Health Column: Medical creep and the DisHeartening case for CPR
MOHLER’S MEDICATION MAXIMS
Free Press Health Columnist
Medical creep, not a doc with bad breathe and mismatched socks, but the trend for physicians to practice “outside the box” has become pervasive. More and more physicians perform procedures or write prescriptions where the evidence to support their practices is flimsy or non-existent. Consider the facts that in the USA, new drugs are brought to market if they are found to work just a little bit better than a sugar pill and that the liabilities of PSA screening for prostate cancer far outweigh their benefits.
CardioPulmonary Resuscitation (CPR) — brought to the fore in 1960 by a group of Johns Hopkins surgeons — is the poster child for medical creep. Those Baltimore docs reported their treatment of 20 pulseless patients with a new technique that involved not cutting open the chest and massaging the lifeless heart, but rhythmically compressing the intact chest and blowing into the patient’s airway. Fourteen of their 20 patients survived without brain damage.
In 1966, as a third-year medical student, I learned how to do CPR. That same year the National Academy of Science mandated that all cardiac arrests in hospitals be treated with CPR. And the creep continued… in the following years, ambulance attendants were taught to deliver CPR outside the hospital.
Fifty years later, CPR is the default treatment for cardiac arrest. Unless you specifically refuse CPR in writing (good to keep the document handy) when you die, you may well be subjected to chest pumping, a tube in your throat and a bolt of lightening to your heart.
In retrospect, the Johns Hopkins patients were all healthy young patients who experienced mishaps while undergoing elective surgery. That situation is quite different from the real world where 90 percent of cardiac arrests occur in older people with underlying heart disease.
How has CPR crept into our lives and remained there?
First, American patients and physicians alike are enamored of the concept that if a potentially useful test or treatment can be done, it should be done! Annual physicals, multivitamins and armpit testosterone are a part of today’s mainstream medicine, in spite of the fact that there is no evidence that any of these interventions are of any value.
Second, the media has painted a very warped picture of how well CPR works. Duke researchers reviewed 97 episodes of “ER,” “Chicago Hope” and “Rescue 911.” Seventy-five percent of the TV patients survived resuscitation and two-thirds of the patients went home from the hospital with full brain function. In Oakland City, Mich., researchers studied 2,600 “real,” out-of-hospital patients who received CPR.
Age, along with percentage of people who survived to hospital discharge:
40s-50s — 10 percent; 60s — 8.1 percent; 70s — 7.1 percent; 80s — 3.3 percent
Unfortunately, the authors did not report on the cognitive functioning of those who went home. Other recent large studies involving only elderly patients have documented CPR survival rates as low as zero and as high as 18 percent, with up to 25 percent suffering permanent brain damage.
My Take: CPR does save lives and is a skill that we should all learn to perform. Most importantly, let your wishes be known — complete a Colorado MOST (Medical Orders for Scope of Treatment) form; they are free and you don’t need an attorney. Communicate with your primary care physician about your wishes for or not for resuscitation.
GJ Free Press health columnist Dr. Mohler has practiced family medicine in Grand Junction for 39 years. He has a particular interest in pharmaceutical education. Phil works part-time for both Primary Care Partners and Rocky Mountain Health Plans. Email him at email@example.com.
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AS OF THURSDAY, OCT. 21