Time’s Up for Sexism in Medicine

I would venture to say that medicine is one of the fields with the most blatant, widespread sexism in the workplace. In watching women in Hollywood stand up to the injustices that women in their industry face, I feel empowered to share the struggles that female physicians face. I wrote about this several months ago but deleted my post in the setting of fellowship interviews as I was concerned that it would seem too controversial or that I would seem as if I were complaining.

I grew up believing that I could be anything and anyone I wanted to be. I excelled in many aspects of life including academics. However, once I entered medicine, I encountered on an almost daily basis people who wanted to strip me of my hard-earned title. Administrative assistants and operators from other institutions on the phone who ask me what my first name is after I introduce myself as “Dr. Villasante.” Not because they want to write my full name but because they want to only write and address me by my first name. Patients who cannot understand that I am a physician even when I introduce myself as such. Who confuse the male nurse as the doctor and me as the nurse.

Our society has such deeply ingrained assumptions that “doctors are male” and “doctors are authoritative” and “women are not authoritative” and “women cannot be doctors.”

Here are some examples.

-We were discharging a patient, Ms. A, on a specialty service. We were talking to Ms. A about setting up follow-up, and she stated “I would like to fellow up with that girl from yesterday. She’s not a doctor though, the therapist that was here.” In fact, she was referring to Dr. J. Our current (male) attending Dr. Y explained that Dr. J was one of his colleague attendings in that specialty and that she had, in fact, trained at this fine institution and was an excellent doctor.

-At a community hospital that we rotate at, I was rounding with Dr. H, a petite blonde female attending. She had laser-sharp precision and was very efficient. We were visiting one of our patients and had a whole conversation with her about her medical care. As we were about the leave the room, she asked, “so when’s the doctor coming to see me?”

-Patient who thought I was his interpreter rather than his doctor, despite the fact that I was the physician who was most involved in his care and made the most management decisions for him.

-It feels that patients and families are much more likely to ask me for directions, some ginger ale, or help to the bathroom than they are of my male colleagues.

-“Can you close the door on your way out, Miss?”

-“Thanks ladies!”

-“As I was telling the girls…”

“Sure, sweetheart.”

“Good morning Doctress”—one of my personal favorites. A well-intentioned but odd greeting a received daily from a maintenance employee at the Veteran’s Hospital my intern year. I just smiled and nodded back.

“Do you have a boyfriend?” – asked by an attending subspecialty surgeon in the middle of the OR during medical school. [A statement like this is not just sexisim but sexual harrassment.]

-“All of my clinic patients are crazy. That’s because I have 70% female patients,” said by a [female] resident physician, overheard a few years ago. “It is hard for me to hear them complain. Just put your big girl pants on already,” she added.

These are just a few examples. These occurrences have become so commonplace for me that I mostly forget them and keep going. I can recall some positive comments as well, like the 96yo woman who told me I was “wonderful” and that she felt so proud that there were so many young women in medicine. Better yet, often gender does not come up at all.

Thinking back to grade school, I remember people being stumped by the following riddle: “A father brings his son into the hospital after they both got into a car accident. The surgeon sees the boy and says, ‘I cannot operate on this boy, as he is my son.’ How is this possible?” The surgeon is the stepfather? The grandfather? The biological father while the other is adoptive? No, the surgeon is the boy’s mother.

Yet, as recently as the summer between college and medical school I was at a party when a young man my age asked with doubt, “but do you really think a woman could be as good of a surgeon as a man?”

Though I encounter wonderful humans who make the daily grind a little bit brighter, from my co-residents to attendings to nurses to patients, I also encounter at least one message every day that says “your status as a female is incompatible with your status as a physician.” I do not blame the individual messengers as, for the most part, they are sending it unintentionally, and not maliciously. They have just been programmed to operate under certain assumptions, and they have not learned to override those assumptions. I am more frustrated with the system that programmed them and continues to program us. And I am hoping to change it.

