Pembirdie

Category: medical

  • No one knows if you will become a vegetable

    Anytime I admit you to the hospital, I have to ask you about code status. In other words, if your heart stops beating, do you want us to try to start it again? (The process of attempting to do so is called cardiopulmonary resuscitation, or CPR.) If you are unable to successfully breathe on your own, do you want us to put a tube down your throat so a machine can breathe for you? (This is mechanical ventilation.) If you want both, that means you are “Full Code.” If you would not want CPR but would want to be on a ventilator, then you are DNR (Do Not Resuscitate). If you don’t want either, you are DNR/DNI (Do No Resuscitate, Do Not Intubate). If you want CPR but not intubation, too bad, you can’t do that. When your heart stops beating you also stop breathing, so you have to be ok with getting both. 

    On the regular, I will ask someone this question and they will answer, “I’d like you to try to revive me, but if it looks like I’m going to be a vegetable then stop.” 

    My answer: We can’t know if you are going to be a vegetable.

    (It goes without saying: you will never be a vegetable. We are mammals. Nothing medical science can do will ever turn you into an edible plant.)

    There is the question, what do they mean by vegetable. I think they usually mean, permanently unconscious: brain dead. Well, guess what. As doctors, even with the best tests we can’t generally say that 100%. There is a surprising amount of controversy in this area. I don’t think most people realize it is so gray.

    But more importantly, we aren’t God. If you heart stops, we have no idea what is going to happen when we start chest compressions, electric shocks and IV medication pushes. We can guess what we think is going to happen, but I’m pretty bad at that. Maybe you are just going to die. Maybe you will wake up in a minute and talk to us. Maybe we are going to pound on your chest for forty minutes and then you will be unconscious and on a ventilator in the ICU and maybe you will wake up in a few days or maybe not, and maybe if you wake up you won’t be able to move the right half of your body. Saying you want to be “Full Code” means you have to be ok with all of those options, you can’t just choose the good one.

    You know what I want your answer to be? If you are a healthy person over the age of 85, I want you to be DNR/DNI. If you are an unhealthy person over the age of 65, I want you to be DNR/DNI. If you are a really unhealthy person over the age of 40, I want you to be DNR/DNI. (Exception being if you are in surgery. Most people, even if they are DNR/DNI, will transition to Full Code during surgery, because it is so successful in this situation.)

    Why? Do I hate people? Do I want to take care of fewer patients?

    Admittedly, it’s probably bias. I haven’t seen that much CPR, actually. But the CPR I’ve seen has not been pretty. It has been brutal. And it has been mostly unsuccessful. Do you want the last minutes of your life to involve someone pounding on your chest, breaking your ribs, shoving a tube down your trachea, shocking your chest?

    Doctors, advanced practitioners, nurses and other healthcare providers go into medicine because we want to help people. Oftentimes CPR feels like we’re doing the opposite.

    I, as a healthy person in my mid-thirties, want CPR. I would want my husband, my siblings and my mom to have CPR. I’m not against it. It’s just not for everyone.

    SDG

  • Something everyone needs

    Everyone should have advance directives. Advance directives specify what kind of medical care you would want in the event you are unable to express a decision. Ideally, these should be written down, along with your designation for medical power of attorney (POA) – the person who would make decisions on your behalf if you can’t make them yourself. If you don’t want your closest relative (spouse, child or parent) to make decisions for you, then a document naming medical POA is essential.

    Perhaps just as important is talking with the person who would be your medical POA so they know what you would want. Ideally, if your medical POA is making decisions on your behalf, it should feel relatively easy for them because they already know what you want – they are just relaying the message to the medical team.

    Advance directives usually have a question about code status, about what you would want if you were expected to be permanently unconscious, or have an incurable and rapidly progressive medical condition that will result in death. Usually they ask if you would want tube feeding for nutrition if you can’t eat. They might ask how you would like your pain controlled, and if you want your organs donated if possible.

