A New Sign in medicine: the Tim Russert sign

Mr. Russert has a negative stress test on April 19th and died suddenly of a heart attack on June 13th.

I therefore propose a new sign in medicine, the Tim Russert sign: death (or MI) shortly after a negative stress test.

The End of the Code

If you watch TV medicine, what you see are a lot of terrifically successful codes, with patients getting back a normal pulse and blood pressure in a matter of mere moments, and that’s where the commercial break begins; it’d be a bit much if they stood and walked out of the hospital before the commercial, that’s why. When they die on TV, it seems the only one who makes the decision is the doctor, which always strikes me as strange, even given televised unreality.

Real life, as you might expect, is different. Not only are there no commercial breaks, the codes usually end with the patients in the state they arrived: dead. Oh, we do all the right things, give medicines in the appropriate doses (which I’m pretty sure would give a rock a pulse, at least momentarily), shocks, ventilation, etc. And yet the survival rate is abysmal if you arrive at the ED with CPR in progress.

The reason has to do with the cascade of damage required to cause the heart to quit in the first place. Stop breathing long enough for the heart to stop (Anna Nicole Smith) and even the Olympic CPR team cannot recover from the profound acidosis and ischemia that was necessary to stop the heart and attract attention. It’s even worse if it was a heart attack that caused the heart to stop: the damage to the heart muscle needed to stop it is substantial, but once it’s deranged there’s not a whole lot CPR is going to add. (This is not to say CPR is futile, it’s clearly not, so do it). What I’m saying is that if the medics cannot get a patient back in the field there’s not a heck of a lot more that can be done in the ED.

Not that we won’t try. We’ll literally wear ourselves out doing CPR, getting IV access and an airway, and generally being as obsessive about trying to save a life as you’d hope we’d be. Everyone tries hard, and as a group revel in the occasional success, but it’s so occasional we can even get someone’s heart restarted so they can die in the ICU it’s notable. And depressing.

When I was but an EMT lad in an ED I witnessed something I’ve incorporated into my own practice, and I think every doc should do it. When it’s ‘that time’, time to stop the resuscitation, in every instance I say something along the lines of “Okay, we’ve been coding this person for xx minutes, and there’s been (brief summary): does anyone here want to do anything else? If so, tell me now”. This does two things which are important for everyone in the room who isn’t dead: it makes them part of the decision making process, and it empowers them to very easily object should they wish, for whatever reason, to continue. “I’d like to give some (whatever)” is then totally fine, and they’re not having to object in a vague way that they’re not done yet with what can be a terrifically personal struggle to save someone none of us has met, or knows as anyone other than a patient. We give the whatever, and after a while, given the persistence of death, I’ll give my speech as many times as it takes (so far, twice has been all, but I’d be perfectly willing to go on for a long time), because it’s important for everyone involved to acknowledge that they did what they could, and to be comfortable with stopping.

Codes end, very occasionally with a happy outcome, more often than not with a patient under a sheet, but the people who were there need to feel like they had a chance to do all they could.

Death is forever, and so is guilt; I want to make certain the dead don’t take the living with them.