antibiotics. There is legislation afoot in Ohio for the MOLST (Medical Orders for Life Sustaining Treatment), but at present the only way to express your wishes regarding specific treatments is in a written advance directive. As you can see, even here, there is room for debate, as some will say that brief life saving interventions would be permissible if the disease process is thought to be easily reversible.

Most patients I encounter do not have clear advance directives on what care they would or would not want, which complicates things for those of us in critical care and emergency environments. We often rely on family members to tell us what they know of their loved one to help us guide what we do. If they have no useful information, then we treat under the doctrine that most people would want to survive under any circumstances. Most of the time EMS is, frankly, not permitted to think beyond the written page. Only honoring a recent, signed, very explicit DNR order is perhaps medicolegally the safest way to go. This also fails to address the majority of futile resuscitation that we will perform. Of course, if the patient never said anything, we'll never know that they wouldn't want to suffer a lingering convalescence. Making this call on limited information, from sources other than the patient, is tough.

There is that critical time, the immediate resuscitation, that makes all the difference. If you can get someone through that initial issue in the ER, it is very likely the patient will survive. It could be that come patients see that respiratory arrest as an easy way out, and in fact, they are often correct, since the one intervention, intubation, at the critical time, is enough to get them over the hump, to a prolonged convalescence, which is what the patient may want to avoid if they have expressed their wishes not to be intubated. Does this change what we do if the causative issue is one that is potentially easily correctable, or iatrogenic, or self inflicted?

In the end, it was all academic. She maintained her own airway and did not require intubation in the ER. The patient was not terribly well educated on her insulin pump, and was also on a long-acting insulin, so it was thought that this, combined with a UTI, caused the hypoglycemia. She was admitted by PCC to the ICU. He made her a full code, and his documentation stated that he "was not satisfied with the documentation of her wishes regarding code status". The husband was apparently pretty unhappy about it, according to the chart. The patient fully recovered, and met with Integrative Care Management. In a well-documented conversation, the patient said she would not want to ever be intubated under any circumstances, and it appears the husband was correct. A DNR-CC form was executed, and the patient discharged home.

I bring this up because of the difficult position I was in, not just with the patient and family but with staff. The nurses taking care of her were very experienced and pretty headstrong, and they clearly would have put up a fight if something happened and intubation was medically indicated and I refused to do it. I'm not sure how that would have played out, but it likely would have involved the resource nurse, the Administrative Officer, another physician from the ER, and hard feelings all around. It would have been fairly ugly. We like to think that we run the place, but when the nurses feel an ethical obligation to do something, they can, and will, stand up to us, and refuse to execute orders they feel are not in the patient's best interest.

'zilla

RichL025
02-08-2011, 21:00
...

There is never an excuse for a health care provider to not know the status (DNR, DNI) of a patient. ....

ss

With all due respect, this is a little strong. Yes, providers should make every effort to clarify the status of a patient prior to intiatiing resuscitation, but occasionally "real life" interferes with "noble principles". The ED or trauma bay can be a very hectic place, and providers have to use good faith efforts - and I have always been taught that the law recognizes this.

Now, the nurses in the example _knew_ the DNR status, they just chose to disagree with it. THAT I will concede, there is never an excuse for.

I wish I could remember the details of the incident, but I once had a POLST (advanced directive) presented to me _after_ we had initiated agressive resuscitation. We had, by that time, regained a perfusing rhythym but, after consultation with the family (who were very understanding as I recall) withdrew medical support and extubated, the patient died shortly afterwards.

I don't remember the specifics of why we didn't know about the POLST, but I seem to remember that it wasn't in the patient's medical records, and a family member brought it by the ICU and explained things to the nurses....

I acted in good faith though, and was not overly bothered by the episode.

Doczilla
02-08-2011, 21:46
Now, the nurses in the example _knew_ the DNR status, they just chose to disagree with it. THAT I will concede, there is never an excuse for.

They knew the DNR status based on the paperwork provided, but disagreed with respect to other aggressive life-saving measures. In Ohio, other specific measures are not listed in the DNR, particularly the DNR-CCA.