We can do it

Red snapper fish for dinner

A Day in the Life of an Intern

She blinked forcefully as she parked her car in the resident lot, fending off her tiredness. She stepped out into the 6am darkness. The morning dew had frozen over, leaving a carpet of frost between her car and the hospital doors. As the cold air crept under her scrubs, she held herself tightly as she briskly walked to the entrance. Once inside, she walked to 1 East, the general medicine floor, unzipping her jacket amid the smothering heat.

Gggguuuaaahhggg….

A guttural scream was heard as she walked through the automatic doors to 1 East. It was the patient in room 15, who had been in the hospital for over 300 days. He had frontotemporal dementia, a form of dementia that causes disinhibition, and he required an enclosed net bed to restrain him. No nursing facility in the area “had the capabilities to care for him,” and the hospital could not push him out. So he stayed. In his cage, in the hospital, for as long as he lived. And he screamed. Every day.

The nurses went on with their business without flinching at the sound of his jarring, spontaneous outbursts. Sienna still jumped every time. She was an intern, or a first-year resident physician, in internal medicine.  She was new to the hospital and to rural New England, having graduated from medical school in New York City six months prior.

Walking into the workroom, Sienna put her backpack under her usual seat and her jacket around her chair and opened up her laptop. She paged the night float intern who called her back to let her know she’d be there in five.

“Hey Sienna,” said Ali, as she walked into the small, windowless workroom.

“Hey Ali, how was your night?”

“Not bad, got a bunch of ridiculous pages throughout the night, but no one crumped, so it was a good night.”

“Awesome. How did my peeps treat you?”

“Not bad. Mr. Martin had some shortness of breath around 10pm that got better after he got his nebulizer…” Sienna received signout on the remainder of her 10 patients, learning about the events that had occurred the previous night. None of her patients were actively sick at the moment, so after she signed into the team pager, she skimmed through the electronic chart to follow up on studies she was waiting for, and glanced at the vitals and labs of her sickest patients. She donned her white coat, her badge, and her pager and placed her stethoscope around her neck.

Grabbing her laptop, she began her process of “pre-rounding,” or seeing all of her patients early in the morning before official team rounds, a ritual that interns everywhere perform daily. She had about two hours left to dedicate to her 10 patients before 8:30am. Taking into account the time needed to walk between rooms, this left her less than 10 minutes per patient, of which she spent about 7 minutes in the room and 2-3 minutes outside the room reading the chart. Within that time, she was supposed to not only gather information, but also formulate her assessment and plan for each patient, and prepare to defend her plan to her senior resident and attending.

Who should I start with? She thought. She decided to do gravity rounds, starting on the 4th floor and working her way down to the 1st. But I’ll leave Aaron for last, she thought. Aaron very medically stable. Interacting with him was also challenging. He was a transplant patient who was stuck on the medicine service for weeks because of an ileus, or slow moving bowels. He was about her age. She had to remind herself to be aware of transference and counter-transference, of the fact that he splits the healthcare staff, and that he often does not respond well to women. That no matter what he says to her, she cannot take it personally, but instead must let it roll off so that she can focus on his care.

No, maybe I’ll leave Betsy for last. She’s so cute and pleasant. She’ll brighten up my day. I’ll see Aaron 2nd to last. Betsy was a 90-year-old lady with cellulitis, a skin infection, on her leg. A typical encounter was as such:

“Good morning Betsy! How are you feeling?”

“Oh I’m fine, better than I’ve been all week! Now how are you doing, dear?”

“I’m doing well, Betsy, thanks for asking. How’s your leg feeling?”

“Oh the leg is doing okay, it looks like it’s getting better with these antibiotics they’re giving me.”

Sienna performed a review of systems and a physical exam. After examining her heart, lungs, abdomen, and legs and taking a peek in her mouth, she asked Betsy if there was anything I could do for her before the rest of the team comes by to see her.

