Saturday, August 9, 2014

Alive ("Shocked" by David Casarett, M.D.)

In a 1998 study from Johns Hopkins University, doctors were given a list of eleven life-saving measures that are commonly used in hospitals and emergency rooms--ones they themselves had undoubtedly used hundreds of times throughout their careers--and asked which of them, if any, they'd want used on themselves if they should ever be in need of immediate care. All eleven of the choices were standard practice, ranging from CPR and IV fluids to chemotherapy and dialysis, and all eleven were used to treat millions of patients every year without second thought. But when results from the survey of doctors were compiled, the results were surprising, to say the least. Over 70% of doctors surveyed did not want a blood transfusion, feeding tube, or invasive testing; over 80% did not want surgery, chemotherapy, dialysis, or ventilation; and 90% of those surveyed did not want CPR. It is that last statistic--the highest percentage of negative responses of all eleven choices--that is the most startling, as CPR is the most basic of life-saving measures:  it does not involve any electrical equipment or medical instruments, can be done by almost anyone with a half-hour of training, and is perhaps the most personal, involving physical contact--hands, chest, neck, mouth--between the living and the dying. In fact, at just over 80%, the only measure that doctors actually wanted was pain medication. In other words, most doctors did not want to be resuscitated or kept alive; they only wanted to die comfortably and without pain.

This 15-year-old survey reveals an uncomfortable truth about our mortality: the people we will someday entrust to keep us alive view these life-saving measures from a different perspective, and they do not like what they see. For all the fantastic depictions of hospital procedures from television shows and in movies, medical practitioners known the reality behind them, and the reality is filled with pain, death, and fear. Take, for instance, CPR--one of the many subjects of David Casarett's Shocked, a book on ways in which the dying and dead can be brought back to life. In order to do CPR successfully, the patient's chest must be pushed down at least two inches, and it must be pushed down 100 times a minute. (The BeeGee's "Stayin' Alive" is a similar tempo and can be sung to help set a consistent pace, though, as Casarett laments, most people under the age of 30 have never heard this song before.) You must stop every 30 compressions in order to breathe into the patient's mouth and inflate the lungs, then return to pushing down on their chest. After a minute, your arms will grow tired, and the compressions will grow weaker and further apart. You will need to be replaced, but even then there's little promise that CPR will actually work without the intervention of trained professionals or medical equipment; in fact, as Casarett reveals in the closing pages, we know very little about how CPR is even supposed to work, and the guidelines for how to perform it successfully continue to change. (Years ago, the breathing was considered the most important aspect; now the chest compressions are advocated over the breathing, even though some wonder if the simple rocking of a body--the sloshing of blood--would be enough to restart the heart.) Even when CPR does work, there may be further damage to the patient, or they might be rendered permanently unconscious and hooked up to ventilation for the rest of their life.

Regardless of how little we understand CPR, it's still favorable to older methods of resuscitation. As Casarett lays out, primitive treatments for drowning victims included rolling them back and forth on a barrel, placing them near a fire, sliding a feather down their throat, and blowing tobacco-smoke up their rectum. Which is the nature of medicine--it is not a perfect art but an evolving one, changing with every patient and study. The medical advances of fifty years ago might be seen today as outdated, laborious, even dangerous, just as the standard practices of today--CPR, chemotherapy, dialysis--might be reviewed with scorn and disbelief fifty years from now. We don't know for sure, but we are at the will and whims of our eras. Thankfully, Casarett spends much of his book investigating new, interesting, and sometimes controversial research that promises--if medicine can do such a thing--to be even more successful at keeping us living healthier and longer.

By far the most interesting of these asks whether it's possible to induce long-term sleep in a human being so they can more easily stabilize after a serious event. In other words, can a person who has suffered a major attack, such as cardiac arrest, be placed in a controlled hibernation so their body can heal and the doctors can better prepare treatment? (This is different than a medically-induced coma, as this would involve the rapid cooling of a patient in lieu of CPR.) To answer this question, researchers must first uncover how blood and organs respond to extremely low body temperatures, its effects on the medical problem compared to other treatments, and any effects it might have on the body. The specific details are grisly at times, but the tests behind this research, which involve enough diverse wildlife to fill a sizable petting zoo, are fascinating, especially when you consider that many of the animals forced into this kind of hibernation are essentially--at least by a layman's standards--dead.

Much of Shocked reads like deconstructed science fiction, and at times it's tempting to submit to childish fantasies by imagining the possibilities inherent in, say, suspended animation or cryogenic freezing. These are fantasies that allow us to comprehend complex possibilities related to our own bodies, sure, but they also give us some distance from thoughts of our own death, which are uncomfortable to consider but also necessary. We shudder at the thought of being kept alive by machines in a hospital bed for weeks, even months, while our family  members debate what to do next. We are told to make plans, write up instructions in the case of a debilitating illness, decide if we'd even want to be resuscitated--or given a feeding tube, or administered pain medication--if that decision should ever need to be made, and yet we avoid these discussions until it's too late. We don't want to think about all the terrible paths our lives could take, especially when those journeys are beyond our control while also paradoxically caused by our own bodies. This is the fact that physicians know, and they're more likely to have made these plans, because they see what happens when those decisions are put off too many times. What's more, they see this multiple times a week--an experience that builds up over a career and leads to a much different perspective than what the average person has. Doctors, we say, know best, but that's only because doctors know more than we'd ever want to. They live their knowledge day after day, and given the opportunity to understand what they do, we decide instead to live--and die--in ignorance.