How Doctors Die

[CardiacCoug]

This is a pretty big issue in my field as I see several "hip" fractures on a yearly basis. National statistics would indicate that the 1 year mortality for these fractures, in patients over 50, is around 30%. Fixing them almost always requires surgery, 3-5 days in the hospital (if there are no problems), and a lengthy rehab stay. Unfortunately, the alternatives to not fixing them are pretty miserable as well. I have had a few patients and their families who have chosen hospice care in the face of a hip fracture. In certain situations I think it is a great option and probably gets underutilized.

Right, we will have this come up once in a while with someone elderly who needs a pacemaker or something like that. Sometimes the kids just say "Please just let her die" -- she just wants to die. Obviously these people are DNR. But the problem is that people don't die immediately -- they might suffer for months. If we don't do a pacemaker then they fall and hurt themselves and suffer even more and still don't die quickly.

Again, it's easy for the accountants to say that we do too much at the end of life, but sometimes there is really no other good alternative.

[ERCougar]

39% of people survive V-fib arrest and leave the hospital neurologically intact. Quality of life similar to general population for those under 65, mildly decreased for those older than 65.

http://www.ncbi.nlm.nih.gov/pubmed/15071386

Quality of life for survivors of cardiac arrest is similar to general population:

http://www.ncbi.nlm.nih.gov/pubmed/12826637

No difference in quality of life between survivors of out of hospital arrest and controls:

http://www.ncbi.nlm.nih.gov/pubmed/11947973

We agree on the important issues here, but I have to clarify for people reading this. I haven't read any more than the abstracts on these but the patients studies received "early defibrillation", a term so tightly defined that they could apply it to a whole 200 people over a period of 11 years. This doesn't even come close to approximating your average patient presenting to the ED in cardiac arrest. Yes, if you cherry pick enough, you can find a cohort where the outcomes are close to a matched "healthy" one, but this is not your typical patient, and certainly not the type where any doctor would consider halting resuscitative efforts.

Here's a little more applicable study:
http://jama.ama-assn.org/content/299/10/1158.short

They were able to achieve a survival rate increase from 1.8% to 5.4% by improving CPR training among paramedics. Note that this is still not measuring neurologically intact survival, which would be still lower (and really, what most patient families care about).

One in twenty--that's how many people survive to leave the hospital, in a good EMS system with well-trained paramedics (and likely a good hypothermia protocol--something most hospitals, including my own, STILL don't have). Probably closer to one in fifty if you're talking about actually walking out of the hospital, and 1 in 200 if you're talking about the average EMS setup in America. Do you want a $100,000+ bill with those odds? (Keep in mind, I'm still talking all comers--not the type of patient that your doctor will even consider halting resuscitation on).

[CardiacCoug]

We agree on the important issues here, but I have to clarify for people reading this. I haven't read any more than the abstracts on these but the patients studies received "early defibrillation", a term so tightly defined that they could apply it to a whole 200 people over a period of 11 years. This doesn't even come close to approximating your average patient presenting to the ED in cardiac arrest. Yes, if you cherry pick enough, you can find a cohort where the outcomes are close to a matched "healthy" one, but this is not your typical patient, and certainly not the type where any doctor would consider halting resuscitative efforts.

Here's a little more applicable study:
http://jama.ama-assn.org/content/299/10/1158.short

They were able to achieve a survival rate increase from 1.8% to 5.4% by improving CPR training among paramedics. Note that this is still not measuring neurologically intact survival, which would be still lower (and really, what most patient families care about).

These are the numbers cardiologists are looking at -- we do therapeutic hypothermia in everyone unless they wake up and start talking to us immediately (56% survival with 92% of those neuro intact):

http://circ.ahajournals.org/content/124/2/206.short

I think a big difference obviously is that the patients that make it to cardiologists tend to have a reversible cardiac cause for their arrest. Agreed that for patients with terminal conditions, cancer, dementia, very elderly, etc. the survival isn't very good.

I think that obviously with better CPR (compressions only) and broader use of therapeutic hypothermia that more people would survive and more survivors would be neuro intact. But part of this is obviously that I see a small subset of the arrest patients (with reversible coronary occlusions mostly) that you see in the ER.

The conversation reminds me of a conference I went to where surgeons at Mayo Clinic swore that almost all of their patients survive Type A aortic dissections and docs in urban centers would say that very few patients survive. It's clearly because the patients that survive long enough to be transferred to Mayo Clinic weren't as bad off to begin with.