    One thing to note is that as humans, we aren’t the best at predicting what we will or won’t be ok with in the future. There is a principle called hedonic adaption that says that we tend to get used to nice things pretty quickly. For instance, in medical school I had the Lasik procedure. In the days that followed (after the sand-in-the-eye feeling went away), it was amazing! No need to put on glasses or deal with contacts! Everything clear! But pretty quickly it became normal.

    Now, maybe every few months I remember that my eyes didn’t used to see 20/20 and I feel a wave of gratitude, and yes, the irritation of dealing with foggy lenses or a misplaced contact doesn’t happen any more, but I can’t say that I’m particularly happier than I was before I got Lasik. My body got upgraded, and my expectations upgraded as well.

    Fortunately, the same thing can happen when our bodies downgrade. Studies show that people are able to adapt to their misfortunes. Again, I’ve experienced some of this myself. With my current hip problems, I can’t go on a casual walk or participate in a lot of fun activities. This has definitely been frustrating and life-altering and I know I’m missing out on things, but am I sad about this all the time? Nope. I don’t think my happiness level is hugely different. If I was miraculously healed and back to my “normal” self, I could see myself being a lot happier – for a week or two, maybe a month. At that point I suspect I would have adapted to my new reality. 

    SDG

  • Side effects of CPR

    Generously, one in three people who undergo cardiopulmonary resuscitation (CPR) in the hospital will survive. (Success rates are lower outside the hospital.) Congrats, that’s what you were hoping for! CPR does have side effects, however… but you only experience the side effects if it successful aka you are still alive.

    1. Broken ribs. This is the most classic side effect. The older you are, the more likely this is going to happen, because ribs get more brittle with age. If you are a little old lady, your ribs are going to snap like toothpicks. What do broken ribs feel like? As far as I can tell, nothing good. Breathing will be painful, so the temptation is to take little tiny breaths instead of big ones and to avoid coughing at all costs. Unfortunately, doing this sets you up for pneumonia, which you are already at increased risk for being in the hospital. So we’re going to be asking you to take those big, deep, painful breaths anyway. You may need to go on opioid pain medication in order to do so, which comes with its own litany of side effects (like constipation, confusion, and dependence).
    2. Brain damage. About one third of people who survive CPR will have brain damage. This does not mean you are an unconscious “vegetable.” But maybe you are. Or maybe you just can’t live by yourself anymore because it’s too unsafe.
    3. Trachea/vocal cord damage. If CPR goes on for more than a few minutes, we are going to try to place a breathing tube. In the process, the tube may injure your throat, including the vocal cords. Swallowing may be painful for about a week. Your voice may never be the same.
    4. More time in the hospital. No one comes out of CPR healthier than when they went in. You will likely end up in the intensive care unit for close monitoring, which is going to involve more tests, blood work, and interruptions. Almost certainly your hospital stay will be prolonged. Longer stays in the hospital mean greater chances for other things to go wrong.
    5. More likely to not go home. You’ll be weaker and may need to spend time rehabilitating in a nursing home. If you are fortunate, you will rehab back to home or move into an assisted living where you have more support. If you’re less fortunate, you’ll be a permanent nursing home resident.
    6. More likely to return to the hospital. Generally, hearts don’t just stop beating out of nowhere. You probably have some serious medical conditions that are not going to go away. You may also have more health problems as side effects of CPR. (See above.) As a result, don’t be surprised if you continue to get ill enough to require repeated hospitalization. Your doctors certainly won’t be.
    7. More likely to die. A study examining CPR in older adults with medical problems like heart failure, COPD, cirrhosis and cancer found more than half of them were dead in 6 months. 

    Again, you only get these side effects if CPR is successful: the alternative is being dead. The older, sicker and more frail you become, the more likely you will experience these side effects and the more severe the side effects are likely to be. You will also be less likely to survive to experience them.

    In general, if you are under sixty, I’d say it’s worth doing. (That recommendation would change if you have metastatic cancer or other severe health problems.) Over sixty becomes more gray as people accumulate more health problems. Ultimately, the decision is up to you, but it’s important to know what your decision means.

    SDG

  • Gaps in my financial experience

    Because of my parents’ generosity, I don’t have experience with two major expenses that it seems a majority of people have to deal with: student loans and a mortgage.