“Oh no, I’m just fine, thank you so much. You all are doing such a fine job taking care of me. Now you go on and have a good day!”

Betsy was the only patient who asked Sienna how she was feeling, and who wished her a good day, and the kindness made Sienna smile.

As Sienna saw each of her patients, she asked them how they were feeling, asked them specific questions related to their conditions, examined them, and studied their charts.

Sunlight began to creep in through the window in the hallway as Sienna power-walked from the staircase to the patient rooms on the third floor. Her stomach grumbled loudly, as she had not had breakfast. For just a moment, she turned her head towards the window, inhaling and exhaling the dim sunlight, her feet never pausing.

By the end of her prerounding, her stethoscope weighed heavily on her shoulders. She placed it in her pocket as she entered the workroom again, sitting down as she waited for her senior resident to arrive from morning conference.  Her pager had begun to buzz incessantly, with nurses calling to ask questions or update her on patient information, and with case managers calling to coordinate patient discharges. She called the pages back, phone held up to her ear by her shoulder, all the while her fingers busy typing notes. She inserted the overnight events, the things her patients said to her, and her exam. She jotted down a couple of key phrases in the plan section of her note to jog her memory of what she wanted to discuss during the assessment and plan component of the presentation—the part she dreaded the most.

Giving presentations made Sienna feel like she was on display, and like everyone was judging her abilities. This was perhaps because she was her own harshest critic. More than carrying the pager, more than writing notes, perhaps even more than having to wake up at 5am, the task that she disliked the most required of her as an intern was giving daily presentations. Even though she had spent the last four years of her life in medical school and the four years prior to that as a premedical college student, she often felt like she knew nothing. Although she had always been one of the brightest kids in the room growing up—highest grade point average every year, valedictorian, magna cum laude at a top ten university, and winner of awards at the national level—in medicine she questioned her own intelligence daily. When pressed by a superior to answer a question about patient data, an academic fact, or her reasoning for proposing a plan, her mind often drew a total blank, no matter how much she knew. Subsequently, all she could think about were her evaluations, and what the program director would think, and how she would fare in the next step of her training. What she liked the most about medicine was talking to patients, and thinking about how their diseases worked and what to do about them. She wished she had more time to interact with and think about her patients. While the team rounded, Sienna presented and then stayed outside of the room to answer pages and enter orders while the attending, senior resident, and medical student spoke to and examined the patient.

By noon, Sienna’s team had finally finished rounding. By that point, all she could think about was lunch. Leaving her stethoscope at her desk, she walked over to the noon conference where a lecture was about to take place for the senior residents and free sandwiches were available. She grabbed a plate to bring back to her cave, as she had two patients to discharge and was likely to have a new admission coming soon. Not to mention all of her progress notes she had yet to finish.

She snuck into the nursing conference room off the floor to do her work and eat her lunch, as that room had a window and more space, and was more often than not empty. She checked her phone, and smiled at a message from her husband wishing her a nice day. Thank God for this man, she thought. She met him while she was doing research, and they fell instantly in love. He agreed to go on this adventure with her, uprooting his life so that they could start their new life together. I hope you have a great day too. I love you.

The rest of the afternoon was a blur. She had to coordinate discharges for two patients and write their discharge summaries, and she also got two new admissions. One was very sick, a man with liver cirrhosis and a gastrointestinal bleed, who would be on her team but staying in the step-down unit, where he would receive closer nursing monitoring and be in closer proximity to the intensive care unit.

By 5:30 pm Ali was back, but Sienna had not yet finished her work, having an admission note still to finish. Although it was not her late call day, it was her day where she could get new admissions between noon and 4pm, and she received two admissions in the last hour.

At 7:15 pm, she was finally heading to her car. As she stepped out into the darkness of the evening, she noticed that the frozen morning dew had melted and the sidewalk was wet but not icy. It was early November but winter had started early this year.