[wuapinmon]

I watched a friend sink thousands into chemotherapy for her cat's inoperable throat tumor because she couldn't bear losing her companion. That was over a pet, when It's a loved one, rational thought goes out the window Lloyd Christmas style.

[doctorcoug]

You're saying nobody has ever survived a cardiac arrest (either out of hospital or in the hospital) to live a normal life with a subsequent normal IQ, normal brain functioning, gone back to work as an accountant or whatever?

Maybe I misunderstand you, but those cases happen all the time. I wouldn't think a family practice resident would be involved in very many of those cases, though, so no big deal.

Cardiac arrest patients almost always end up on, at least, aspirin, plavix, beta blockers.

That is not normal. I deal with beta blocker side effects every day. Depression, marital problems, fatigue. Ask your patients how they feel...they aren't normal.

Our door to PCI is less than 90 minutes for our 60 minute capture. We cool our patients. We perform effective CPR. We have excellent first response protocols for early defibrillation. Patients still have a crappy prognosis at our hospital if they survive, and they most definitely aren't normal.

I'm taking the high road to continue amicable discourse.

[Mormon Red Death]

Cardiac arrest patients almost always end up on, at least, aspirin, plavix, beta blockers.

That is not normal. I deal with beta blocker side effects every day. Depression, marital problems, fatigue. Ask your patients how they feel...they aren't normal.

Our door to PCI is less than 90 minutes for our 60 minute capture. We cool our patients. We perform effective CPR. We have excellent first response protocols for early defibrillation. Patients still have a crappy prognosis at our hospital if they survive, and they most definitely aren't normal.

I'm taking the high road to continue amicable discourse.

I would like to clairfy my position on the matter. I think that we need to come to some sort of consensus as a society that when someone reaches an advanced age (whatever the experts might agree on) and has a terminal disease medicare doesn't pay for expensive treatment.

Let the people die with some dignity being as comfortable as can be.

Sent from my SGH-T839 using Tapatalk

[wuapinmon]

Cardiac arrest patients almost always end up on, at least, aspirin, plavix, beta blockers.

That is not normal. I deal with beta blocker side effects every day. Depression, marital problems, fatigue. Ask your patients how they feel...they aren't normal.

Ask yours if they'd rather have died in the ER. Given the choice between what you've described and death, I'm guessing 99% would say they'd choose life.

[CardiacCoug]

I would like to clairfy my position on the matter. I think that we need to come to some sort of consensus as a society that when someone reaches an advanced age (whatever the experts might agree on) and has a terminal disease medicare doesn't pay for expensive treatment.

Agreed. Medicare already has pretty strict rules about certain expensive procedures (like defibrillators) and I think we will see these rules continue to expand and that's fine with me.

Currently there are no age restrictions on any Medicare reimbursement as far as I'm aware. You see very expensive things done for people well into their 90s -- you can put a defibrillator in a 100-year old right now and Medicare would still pay for it.

[doctorcoug]

Ask yours if they'd rather have died in the ER. Given the choice between what you've described and death, I'm guessing 99% would say they'd choose life.

Did I say that? I only meant to show that post-arrest patients are very far from normal.

[wuapinmon]

Did I say that? I only meant to show that post-arrest patients are very far from normal.

That wasn't CC's point though. "Normal" is subjective anyway. How many people were depressed and had marital problems before they arrested?

[UtahDan]

http://mobile.reuters.com/article/idUSTRE7BE2AR20111215?irpc=932

[doctorcoug]

That wasn't CC's point though. "Normal" is subjective anyway. How many people were depressed and had marital problems before they arrested?

I don't have numbers, but I can tell from anecdotal evidence that the incidence increases.

If it wasn't his point to claim normalcy, no statement to that end should have been made.

[CardiacCoug]

I don't have numbers, but I can tell from anecdotal evidence that the incidence increases.

If it wasn't his point to claim normalcy, no statement to that end should have been made.

So you're not living a "normal life" if you have to take a couple of pills?

I guess that's one extraordinarily pessimistic way to look at it.

[doctorcoug]

So you're not living a "normal life" if you have to take a couple of pills?

I guess that's one extraordinarily pessimistic way to look at it.

Just got off the phone with a patient who is complaining of dizziness and fatigue. The cardiology PA increased her coreg dose from 25 daily to 25 bid. Is that normal, to take 50 mg a day of coreg? She is miserable.

[Donuthole]

Just got off the phone with a patient who is complaining of dizziness and fatigue. The cardiology PA increased her coreg dose from 25 daily to 25 bid. Is that normal, to take 50 mg a day of coreg? She is miserable.

Just stop digging, dude. Stop.