Posts Tagged ‘resuscitation’

It’s harder to keep the patients alive after they’re dead

January 20, 2016

The question came up to me

About patients, who number three.

Should we try to restart

A non-beating heart?

Or perhaps just them be?

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

Today I wrote Do Not Resuscitate orders for 3 hospital patients.

Television and movies thrive on the tension of cardiopulmonary resuscitation (CPR): doctors shout, orders fly through the air, the seconds tick while a life hangs in the balance, and in the end the dead come back to life. In Hollywood, CPR always works.

In real life, CPR patients rarely make it out of the hospital. The ones who have the best chance are the ones who didn’t have much wrong to start with: the young, the athletic.  Those with a tenuous hold on life, the ones most likely to have their hearts stop, do not do well.  Perhaps a third of those with cardiac arrest survive what the doctors call the code.  Most live long enough to generate six- or seven-figure medical bills, but die before they leave the hospital.  And lack of oxygen leaves many survivors with permanent brain damage.

New Zealand’s national policy, when I worked there in 2010, held that age greater than 75 constituted an absolute contraindication to CPR.

Now when I have an end-of-life conversation with a patient or a medical Power of Attorney (POA), I ask, “If your heart stops beating, do you want us to try to restart it?” always prepared for a long answer. Nobody gets to the end without a really great backstory; those who love the frail unambivalently need much less time than those with mixed emotions, and the human condition results in contradictory feelings.

A negative answer comes rolled in with long justification.

For a positive answer I have to explain what CPR and shocks do.

The act of pressing on the chest to keep the blood circulating breaks ribs in everyone over the age of 30, and almost everyone over the age of 20. Electric shocks hurt, and the shock of the defibrillator hurts worse than any shock the average American has ever felt.

Then I get to the question of the tube in the windpipe, which requires unconscious ness and eventually a ventilator.

Few of those born before WWII who retain all their faculties choose resuscitation after my discussion.

None of the patients during today’s discussions wanted CPR. Each conference took a long time.  But trying to rush such a talk is rude and disrespectful, and hurrying it can obscure patients’ real wishes.

So I gave my complete attention, easy when listening to wonderful tales, stuff I couldn’t make up.


Morning rounds before Thanksgiving.

November 22, 2012

I started my work in the dark,

At the hospital next to the park.

Up and down floors

And in and out doors

The contrast and irony stark.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

I enjoy starting early.  On Mondays and Wednesdays I do my group’s hospital rounds, and I like being in that first wave of doctors that hits the nursing floor before the chaos of shift change.

The more efficient I get, the more I enjoy inpatient work.  A doc can save a lot of time if he or she starts at the top and works down but today I started with the sickest patient admitted overnight, on the fourth floor, not the sixth.

I gained time because comatose patients don’t talk, and lost every minute trying unsuccessfully to access the outpatient record electronically.   Faced with an unconscious, non-English speaking patient, no available family members or other source of data, I did the best I could.  I left orders for social workers with interpreters to locate family and clarify the Do Not Resuscitate status.

Down the hall, the next patient, also requiring a history and physical, presented a dilemma: a narcotics addict with a legitimate, acutely painful physical problem.  I wrote orders for generous doses of narcotics in a patient-controlled anesthesia (PCA) pump.

I dealt with nurses panicking about a rumored bedbug found in the ER, pointing out that wearing infection control gowns , gloves, and caps wouldn’t do anything to prevent the spread of real bedbugs.

On the other side of the nurses’ station, I discharged a large patient with a 14 item problem list, who will need outpatient IVs for weeks.

I didn’t see the last patient on that floor, absent for treatments across town, but the ward clerk told me when to return.

Five minutes here and there add up, chasing patients wastes time, and I could feel efficiency fleeing in front of me.

I set off upstairs.

Some people don’t stop unhealthy behaviors soon enough, and physicians like me sometimes have to sit down with families and talk about time expectations measured in a week or two.  We discuss ventilators, resuscitation, and the vital business of saying what you have to say to the people in your life NOW because you might not be around to say it on Monday.  The patient said, “I’ve had a good life.  I’m not afraid to die.”  I talked with the consulting subspecialist who confirmed a very poor life expectancy, and gave me a decades-old formula . My calculator came to 63 when anything over 32 means less than a dozen days.

Three doors down I discharged another patient, mixing Spanish and English, and getting pieces of a fascinating life story, an odyssey crossing and re-crossing international boundaries.