Aaaah. A sigh of relief as she sat in her car. She plugged in her phone and turned on her favorite playlist. She was looking forward to dinner with Jake, and was also thinking about her plan for tomorrow and what she had to follow-up on in the morning. She was calculating that by the time she was home, she had give or take an hour and a half to shower, eat, and spend time with Jake if she wanted to get 8 hours of sleep before the next day. Ha, she thought, slim chance of me being in bed by 9pm.

As Sienna entered the apartment, she could smell the delicious dinner Jake was cooking.

“Hey babe!” she called, as she walked into their apartment.

“Hey sweetheart. How was your day?”

“Eh, it was okay. How was your day?”

Jake loved to cook, which made Sienna’s life so much easier.

Sienna hung her jacket and placed her bag and shoes in the coat closet. She caught a glimpse of herself—dark hair pulled back, no makeup on her face, glasses on. Do I still look like me?

She threw her scrubs in the hamper and got in the shower. Ever since third year of medical school when her clinical rotations began, she developed a daily ritual of showering first thing when she got home. She let the stream of water wash away all of the events of the day. All of the sins of the hospital. In the shower, she had time to reflect, and time to forget, depending on what she needed that day.

Another day down. And it’s only Monday.

Red snapper fish for dinner

Written by Alexandra Villasante Fricke, MD in 2015.

Hand Washing

How To Avoid Cold and Flu

The winter chill is in the air and everyone around you is sneezing. What can you do to steer clear of cold and flu viruses this season?

Hand Washing
Prevent illness by washing hands frequently!

The best medicine is prevention.

The first step is to avoid getting sick in the first place. Here are my tips:

  • Wash and sanitize your hands frequently. This is the best way to avoid getting sick. In the hospital there are Purell dispensers in front of every patient room and sinks easily accessible. I sanitize my hands before and after every patient encounter. I also wash my hands before eating or before touching my face. I carry hand sanitizer in my purse and in my car.
  • In fact, I avoid putting my hands near my face unless freshly washed. (This is no easy task for a former nail biter!)
  • Avoid people who are sick, especially if you are immunocompromised. If you must come in to close contact with someone who is sick (e.g. your child), wash your hands after any contact with them and before eating or putting your hands near your face. Consider wearing a mask.
    • If you are in close contact with someone with documented influenza, discuss with your PCP whether you should take prophylactic oseltamivir (Tamiflu) medication.
  • GET YOUR INFLUENZA VACCINE! Everyone. Even if you have never had the flu. Even if you are otherwise healthy. I cannot stress this enough to my patients. The influenza vaccine saves lives. Some myth busting:
    • You cannot get influenza from the injected influenza vaccine. You may develop a day or two of malaise and even a low-grade fever as your body creates antibodies to the vaccine. However, you cannot develop influenza.
    • Vaccines do NOT cause autism. More on this in a later post, but read this for more.
    • The vaccine is not 100% effective (nothing is in medicine). However, it significantly reduces the incidence of influenza.
    • See the CDC website for more.
  • Get your pneumococcal (“pneumonia”) vaccine if you meet criteria (eg. if you are above the age of 65 or if you smoke, have diabetes, or a variety of other chronic illnesses). This will help protect you from one of the common causes of bacterial pneumonia. Discuss with your PCP.

But why should I care about avoiding getting a respiratory infection in the first place?