    My parents funded 529 college savings plans for all of us. Thanks to my highly specific skill at excelling at standardized multiple choice exams, scholarships covered my college tuition and half of my medical school tuition, but the 529 plan paid for college room and board and the other half of med school. (I think I paid for the four pre-med classes I took at USD, but they weren’t very expensive.) (I also know my 529 plan didn’t pay for it all, Mom moved some around from my brother’s plan, as he had an all-expenses paid education at the Air Force Academy.) Making it through college and medical school without student loans is a major boost and has no doubt saved me countless worries.

    When my husband and I decided to move back to Omaha, Mom told us we didn’t have to worry about applying for a loan: she’d give us the money for the house, and we’d pay her back. In retrospect, I don’t think we set the arrangement up correctly – turns out you can’t just give someone a large sum of money and have them pay you back without some contractual and estate planning considerations – but this arrangement has worked out great for us. Turns out there are a lot of extra expenses you don’t have to worry about when you pay for a house with cash. We have a very reasonable “mortgage” payment that I transfer to Mom’s bank account every month, and with the inheritance we received from various estate sell-offs (again, a major boost!), we’re going to have her paid back in the next seven years, God willing.

    As a result of my family’s wealth and generosity, I won’t be able to offer advice based on personal experience for several areas that typically have a large impact on a person’s financial life. This is a good problem to have, but something I will need to keep in mind when I’m tempted to compare my financial situation to someone else’s.

    SDG

  • How much is walking worth?

    On Monday, someone came from the wheelchair company to measure me for a wheelchair. He explained that the standard-issue wheelchairs are made in Mexico, but the fancy ones are made in Wisconsin. I’m not sure if he was implying that Wisconsinites make nicer wheelchairs than Mexicans or if that was his explanation for why the nicer wheelchairs are so much more expensive.

    While the insurance gods will ultimately determine what kind of wheelchair I get, we’ve decided to “try” for the fancy kind that has removable wheels and an extra light frame and comes in whatever color you want. (I’m going with candy red. It might be a mistake.) The man estimated that if we meet our deductible the wheelchair will cost around five hundred dollars. If that will allow me to consistently get to work by myself and diminish my fears of the wheelchair making me fall over as I try to get it in/out of the trunk — worth it.

    Even better, if, as per Murphy’s law, paying a lot of money for a fancy custom wheelchair would increase the chance of my hip problems spontaneously going away, that would be five hundred dollars extremely well spent.

    As I was thinking this thought to myself whilst driving home after almost falling over getting my wheelchair into the trunk at 11 PM at night, I kept on the same track and wondered, if I could pay money to make my hip problems go away, what’s the most I would pay?

    That is a tough question. Of course there are variables. Could the problem spontaneously remit on its own, or are we assuming there is otherwise no cure? Would this payment essentially keep me healthy for all time, or could I get another debilitating ailment the next year, or could the condition come back? Could other people contribute to the monetary amount?

    Ten thousand dollars, I would pay without thinking about it. Twenty thousand dollars (essentially our three-month emergency fund)? Mmmph… probably. Ninety thousand dollars (essentially what we have in our taxable account)? Yikes, that seems like too much. But we could probably afford it. Is ninety thousand dollars too much to pay for the ability to be able to roll around in bed without waking up to think about it, painless sex, being able to walk to Lindy’s grave, hiking?

    If there weren’t other options, I think I’d do it. If I wasn’t in a position of being blessed with monetary resources, then I guess it would be tough luck. Despite this being a hypothetical scenario, it seems problematic that I would be able to pay my way out of not being able to walk when someone without my resources would not be able to. On the other hand, my parents have paid me out of having to wear glasses or contacts (thank you, Lasik!) and smiling with crooked teeth, and that doesn’t seem so problematic. Maybe it’s because those “upgrades” seem more superficial, but I guess everything is on a sliding scale.

    SDG

  • On death and dying

    I haven’t had as much experience with death as some.