'zilla

Retiredfire
02-12-2011, 09:22
They love their BiPaP here in South Florida. People with valid DNR orders in respiratory failure are frequently ordered on BiPaP. It can not a ventilator, and doesn't require intubation. I think it is ethically wrong and nothing more than an attempt at an end-run on the patients wishes. People deserve the right to die on their terms. To all those that feel an need to save something, i suggest: http://www.savethetatas.com/

swatsurgeon
02-12-2011, 19:46
They love their BiPaP here in South Florida. People with valid DNR orders in respiratory failure are frequently ordered on BiPaP. It can not a ventilator, and doesn't require intubation. I think it is ethically wrong and nothing more than an attempt at an end-run on the patients wishes. People deserve the right to die on their terms. To all those that feel an need to save something, i suggest: http://www.savethetatas.com/

Being that it is non-invasive, some docs feel that it is a bridge to allowing the patient to hopefully get more time to be with their families, allowing us to intervene "non-invasively", and following a patient's wishes of no intubation, etc.
It respects the patient's wishes while also giving them a chance at prolonged survival ...if this is within their wishes. It should not be offered if they do not want it, but if they do agree, it can be a means to more time with their family.
The two parts of this are the desire on the part of the medical team to promote beneficience and non-malfesience while maintaining the patient/physician trust in the decisions made by the patient (either written or discussed) with our desire to help our patients. Most people on the 'outside' don't understand the dynamics involved when I have spoken to the patient and or family and are simply following their wishes....it confuses some of the team members because they are not involved with the day to day happenings of the patient and don't read the progress notes that we leave on the discussions with the patient. We are judged by everyone who does not know the details of the discussions or the caring that goes into the relationship between doc and family during end of life care..

Don't judge until you are on the inside.....

ss

Retiredfire
02-12-2011, 21:03
Sometimes it seems that the patients wished are forsaken for the families inability or unwillingness to let go. I am curious as to the right of a family member to modify an advanced directive.make sure you appoint someone you can trust to follow your wishes, and don't wait until you are in the hospital.

Saturation
02-13-2011, 09:37
I am curious as to the right of a family member to modify an advanced directive.
Years ago I had an ICU doc state- it's not the patient I save that is going to sue me but the family when he dies. Of course that has changed (see earlier posts) and I have seen that attitude shift as well. Generally I have seen families greatly relieved that there is some sort of direction (and by extension less responsibility and less guilt). My experience is that families don't try to change the Advance Directives until the doctors are saying the care is futile but the person wanted everything done.

I don't run into as many bipap machines as you do but many families need that time to process the reality of what is happening. Inasmuch as it's non-invasive it is typically accepted in end of life care.

As you stated being in South Florida, you are probably familiar with many of our residents not having local family and many times limited interaction with their family out of the area. If the family is interested enough to actually make the trip, that family member is seeing the patient for the first time in years??? and then feeling like they are 'pulling the plug'.

Don't worry, some don't even come- they just handle it all through the phone and fax machine.

Retiredfire
02-13-2011, 10:49
I can remember as a newly minted medic being called to the unresponsive patient. upon arrival I discovered a 70 something male with a history of metastatic lung cancer. His RR was like 4 and pupils pinpoint. A concerned family member states that she thinks he OD'ed on his Oromorph. I treated accordingly to the standard of care and the patient lived to suffer another day. I wish i didn't have render treatment, but he was immediately faced by a reversible condition that could be corrected without violating his Advanced Directives. (literal interpretation as Intent is reserved for Judges and Scholars). Was my decision to give enough Narcan to correct his hypoventilation morally and ethically correct? Anyways I'm sure the family member that called 911 would of sued if i didn't.

MAB32
02-23-2011, 23:14
When I was Deputy Sheriff we were always called along with the FD to a scene to make sure it wasn't going to be a crime scene first.

One night my partner and I received a call to go to such-and-such a place along with the paramedics because of a person supposedly dying. We get their first and see him sitting at the dinner table. His wife is on the couch.

We ask him what is going with him and he says a bad heart. He collapses right after that. We just started to get him in position for CPR when the medics arrive. They come on in and take up where we had just started. One medic and I are asking her some questions about her husband laying there. Mine were short and sweet because it all smells fishy to me on why she is not emotional about what is happening all around her. Paramedics have now been working on this guy for over 5 minutes now and has coded twice and after each defib it returns back to normal for a few minutes then goes back again into V-Phib. I offer the medics some of my help and they tell me if i can get on the horn to the hospital then give it to one of them that would be great. I did. I go back to the wife to ask her more questions and now she will not tell me anything, period. In fact she stopped talking to the medics too. Now a few more minutes goes by and they are talking to the ER doctor.