On the other side of the building, inside the locked doors of the psychiatric unit, I discharged a person showing remarkable insight and taking complete personal responsibility, after a discussion of the fine points of a borderline vitamin B12 levels.

Two stories down, I discharged another from the orthopedic floor, who also had vitamin B12 problems and severe vitamin D deficiency.  Two doors up the hallway, the patient showed progress but not enough to leave.

Up the stairs again on the fourth floor, five minutes fled while the patient arrived from across town.  Optimism suffused the visit with four family members and a patient with a grim diagnosis and a good attitude.

Two floors down another admission involved a newborn, with the shortest of histories and the most efficient of complete physicals.  I spent more time talking with the parents than actually examining the patient.

Thus in the course of my hospital morning, I took care of 8 patients including 3 admissions and 3 discharges (with discharge summaries).  Diagnoses included metastatic cancer, end-stage liver disease, hip fracture, kidney failure, dementia, end-stage pulmonary disease, bipolar, alcoholism, depression, diastolic heart failure, sepsis, epididymitis, diabetes, hypertension, coronary artery disease, stroke, narcotics addiction, sepsis, urinary tract infection, and completely normal.  Life expectancy ranged from less than a week to 86 years.  Family involvement went from none to surrounded by warmth, and emotional impact of disease ran the spectrum from despairing acceptance to outright joy.

Contrast is the essence of meaning.  I finished before noon.  I lunched with my colleagues in the doctors’ lounge, discussing hospitalized patients with consultants. The erudition beat the chili.

A refresher in resuscitation and a visit to Te Papa, the New Zealand National Museum

March 16, 2011

I’m trying hard to decide

When everything else has been tried,

     What drugs should we give

    To make the dead live,

After a patient has died.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  Just back from a six-week assignment in Barrow, Alaska, the northernmost point in the United States, we’re in Wellington, New Zealand.  I’m prepping to work here.

The third morning of orientation today started with a discussion of emergency medical services in New Zealand, while concern about fallout from the Japanese nuclear disaster remained an undercurrent in everyone’s mind.

Four entities provide EMS in this country; three cities have their own, and St. John provides the rest.  They also do a lot of other civic stuff, including operating the largest youth group in the country.  There are four levels of providers. 

It came as no surprise that the lowest level of emergency service provider administers acetaminophen (Tylenol or Panadol) routinely.  It came as a shock to learn that the more advanced can also administer low doses of Fluothane, an inhaled general anesthetic that fell out of American OR favor in the ‘90’s. 

The higher levels paramedics are allowed to give small quantities of ketamine, which is closely related to angel dust or PCP.  It’s also a great general anesthetic, dissociating the patient from the pain experience, but sometimes people freak out.  I learned that in the low doses used by the EMS providers, pain relief is prompt and bad reactions are rare.

In some circumstances, specially trained rural GP’s attend trauma patients at the accident scene.  

At the Advance Trauma Life Support (ATLS) course I took in December, the instructors recalled the days when they went out in the helicopter and took care of trauma victims in the field.  Their faces lit up when they told their stories.  Doctors in the States don’t do those things anymore.

The instructor gave us a brief refresher in ACLS.  The Automatic External Defibrillator movement has just started here.

New Zealand has prioritized resuscitation to those people with a reasonable prognosis (for example, not those with massive stroke).  By comparison, the barbaric American way gives everyone gets a “full code” (including shocking, intubation, ventilators, and chest compression) unless a document to the contrary comes to hand immediately.

 Resuscitation trends have come and gone, algorithms have changed, and the rate of successful resuscitation has improved in the thirty-two years since I first took ACLS.  Most of the drugs originally recommended have been dropped from the armamentarium.  Since I took the Basic Life Support course last spring, chest compression only has supplanted mouth-to-mouth combined with chest compression.

But some things don’t change.  Our instructor mentioned his wife, now thirty-eight weeks pregnant and four hours away, and his concern.  I remembered back to February 1984, when we lived in New Mexico and Bethany’s second pregnancy went past her due date.  I worked at an outlying clinic forty-five minutes distant, and I hated leaving her.  I had no peace of mind till I started back home.

Three of the docs and two of the wives lunched together and went to Te Papa, the New Zealand national museum.  I was impressed by the wisdom and knowledge of our Maori tour guide, who has instructed at the University level in, among other places, Wisconsin. 

I would have loved to just sit and talk with him for an afternoon.