Do you know what it really means to be a “Full Code”? You should.

Last week, the proverbial dragon of chaos manifested itself in a simple sentence overheard while passing by a patient room. “Oh, okay, yeah we need to get him back in bed . . . like stat.” It wasn’t the sentence that stood out, or even the tone, but rather the source: The hospital’s rapid response nurse, Molly. She is a highly-trained nurse who floats among units, checking in on patients who may soon require a higher level of care – a COVID patient who might need a ventilator in the next few hours is a good example. Molly has seen it all, and she is unflappable. When she uses the word ‘stat’, it gets people’s attention.

Instinctively, I go and retrieve our unit’s “code cart,” which is exactly what it sounds like, containing all manner of invasive life-saving equipment. I return just in time to see the respiratory therapist slam the head of the bed down and begin pounding the patient’s chest. Okay, yup, this is real; no mistaking this. I call the emergency line, sending the “Code Blue” call out overhead. The experts are here, and more are on their way. I’m good to just get out of here, right? I’m about to scurry away when Molly’s voice interrupts me: “Alright Nathan, you’re next for chest compressions.”

I pause for a half-second before replying: “I’m next for chest compressions.” Basic and Advanced Life Support classes always emphasize the importance of closed-loop communication during hospital codes, confirming that you’ve received and understood your orders. At this moment, I’m thankful for that training. This small exercise of protocol helps me relax and remember that there is a protocol. I take a deep breath and try to remember my training: “Alright, compress to the beat of ‘Stayin Alive*,’ keep your arms straight, and push with your back, not your shoulders.”

The physician arrives and calls for a rhythm check. Everyone steps back, and I take the respiratory therapist’s spot in preparation. A robotic voice states, “No shock advised.” A nod from the physician and I place my hands, one atop the other, on the patient’s sternum. I begin compressions.

I always thought nothing could prepare someone for the experience of performing real-life CPR. Most medical simulations are painfully unrealistic, and I had no reason to believe that the CPR dummies were any exception. Where the dummies feature a pliable chest wall easily compressed, surely human bones and cartilage would put up a bigger fight. Wrong. Turns out, those dummies are incredibly realistic. This person’s chest was unnaturally, creepily soft. For a split second, I had the surreal feeling that this was all a fake code – an elaborate simulation designed to foment team-building. A glance at the patient’s face broke the illusion. Nope, this person is real.

In CPR training, we’re told that high-quality chest compressions are likely to cause some degree of trauma. “You’ll probably break ribs, and that’s okay,” they say. But this was different. The realization hit me like a brick: Just three minutes into chest compressions, this patient did not have merely a broken rib or two. Rather, their sternum and ribs were clearly in fragments, providing no resistance whatsoever to my compressions. This realization sparked another: If each compression really does need to reach a depth of 1/3^rd of the chest wall – and it does – then is the only way it happens. Good CPR necessarily requires double-digit fractures.

I didn’t have time to consider the weight of these realizations, and I kept my attention on the task at hand. Two minutes later, my time was up and I yielded to my replacement. Despite another twenty minutes of herculean efforts, the patient did not survive.

Honestly, I wasn’t particularly torn up. I had not been assigned to this patient during my shift – I had simply been in the right place at the right time. But the experience did make me consider whether we do a good job educating patients on what CPR is actually like, especially concerning its efficacy and side effects. You see, not only is CPR incredibly traumatic (I wasn’t joking, this study estimates the average number of fractures at about 11), but it is also not nearly as effective as the general public believes. The American Heart Association, an organization with every incentive to pump up the efficacy of CPR, reports that among patients 65 and older, just 18% who code in the hospital survive to discharge. Outside, very few make it to the emergency room alive.

Much of the misperception surrounding the efficacy of CPR can be traced back to Hollywood. Hit shows like “ER” regularly portray codes, and nearly three-quarters of them depict the patient surviving their cardiac arrest. This leads to an all-too-common scenario wherein patients and doctors don’t even discuss code status when admitted to the hospital. Since CPR is thought to be effective, patients assume “Do Not Resuscitate” orders to be reserved only for those clearly approaching their final days. This is not true.