  • According to the CDC, about 36,000 people die of influenza each year.
    • In my ICU rotation my intern year, I took care of an otherwise healthy 45 year old man who developed acute respiratory distress syndrome from the flu and was on a ventilator for 5 weeks.
    • I personally got the H1N1 flu in 2009 and, though I was otherwise perfectly healthy at the time, I was completely out of commission with a high fever for 11 days. This was followed by another week of so of pneumonia and a pleural effusion. The flu is no joke!
  • It’s bad for the economy. No, seriously. According to the CDC, influenza alone causes workers in the US to lose up to 111 million workdays, totaling to an estimated $7 billion per year in sick days and lost productivity.
  • Even a simple “cold” (a viral upper respiratory infection) can be fatal for people with chronic conditions such as asthma and COPD, people who are immunosuppressed (eg. people with cancer on chemotherapy, people with autoimmune disorders on immunosuppressing medications, people with HIV/AIDS).
  • You can pass it on to other people, including people with the above conditions.
  • It’s a hassle! Whether you are the one who is sick or your child, spouse, or loved one is, respiratory infections are a nuisance.

I’ve caught a cold (or flu)! Now what?

  • If you have a fever (temp > 100.5F), consider getting tested for influenza with your PCP or at an urgent care center, as you may qualify for receiving oseltamivir (Tamiflu). You must present within 48hr of symptoms to have any benefit from Tamiflu. This medication can reduce symptoms and shorten duration of illness by 1-2 days.
  • If you have fever and cough productive of sputum (of any color), or symptoms that do not get better within a week, seek medical examination as you could have a lower respiratory infection such as pneumonia.
  • For all other viral upper respiratory infections (symptoms such as sore throat, runny or stuffed nose, runny eyes, sneezing), no medication is needed. You may take supportive medications (i.e., medications to make you feel better). Your body will fight the virus on it’s own.
  • Get rest, drink plenty of fluids, and avoid close contact with other people in order to prevent passing the virus on.
  • If you have malaise, muscle aches, headache, or fever, ibuprofen (the active ingredient in Advil and Motrin) and/or Acetaminophen (the active ingredient in Tylenol) can help relieve those symptoms.
    • Discuss with your doctor whether these medications are safe for you. For example, those with kidney problems and those at increased risk of bleeding should not take ibuprofen without OK from your doctor. Those with liver problems should check with doctor before taking acetaminophen.
    • Seek medical care if you have a severe headache, especially if you do not typically have headaches or if it is the worst headache of your life.
  • If you have a stuffy or runny nose, consider saline nasal spray or using a Neti Pot. Decongestants such as DayQuil can help (contains 3 ingredients: acetaminophen, a cough suppressant, and a nasal decongestant) though I personally never use these myself. Ask your doctor before using decongestants (ingredients such as phenylephrine) especially if you are prone to a racing heart, high blood pressure, or glaucoma.
  • If you primarily have phlegm and a productive cough, you may benefit from a cough suppressant such as Mucinex (tablets) or Robitussin (liquid). I order them frequently in hospitalized patients.

Using these tips I have avoided getting sick so far this season (knocking on wood!). Stay healthy and be well!

See my About page for all disclaimers.

Welcome back!

Welcome to the revamped version of Medicine Simply! I am currently a third year resident physician in internal medicine. I graduated medical school and obtained my MD in 2015. I currently see patients every day, either in the hospital or in the clinic, under the guidance and supervision of attending physicians. This summer I will complete my residency, apply for a full, independent medical license (I currently operate on a training license), and sit for the boards in order to become “board certified” in Internal Medicine. I will also begin specialty fellowship in July 2018.

In the next series of posts I will be providing you with affiliate links through Amazon Associates. For example, in my last post, I provided a link to Afrin No Drip Extra Moisturizing Pump Mist 15 ml, a brand name version of the nasal decongestant oxymetazoline, as I have used oxymetazoline in practice. If purchases on Amazon are made by readers who click on the links, I will make a small commission. I am not partial to any particular brands and will aim to present multiple options when available. I will only highlight products and over-the-counter medications that are evidence-based and/or widely recommended in practice. I have already turned down offers to review herbal supplements because I do not believe in those products, for example.

Future posts will include further medical lifehacks such as how to avoid cold and flu, recommendations on my personal favorite skincare products, and information on your burning questions such as, what does “gluten-free” really mean? I will always continue to incorporate my experiences as a resident physicians. Stay tuned!

