Against the odds

Hit me.

Really? The dealer’s showing a 4!!

But we take the hit with fantasies of sailing away on a yacht. Against all odds. Against the warning from the dealer,  against the wishes of the man sitting at 3rd base (last position at the Blackjack table) and against our intuition. But let’s get real for a moment, who isn’t lured by the thought of Benjamins dancing in her head, by telling her boss to “fuck off” before quiting, leaving a trail of 50s behind her as she walks out the door?  And when we bust, we walk away saying “WHY DID I DO THAT?”

In healthcare we take the hit, too, only it’s in the form of joules or chest compressions despite evidence of its failure.  Because with CPR comes the the ultimate payoff….  life, or so we think. Last month during my PALS recertification, I learned that  survival rates for in hospital CPR is 20% and 27% for the pediatric and adult populations, respectively, with post CPR to hospital discharge survival hovering near 15%.   It’s OK to be stunned, I was too.  

Mr. and Mrs. Latvia were set to celebrate their 70th wedding anniversary in April when she was re-admitted to the ICU from the nursing home. They were 91 & 92 years old. Cute. Until I looked at Mrs. Latvia’s aged, frail and pale body, life fading from her eyes. She had suffered strokes, respiratory failure and was trached. She had undergone heart valve replacement surgery, had CHF, a malignancy on one of her kidneys and now she was bleeding internally. Mrs. Latvia didn’t look good, as we say, and I knew she was not going to leave the hospital alive.

Mr. Latvia was so attentive, loving, caring, inquisitive as well as informative. He knew her lab numbers for one of the medications she was on and knew what they should be, he knew how she liked to be positioned in bed, he knew her medical history, medication list and doctors’ names without having to look at a piece of paper. He knew he loved her and he knew he wanted to celebrate their 70th wedding anniversary. He didn’t know why she was back in the hospital, he didn’t know why I couldn’t make her better, he didn’t know why she wasn’t allowed to eat.

I knew I wasn’t going to code Mrs. Latvia because I knew I had a whole team of people who would. I knew that Mrs. Latvia’s body had taken so many hits, especially in the recent months that she would not be in the 27% saved by CPR or the 15% to survive to discharge.  I knew I wouldn’t have to ask Mr. Latvia about an advanced directive or if he wanted us to perform CPR in the event Mrs. Latvia’s heart stopped, they wouldn’t be in the hospital otherwise. I knew that I would hold Mr. Latvia’s hand during the code, explaining everything that was happening.  I knew that I would talk to Mr. Latvia about their years together, good times and bad, I knew I would reassure him that we would find and stop the source of Mrs. Latvia’s bleeding and I knew I would never promise him that they would celebrate their 70th wedding anniversary. I knew that I would ask him if there was anyone I could call to the hospital for them and I knew I would ask the doctor for a palliative care consult, a request that was denied. Crazy.

So why are survival rates for in hospital CPR so low? Existing research offers many conclusions but ultimately all the research ends with the same conclusion, that we are performing CPR on individuals who have reached the end of his or her life. So why do we procede in the face of futility?  It’s partly because  too many of us are afraid to die (understandable), too many think medical technology can do more than it does, and too many believe (or want to believe) that God or Dr. House will save us in the 11th hour. But mostly it’s because too many of us don’t have an advanced directive and now some of our “leaders” are heinously proposing such conversations to be immoral, illegal and irrelevant. Maybe Sarah Palin should actually spend time with nurses and doctors (her lobbyists don’t count) and in hospitals before spewing drivel from her mouth! In 2010, the AHA will release the new statistics regarding survivability after CPR. I don’t expect the numbers to be any different. I do hope the number of people talking about advanced directives with doctors and nurses increases, contrary to the thoughtless idiocy spewed by some of our “leaders”.

The code to “save” Mrs. Latvia’s life occurred at 2130, after I had gone home. Mrs. Latvia was pronounced dead at 2142. I was not there to hold Mr. Latvia’s hand but I hope someone was.