Now, don’t misunderstand me. I’m not telling you to refuse life-saving or sustaining interventions. If you want us to do everything we can, we will. And of course, survival statistics are much better for the “healthy dead”; those who are young and without co-morbid conditions. However, if you’re of advanced age or poor health, you need to ask yourself whether you want your last minutes to be spent with a crowd of strangers traumatizing your ailing body with little chance of a positive outcome. Given the choice, perhaps you’d rather spend that precious time surrounded by your loved ones. You have a right to make an informed decision on this matter.

So, if you are admitted to the hospital for any unexpected reason, you should insist that you speak with your physician about your code status. Before you decide you want the full extent of the ‘miracle’ of modern medicine, you should know what you’re buying.

 

*Yes, this is often part of official curricula – compressions need to be done at 80 to 100 beats per minute, and singing “Stayin’ Alive” in your head is an effective way to keep pace.

 

Edit: Original Title and Byline appeared as “Double-Digit Fractures” and “Do you know what you’re getting into with the “miracle” of modern medicine? You should.”

How much quality of life and life-expectancy should we be expected to sacrifice to flatten the curve? The answer is not “infinity.”

(The following piece was originally published on Medium on March 24, 2020.)

The past few days at work have been surreal. In preparation for an expected influx of COVID-19 patients, and to preserve our dwindling supply of personal protective equipment (PPE), all elective surgeries at my hospital have been canceled. This leaves me, a standard surgical floor nurse, without the majority of my usual patient population. In the calm before the storm, it strikes me as strange that the rest of the world isn’t functioning. I casually chat with a co-worker who tells me that her small business is now underwater. Everyone I speak with knows someone who is now suddenly out of work.

And in some sense, this is necessary. I learned early in college nursing classes about the importance of social distancing and public quarantine interventions when addressing a pandemic. During the Spanish Flu, cities that implemented interventions early saw relatively few casualties, and those that did nothing were immediately overwhelmed. Businesses and individuals can stand to pause for a while for the sake of their fellow citizens — lives are on the line, after all.

But the preceding moral proclamation, righteous as it feels, leaves one serious element unspecified: Time. How long exactly can our country remain at a standstill? Waiting even six months seems likely to fundamentally disfigure the society we’re trying to preserve. I’m not saying I know exactly how much economic growth is proper to sacrifice to save a life, but it isn’t unlimited. In a capitalist society, gainful employment is health and well-being. The consequences of sky-high unemployment will manifest in population health statistics years down the line.

The issue here is … well, death. Won’t people die if we lift restrictions too early? First, remember that people will die no matter what; it’s how many that matters. Second: We have no reliable data on which to base our decisions. We’re instituting widespread quarantine based on nothing because the consequences of betting wrong at this stage of the game are near limitless. However, the appropriate length of societal shutdown expands or contracts based on answers to the following questions:

• What percentage of overall cases require hospitalization?
• What percentage of hospitalized patients younger than 65 require ICU care?
• How many intubated patients above age 75 survive?
• What percentage of intubated patients suffer lifelong morbidity related to chronic lung injuries?
• How much extra capacity has our health care system added to prepare for a surge in critical patients?
• How much damage has our economy sustained so far, and when will the damage begin to cause fundamental and irreversible insults to mobility and quality of life?

Right now, we don’t have good answers to any of these questions. Pundits who speak or write as if we do are speculating at best. However, in a few weeks, we may finally have some decent answers (in the form of slightly tighter ranges of outcomes) to these questions. Each possible scenario will result in a certain amount of lives lost to COVID-19, and our leaders will have to pick the range of outcomes they deem most bearable. The wider the range, the less clear the decision. I am not a public health expert, but I worry that the majority of these scenarios will involve a choice between continued economic shutdown for six months or more and an epidemic curve that outstrips hospital capacity.

