Agraphia Medical Tragicomedy

10Jul/11Off

Megacode

She rolled in to Resuscitation Bay One an ashen grey, the tired paramedic straddling the stretcher doing chest compressions.  Sweat poured down his brow and arms.  They had been at this for an hour en route to our hospital on dark, twisty back roads.  She was just shy of 90 years old.

She died for the first time at home while washing the dishes; her husband heard a plate shatter and found her dead on the floor.  He started CPR while calling 911 and valiantly kept doing chest compressions until the medics arrived.  They jump-started her heart with a defibrillator, but she died for the second and third times on the way to us.

There is a hue about truly dead people - an aura, almost.  Extremities pale and mottled, lips colorless.  When she arrived the other physician and I shared a knowing glance.   This would not end well for her.  She was long gone already, but her wishes were to "have everything done".  So, we started doing everything.

It is a peculiar feeling, cracking someone's ribs while doing CPR.  The heart is simply a series of one-way valves; by doing chest compressions blood is forced out of the heart to the rest of the body.  Unfortunately generating that much pressure is often too much for osteoporotic, elderly bones to handle.  The result is a *snap* as ribs break from the force.  It feels like torture.

Broken ribs are unbelievably sharp.  Chest compressions generate inward force, and so the bones rip and tear the lungs, causing air to leak out.  With nowhere to go, eventually the air pressure deflates the lungs.  The solution is to "decompress" the pulmonary cavity with large bore needles stabbed directly though the chest wall.

As her heart began to fibrillate we began to shock it with 200 joules of electricity, over and over, in an attempt to regain a normal rhythm.  Caustic medications were pushed through her IV's to try to stabilize and restart the heart muscle.  None of it worked, of course, but she wanted everything done.

In ACLS training this is referred to as a Megacode - a code situation where every therapy and every algorithm is used.  It's purely for training purposes; you never survive these extensive measures.

She briefly regained a pulse and then died for the fourth and final time, with a tube in her trachea and esophagus, every rib broken, a needle in each side of her chest, IVs in each arm, special intravascular devices to each groin, and a catheter up her urethra.

I wish I could bestow my entire medical knowledge on patients and families before they ask to have "everything done".  They cannot possibly understand what they ask me to do to the ones they love.

Comments (12) Trackbacks (0)
  1. Fabulous and accurate post. I’ve been in the position of being the one doing CPR and breaking bones, and I always try to communicate what CPR actually means to patients when they’re asking for full resuscitation. I think it’s important that the public become more educated as to what resuscitation entails and to how unlikely it is to ever bring someone back in most situations (especially patients with underlying terminal illnesses).

  2. I’m surprised her ribs weren’t already broken by the time she got to you.

  3. I never realized that a full resuscitation could literally be so violent until I started reading blogs by physicians like you, and even then I never really knew what “everything” entailed until now. Even though patients/family members ask for it, it still feels like the body is being violated.

    Thank you for this post.

  4. Everyone remembers the first time they do CPR on a dead person. I wince every time I see a TV show pretend that chest compressions are a modern day equivalent of smelling salts.

  5. Oh, dear God… tell me the best place to have D.N.A. (do not resuscitate) tattooed on my body?!!

  6. A defibrillator cannot jump-start a heart. A doctor should know that.

  7. Howdy! This blog post couldn’t be written any better! Reading through this article reminds me of my previous roommate! He constantly kept preaching about this. I most certainly will forward this information to him. Pretty sure he’ll
    have a very good read. I appreciate you for sharing!


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