The wife now gets up and walks into their bedroom saying nothing. This isn't looking good so I follow her. Once inside the bedroom she is motioning me to get out. I motion back telling her I am not leaving, and that I ask her out loud wha is she going to be doing here in their bedroom. She pulls a piece of paper out of a drawer next to the bed and hands it to me.

I look at it and immediately I know what I have here in my hands. It is on a white prescription note pad in big letters "DNR" and then it just goes on further to explain what DNR stands for and nothing else but the patients name. Nothing else.

I hand it to the medic who is wrighting down on what meds to shoot and other things such as his vitals. He then looks up at me and notices the paper I have in my hand and say what you got there Mark. I hand it to him and he cannot believe it and talks over the doctor and tells him we now have a DNR. You can hear the doc on the other line saying some 4 letter words and is really ticked off. His answer to the DNR is "F___k It, bring him in anyways!".

He dies that morning around 0830 give or take a few minutes.

Any Legal complications here?

Red Flag 1
02-24-2011, 17:39
When I was Deputy Sheriff we were always called along with the FD to a scene to make sure it wasn't going to be a crime scene first.

One night my partner and I received a call to go to such-and-such a place along with the paramedics because of a person supposedly dying. We get their first and see him sitting at the dinner table. His wife is on the couch.

We ask him what is going with him and he says a bad heart. He collapses right after that. We just started to get him in position for CPR when the medics arrive. They come on in and take up where we had just started. One medic and I are asking her some questions about her husband laying there. Mine were short and sweet because it all smells fishy to me on why she is not emotional about what is happening all around her. Paramedics have now been working on this guy for over 5 minutes now and has coded twice and after each defib it returns back to normal for a few minutes then goes back again into V-Phib. I offer the medics some of my help and they tell me if i can get on the horn to the hospital then give it to one of them that would be great. I did. I go back to the wife to ask her more questions and now she will not tell me anything, period. In fact she stopped talking to the medics too. Now a few more minutes goes by and they are talking to the ER doctor.

The wife now gets up and walks into their bedroom saying nothing. This isn't looking good so I follow her. Once inside the bedroom she is motioning me to get out. I motion back telling her I am not leaving, and that I ask her out loud wha is she going to be doing here in their bedroom. She pulls a piece of paper out of a drawer next to the bed and hands it to me.

I look at it and immediately I know what I have here in my hands. It is on a white prescription note pad in big letters "DNR" and then it just goes on further to explain what DNR stands for and nothing else but the patients name. Nothing else.

I hand it to the medic who is wrighting down on what meds to shoot and other things such as his vitals. He then looks up at me and notices the paper I have in my hand and say what you got there Mark. I hand it to him and he cannot believe it and talks over the doctor and tells him we now have a DNR. You can hear the doc on the other line saying some 4 letter words and is really ticked off. His answer to the DNR is "F___k It, bring him in anyways!".

He dies that morning around 0830 give or take a few minutes.

Any Legal complications here?

Lot of dynamics going on there Mark! Trip to the ER was probably a good idea. The doc on the phone had the ball, and you did what he said.

RF 1

Saturation
02-24-2011, 19:27
.... It is on a white prescription note pad in big letters "DNR" and then it just goes on further to explain what DNR stands for and nothing else but the patients name. Nothing else.

Any Legal complications here?

Based on what you describe on the paper, it was an improperly executed document. One could argue the intention was present but that's not something you can figure out in this context.
In my mind the intention was not strong enough---- meaning a Dr's signature on such prescription note and the individuals' signature would have given me more pause.

FWIW- In FL- if your DNR paper is completely signed, dated, MD license #, etc and on white paper- INVALID. On yellow paper (any shade mind you)- it's good to go.

MAB32
02-24-2011, 22:19
Thanks guys. She did however sue all the way to the top and got down almost to me and the SO. She dropped short of us and got the medics on duty that night. From what I remember she didn't really have a leg to stand on and the Doc's DNR was questionable at the very least to all.

I agree RF1, it was one heck of a night.

Mark