I’m not excited about the idea of outstripping hospital capacity. This will put me — and more so the physicians I work with daily — in horrible ethical positions of deciding who lives and dies. The trauma and stress will be overwhelming. The lives lost will be real — they will not have been expendable. They will include people like my aunt and uncle from Enumclaw, WA. Mobile and vivacious in their 70s, their “retirement” consists of full-time volunteering with senior services like meals-on-wheels, as well as full-time caregiving for my wife’s WWII veteran grandfather. Words cannot describe the level of grief and despair my family would endure with their loss to this terrible disease. This is personal.

Equally traumatizing will be the depression and despair of millions left unemployed, hopeless, and poverty-stricken. Not to mention the early deaths and chronic diseases associated with impoverished health behaviors. No one gets out of this alive and intact. Make no mistake: Six months of an economic shutdown will cause a depression that makes 2008 look like the roaring twenties. The American experiment may well cease to exist, at least as we currently understand it.

I’m not saying I know how to strike the proper balance. However, as we approach this conundrum, consider this: Everyone understands that there is a difference between death resulting from negligence and death resulting from tragedy. If a nursing home resident gets COVID-19 because an employee didn’t wash their hands, this is negligence. A human caused the infection through willful blindness, and this rightly triggers a sense of moral outrage at such injustice. However, notwithstanding regulatory negligence on the part of the Chinese government, no human “caused” this virus. At least as it regards our current predicament in the United States, there is no one to blame for this tragedy. Our cries of outrage and grief go up against the fabric of existence itself; even against God if we haven’t quite killed him yet. And now, we’re faced with a horrible truth: Endless preservation of life will become destructive to its ends. Though politicians and pundits obfuscate and pretend that this amounts to ageist genocide, it is at this vital moment that these honest conversations must take place.

Now, no matter how carefully I edit and revise this post, some people will find a way to accuse me of “hating old people” or something similarly slanderous and absurd. That is fine. I have worked in nursing homes and hospitals with this 65+ population for my entire nursing career. I am happy to let their consistent words of thanks for my compassionate and high-quality care to do the talking for me. Still, I will remind readers of what I’m NOT saying:

• We should lift restrictions right now (we shouldn’t).
• The economy is more important than the lives of the old and/or senile (it isn’t).
• We should not make substantial economic sacrifices to save hundreds of thousands of lives (we should).

Rather, I’m simply stating what we already know, but are too afraid to say clearly: The level of our sacrifice should be substantial, but not unlimited. There is a limit, and it can only be defined if we’re both courageous and humble enough to admit its existence.

Recent studies reveal a strange truth about the nature of our societal divisions.

I got an email a few weeks ago from the Washington State Nursing Care Quality Assurance Commission (NCQAC). As a Registered Nurse, I’m used to receiving occasional emails from them about various regulatory and public health matters. However, this email was different: “COVID-19  Information.” This appeared to be worth my click.

What followed was an official COVID “myth-buster” from the Washington DOH. For the most part, it was fairly benign, busting various myths such as “I should probably stock up on some more groceries” and “These wipes are flushable.” However, the second-to-last myth-bust stood out from the others.

The “Myth” was fine, if somewhat out-of-place for an email to the state’s nurses: “Myth: We’re going back to normal after this.” Most of the answer was also fine, centering around the acknowledgment that we won’t go back to “normal” again in the same way. The author went on to speculate regarding the possible ways in which our society might change.

“Maybe we’ll hug our people tighter, maybe we’ll savor our time together more.”

Yeah, maybe it will increase our appreciation for each other. No problem here. Sure thing.

“Maybe we’ll help to keep the air clean by working at home more often.”

Well, Washington already has very clean air . . . but working from home is a good thing. I don’t have an issue with this.

But then the other shoe dropped:

“Maybe we’ll decide it’s important for everyone to be able to get health care when they need it.”

Uh-huh, because right now, “we” don’t believe it’s important for people to be able to get health care when they need it. Sure.

The author’s subtext reads like a disapproving mother scolding her stubborn children. It is obvious who the author is talking about: Those evil conservatives, holding society back with their desire to maniacally withhold healthcare from poor people. What a perception to have about an entire side of the political spectrum, putting aside the fact that the biggest issue in our health care system is cost, not (as much) access or outcomes (more on that in a future post). And shouldn’t an official governmental regulatory body be above partisan political jabs?