    On one hand, my childhood contained plenty of animal death. Cows died sometimes. My dad shot three of our dogs when they got too old to move, and we tearfully brought another dog to be euthanized at the vet when it was diagnosed with diabetes. Countless cats disappeared, and more than a few kittens kicked the bucket, some in gruesome ways. One night when I was ten or eleven, I wanted to feel sad (kids are weird) and tried to tally up all the animals I knew that had died. I can’t recall the total but it seemed like it was over fifty.

    On the other hand, I was spared the death of someone I loved until after college.

    My dad died in a plane crash the summer I turned twenty-three – that was my first real experience.

    A fact about me I’m ashamed to share: I’ve never performed CPR in a read code event. The opportunity never came up in med school, and when someone coded in the ICU during residency and I saw everyone lining up for their turn at chest compressions in what seemed quite obviously to be a futile attempt at resuscitation, it didn’t seem like giving a few of my own chest compressions was going to help me or the patient.

    I’ve observed several codes, none of which ultimately was successful. (This demonstrates how few I’ve seen, because statistically in the hospital about 1/3 to 1/4 are at least successful at restarting the heart.)

    I didn’t pronounce someone dead until my fellowship year. An older woman in my care had been placed on comfort care with the goal of leaving the hospital on hospice. She wasn’t doing well, but had been stable for several days. Right before the end of my shift, her nurse paged and asked me to come up, because my patient had died. In a moment of gallows humor, I had a shock when I was listening for a heart beat and watching the patient’s chest – it was rising and falling. Then I realized her air bed was still on. The nurse turned it off, and she was still.

    Our daughter, Lindy, died in our arms. She just gradually stopped breathing. The nurse listened to her heart and said she had died, but when the nurse practitioner came to confirm, her heart was still beating, slowly. It kept beating for a few more hours as we held her close in the hospital bed.

    Yesterday I spent the afternoon sitting next to a great aunt who is dying. Part of the time she moaned and moved her head back and forth, most of the time she slept. I don’t think she knew I was there. Her pulse was high, probably 120 beats per minute. Still breathing steady but sometimes with a rattle. I sat with her in the hospital in July and thought she was dying then, although she’s further down that path now. I don’t know how long her earthly journey will continue. Sometimes it happens so quickly, like with my dad. Other times over a few hours, with Lindy. My great aunt is taking a harder, longer road, God only knows why.

    I hate death. People say death is just a part of life, but they’re wrong. It wasn’t supposed to be like this.

    What I do know is that the God of the universe experienced death as Jesus Christ, and he conquered it.

    Resurgam.

    SDG

  • PSA regarding cat bites

    I like cats. I even love my cats, despite the old wisdom stating you should “never love something that can’t love you back.” Saying our cats love me is a stretch.

    However, liking cats doesn’t stop me from acknowledging that cats’ mouths are nasty. (This isn’t just a cat thing. One of my professors said, “If you lick the seat of a toilet, it should be the toilet that says, ‘Gross!’” Except of course that toilets don’t talk.)

    In addition to cats’ mouths being a fertile breeding ground for all sorts of anaerobic (oxygen-hating) bacteria, cats have pointy little teeth. Dogs’ mouths are just as nasty as cats’, but their teeth are generally thicker and they make big tearing bites, whereas cat bites are almost like little needles piercing your skin. It’s a lot harder to wash bacteria out of little tiny wounds, and the anaerobic bacteria thrive deep in your tissue away from the oxygen that’s at your skin’s surface.

    For that reason, if you get a cat bite, particularly on your hand, don’t wait to see if it swells and gets red and warm and painful. If you wait that long, it might be too late and you just may end up getting admitted to the hospital for IV antibiotics and an orthopedic or plastics hand consult for a wash out. No one wants that.

    Instead, get an urgent care appointment. Who knows, Amazon might even work for this situation. A reasonable provider will give you a prescription for Augmentin and you’ll kill those bacteria before they can do any damage.

    Are you guaranteed to get a dangerous infection if you don’t go on antibiotics? Of course not. But the danger is real, the prevention is relatively safe, and the overall balance of risks and benefits falls on the side of prevention in my book.

    SDG