I just finished my recertification in Advanced Cardiac and Pediatric Advanced Life Support this week. Over three evenings myself and several other people went through a few lectures and plenty of practice resuscitations on adult and child mannequins. I’ve taken ACLS many times over the years and have watched as the algorhythms and guidelines have changed and been simplified each time I did it. I also remember one thing rarely changed though in most of the times I took it – we rarely had any of our “patients” live.
Over the years, despite all science and training and public service announcements, people still die from heart attacks and sudden cardiac arrest. Automated External Defibrillators have increased the incidence of lives being saved at time and point of arrest (and I personally know some folks that are alive today for that very reason), as well as having paramedical personnel more readily available to help when people are struck down, but despite what all the old episodes of ‘ER’ will tell you, the vast majority of cardiac arrest victims still die.
When an arrest victim is brought in, a pile of people descend upon them to try their damnedest to squeeze blood around the body and get air in and out of the lungs. They stick needles into veins to get drugs in to try and stimulate the heart back into beating properly or even at all. They repeatedly push, well really pound, on their chest. CPR is a brutal, yet necessary, thing to try and get blood to the heart muscle and the brain so that the patient might have any hope of surviving.
These days, we will sometimes invite family into the resuscitation bay so that they can witness not only how hard people are fighting for their loved ones’ lives, but what that person is actually going through. Their are times when some (not all) people are needlessly put through this process…folks with very advanced or terminal illnesses, the very frail or aged. Some of these folks may have had “the talk” with their doctors abut how they want to be treated after a certain point in their lives or illnesses, but their families sometimes, at that moment, cave in to the emotions of the time and want all stops pulled to save their family member. The unfortunate thing about that is the potential suffering that the patient may in fact go through as the result of a successful resuscitation may be worse than they’ve already been going through what with bruised chest, fractured ribs and the like added to whatever else may be ailing them. I remember as a young medic one of my officers telling me about a code he was at…the fellow was a religious person and offered a prayer for the patient in question while the resuscitation went on. This patient, while successfully resuscitated, ended up living in constant pain for another few short days.
I am not anti-resuscitation by any stretch of the word. I’ve worked full out on a number of folks over the years, witnessed a precious few where we literally made Lazaruses out of some folks, however, the net result is still in favour of fate, Mother Nature, and the various gods that oversee us. To paraphrase a TV physician, everything we do in medicine is to slow down the inevitable that is programmed into our DNA – humans are machines with a shelf life and a limited extended warranty plan for those that are able to pay in time and effort to look after themselves. Sometimes we can reverse the process in mid-cycle, sometimes we can’t. I always tell patients that there are certain laws in the physical realm we can bend to a point -the laws of genetics being some of them. I liken those laws to the Law of Gravity like this – if you jump out of an airplane, regardless if you have a functioning parachute or not, you’re going to hit the ground eventually; the only difference is how fast and hard. Same goes with our bodies – if we look after them, it becomes like a parachute of sorts. If we have bad histories in our families of say, early heart disease, we can ensure that we don’t tempt fate by making sure we don’t smoke, eat reasonably well, get periodic check ups, exercise regularly, keep blood pressure a stress in check, etc ad nauseum. If you choose to play chicken with fate though and jump without a functioning chute or reserve, you might just end up in an ER having the proverbial BIG ONE or worse, having the proverbial BIG ONE and several folks pounding on your chest.
I think that all people should give some thought to what they want done to them if their hearts and breathing fail them and make sure that your primary care givers and your families are aware of your wishes. Have these written down somewhere and revisit them as often as things in life change. Some of us joke about tattooing our chests with “DNR” or “Do Not Place Hands or Pads Here”…but it’s not a joke to be doing a full code on someone who has little to no hope of anything like a meaningful life IF we even manage to bring them back. That takes a toll on families, the patient and the caregivers involved. So have that talk.