In reality, the author almost certainly does not see herself (assuming the author is female) as a political partisan trying to prejudice the opinions of Washington nurses. Rather, she is falling prey to a filter bubble that cuts her off from a nuanced understanding of conservative political thought. This is increasingly the case for members of both sides of the political spectrum. But you already know that – there has been plenty of media attention on this reality over the last several years. What you might not know is that one aspect of this increasing polarization is unbalanced in its distribution.

You would think that increasing polarization would lead to an equal and mutual lack of understanding of divergent political views. A study by Dr. Jonathan Haidt (written about in his remarkable book “The Righteous Mind”), suggests this is not the case. In the study, participants were challenged to guess how a person of a differing political viewpoint would rate (agree vs disagree) a given moral statement, examples including, “One of the worst things a person could do is hurt a defenseless animal” or ”Justice is the most important requirement for a society.” Liberals assumed that conservatives would disagree with these statements.

The results were clear and consistent. Moderates and conservatives were most accurate in their predictions, whether they were pretending to be liberals or conservatives. Liberals were the least accurate, especially those who described themselves as “very liberal.”

(Pg 334 of “The Righteous Mind”)

Bear in mind that Haidt and his co-authors are political liberals themselves. You can listen to Haidt argue with Ben Shapiro about Obama’s legacy if you need confirmation.  

[There are many books to be written about Haidt’s contribution to the political landscape, particularly regarding his Moral Foundations Theory, but suffice it to say that Liberals base their moral decisions based on Care and Fairness, whereas Conservatives base theirs evenly across Care, Fairness, Purity/Sanctity, Authority (Respect for), and Loyalty (to one’s group).]

This liberal blind spot is a product of many overlapping factors, but none more so than their domination of our education and media spheres. Studies repeatedly show that liberals vastly outnumber conservatives in higher education, in some departments by ratios as high as 20:1 in Journalism and 11.5:1 overall.  Similar ratios prevail for primary and secondary education. This unavoidably creates a scenario wherein children growing up in liberal families today might never encounter a single cogent conservative argument for the entirety of their education. So while the kids in conservative families are repeatedly exposed to both sides, liberal kids are not.

Similar figures pervade regarding the political leanings of current journalists. As few as seven percent of journalists identify as Republicans, compared to sixty percent or more who lean Democrat.

All of these factors combine to create a situation where left-leaning thought is automatically equated to “normal” opinion – an infuriating position for a moderate conservative to be in when he or she self-censors for fear of being labeled and shamed for a relatively benign opinion. I recall a situation back in 2016 wherein a leader of a scholarship program I had participated in during college, upon learning that my then-girlfriend was doing an internship with Rep. Cathy McMorris-Rodgers, narrowed her gaze and muttered with disgust ” . . . she’s a republican.”

What in the world? Did this person really think that her public scholarship program only sponsored left-leaning students? Apparently so, as I demurred “Well, uh, I mean we’re all pretty moderate . . .” and scurried away to end the tension.

My purpose in writing all of this isn’t to cast myself as a victim. I am far from victimized here, or in any other area of my life. Regardless, I think a path toward a society that prospers and remains united for another hundred years requires a dialogue set on equal footing. Both sides have their crazy radicals to police, but it is clear that the left has some unique work to do in regard to understanding moral foundations, especially considering their unique domination of academic and media spheres.

Now, perhaps I’m not the best mouthpiece for this message. As a conservative, a message from me is unlikely to be heard in quite the same way as it would from a good-faith liberal – who do, of course, exist. So, if you’re a left-leaning friend or co-worker of mine bristling at the idea that the party opposing Donald J Trump has the real soul-searching to do, I’d encourage you to ignore me, and go read Jonathan Haidt’s “The Righteous Mind.” Seriously, if you’re interested, I will buy you a copy. I’ve already bought like 15 copies of this book for other people.