DNR

The fear of death follows from the fear of life.
A man who lives fully is prepared to die at any time.
-- Mark Twain

Have you been lied to by the TV? TV taught me that most people are young and fit and attractive and having fun. TV taught me that husbands and mothers clashed like oil and water. And TV taught me that in a cardiac arrest, it was possible that the patient might die, but in the majority of cases, when resuscitative efforts were continued well past the recommended limits, the person returns to the full glory of their former consciousness. None of these things have turned out to be true in my experience, but I'll address the last one today.

Yesterday night, an ambulance brought a relatively young (ie less than 65) woman who had been sitting with her family, apparently having a few drinks, when she collapsed. Her family was not familiar with the practice of CPR, so she was left alone without a pulse or breathing for approximately 20 minutes before paramedics arrived at the scene. When they did arrive, they found no heartbeat, no blood pressure, and no breathing - Vital Signs Absent. Paramedics are generally skilled people, but they are required to follow treatment algorithms aimed at saving patients' lives. In this case, they shocked the patient, and placed a breathing tube in her trachea. Down the tube, they passed some cardiac drugs. I understand that they were about to cease their efforts when something changed, and the patient's heart started beating, a blood pressure returned, and with some assistance, she started breathing.

Here's where the story diverges from "as seen on TV".

Twenty minutes without oxygen does bad things to one's brain. While her vital signs were restored, she was unresponsive. Obtunded. Comatose. She breathed initially only with the aid of someone forcing air down the tube ("bagging"). Her pupils were fixed and dilated. She responded in no way to a "sternal rub" (a maneover wherein I rub my knuckles forcefully over her breastbone, whose only purpose is to provoke deep pain, and see if the patient is even a little awake). Really she had died, and been been brought back, but only halfway back.

After the time she had been out, it was unlikely that she would ever recover from the brain injury. In this scenario, her "best" prospect will be to continue in a persistent vegetative state, but people will retain hope that she'll wake up (again, as seen on TV), and be her normal self. As I arranged transfer to a centre with an intensive care unit (much to the chagrin of the receiving physician, who predictably asked why I would send him someone with no hope of recovery), I speculated that what would actually be "best" would be for her heart to return to its unstable rhythm, for her not to respond to the drugs, and die without her family having to decide to take her off life support. There's a good chance this will sound callous, but I encourage you to relate the scenario to anyone who works in health care and find out what they'd want if it were them.

This brings me to my point: CPR. It's a great tool, but it is generally only of use if the patient is in previously good health (mine was not, incidentally), and if it's commenced immediately and effectively. The vast majority of patients who are admitted to hospital (particularly in a small hospital without an ICU) have never contemplated their own demise. If I am admitting them to hospital, I ask what they would want done if their heart or breathing were to stop, and many say (or a well-meaning family member suggests on their behalf) that they want "everything done". Having seen "everything", I for one would not want that.

I have no tattoos. I have seen many tattoos, some amusing, some offensive, some tasteful, and some not. But the only tattoo I think I like enough to get is one I have only heard about. It is reputed to be worn by an emergency physician, and it reads "DO NOT RESUSCITATE" in clear printing across the chest.

I am getting this tattoo. Only two questions remain. One is when to get it. Were I to have a witnessed arrest today, I'd still opt for CPR if it was started right away. If I get a severe illness, or if I don't die before my age makes a recovery unlikely (among patients this age tends to be a moving target, since people define "old" as being "older than them" - Presently my target is somewhere between fifty and sixty), I 'll get it then. The second question with a tattoo is of course that of the font. I'm happy to consider suggestions; the purpose of this tattoo is clear communication, but a tattoo is also supposed to look good. Maybe I'll get it in English with Cantonese on one side.

Chinese lettering is so pretty.