GeriPal - Geriatrics and Palliative Care Blog

During my senior year of residency, I brought an elderly gentleman to the operating room with peritonitis and a benign-appearing CT scan only to find a belly full of black, necrotic bowel. We closed him up, told his family, and he died peacefully several hours later.

When I presented the case at Mortality and Morbidity conference, one of the attending surgeons asked me why this patient had dead bowel. I ran off a long list of pathophysiologic possibilities, and he replied, "You know, Gretchen, sometimes it’s just a way to die."

At the time I thought this was strange, but since then I have come to understand what he meant.

Patients often come to the hospital when they are dying. Fear of the unknown and pain typically bring them in, and it’s not uncommon for their primary complaint to manifest as a surgical problem – a gangrenous toe, a dead gallbladder. As surgeons, we often step in and operate right before they die. After a string of poor outcomes, a close friend from resid…

A fascinating study by Zachary Goldberger and colleagues was just published in the Lancet. The study gave us some good data on the bad outcomes of CPR in hospitalized patients, and brought up some challenging results on whether hospitals that attempt resuscitation for longer periods of time are more likely to have patients survive to discharge.

Brief Run Down on What They Did

The authors used the American Heart Association’s Get with the Guidelines-Resuscitation registry to look at 93,535 patients aged 18 years or older whose hospital course was complicated by an in-hospital cardiac arrest.

The authors excluded patients with cardiac defibrillators, and patients whose cardiac arrests occurred in settings that are often the atypical cardiac arrests in hospitalized settings. These included 18,604 arrests in ERs, ORs, post-op areas, procedure areas like cardiac catheter and EP labs, rehab areas, and those where the cardiac arrest location was unknown or missing. They also excluded th…

Following on Sei's thoughts about robotic-assisted surgery, a fascinating job posting rolled through my inbox that I just couldn't resist sharing. It describes an important driver of US healthcare costs with almost haiku succinctness:
General Internist Step into a lucrative mature practice, no buy-inPractitioner has been here 21 yearsPractice located in new clinic building attached to HospitalPractice managed by HospitalNeed to be able to do stress tests and cardiolytesReading echocardiograms a plusEndoscopy also encouragedNice, quiet community in Northeastern [large Western state].  What do stress tests, cardiolytes, echocardiograms and endoscopy have to do with serving a small, (presumably) elderly rural community with a 49-bed hospital? Especially by a general internist? "Lucrative" is indeed an apt description for this particular skill set, for surely it isn't very likely to be "healthy", "caring" or "evidence-based".

But what fod…

Let's do something together.  Let's ban the phrase "do everything."

Judy Citko gave me a heads up about an article in the pediatric literature titled, "The Darkening Veil of 'Do Everything.'"  (PediPal, where are you?  An opportunity waiting to happen!  www.PediPal.org is available...)

I'm sure each of us has heard the phrase, "Do everything." As in a clinician saying, "Do you want us to do everything?" Or a surrogate decision maker saying "I want you to do everything for him!"

In the Archives of Pediatric and Adolescent Medicine, Chris Feudtner and Wynne Morrison from Children's Hospital in Philadelphia authored a nice thought piece about the dangers of  "do everything."  Among the arguments:

We can't do everything.  "One simply cannot simultaneously cradle a grievously ill infant in one's arms and at the same time insert vascular cannulas for extracorporeal membrane oxygenation; nor can …