How to Stop Nosebleeds

*Buzzzz* My pager buzzes with the following message: “patient in 233 having a severe nosebleed, come now.” The patient is a 72yo woman on aspirin (an antiplatelet drug) and warfarin (an anticoagulant). When I walk into the room, multiple staff members are surrounding the patient. One is holding gauze under her nostrils as bright red blood is dripping down. I see that the patient is breathing normally and thinking clearly and is not in distress.

I instructed the nurses to hold firm pressure at the tip of her nose for 5 minutes without letting go. Also to keep the patient’s chin close to her chest in order to prevent blood from going into her trachea. Instead any blood would drip back into her esophagus or out her mouth. However, sensing the nurse’s reluctance, I placed my gloved hand over the patient’s nose and pinched firmly for 5 entire minutes without stopping. It must be a firm hold, to the point of slight discomfort to the patient. During the hold, the patient had some clots come out of her mouth during the first minute or so, but the bleed seemed to be slowing down. I timed the 5 minutes on the wall clock and then examined the patient’s nose.

When I let go, there was no further obvious bleeding. On exam with a light, there was an oozing spot visible in her right nostril. I ordered oxymetazoline (Afrin) nasal spray and had her RN apply two sprays to each nostril in order to cause constriction of the blood vessels in the patient’s nose. The patient had no further bleeding.

Most (about 90%) of the time, epistaxis (aka a nosebleed) comes from the front or anterior part of the nose; specifically, from a group of blood vessels called Kiesselbach’s plexus, as shown in the photo below. Compressing them can stop this kind of bleed.

©2017 UpToDate, Inc. and/or its affiliates.

If a nosebleed happens to you or a loved one at home,

  • 1. the first step is to make sure that the person bleeding has a pulse, is breathing, speaking, thinking clearly and able to protect their airway; if any doubt on their ability to protect their airway, call 911.
  • 2. The next step for those who are safely protecting their airway is to begin by applying firm pressure as such, with the chin tucked close to the chest:
Anterior nasal pressure and chin tuck. Copyright Medicine Simply.
Anterior pressure, side view. Copyright Medicine Simply.
  • 3. Do not let go for a minimum of 5 minutes.

During the process of holding you may see some clots come out of your mouth or feel them go down your throat. However, if you continue to have unchanged, profuse bleeding, in particular down the back of the throat, despite firm anterior pressure, call 911 and go to your closest hospital emergency department as you may have a posterior nasal bleed. Posterior bleed tend to be dramatic–they don’t drip, they run like an open faucet. For anterior bleeds, however, firm pressure should noticeably dampen the bleed.

  • 4. After 5 full minutes of firm pressure, let go and inspect the nose for bleeding. If any further bleeding, apply two sprays of Afrin to each nostril and continue to hold firm pressure for another 5 to 10 minutes. If after 15 total minutes the bleeding has not stopped, seek emergency medical care, as you may need nasal cautery or packing by an ENT or emergency room physician or advanced provider.
  • 5. If bleeding has stopped but there is some oozing at the source, it is reasonable to apply two sprays of Afrin in the nare. Watch carefully for at least 30 minutes to ensure no recurrence of bleeding. Make note that Afrin is a great vasoconstrictor and decongestant but it should only be used for more than three days in a row as it can cause rebound nasal congestion.
  • 6. Once the bleeding stops, care for the site of bleeding by gently applying an antibiotic ointment such as bacitracin three times daily for three days.

If nosebleeds happen to you frequently, discuss them with your primary care provider (PCP) in order to discover why they may be happening.

See About Me page for Disclaimers.

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Brain Death and Basketball

In reference to the recent unfortunate events regarding basketball player Lamar Odom, I have heard many inconsistent reports, from declarations that he is “brain dead” to reports that he woke up and spoke. This got me to thinking about how brain death, death, cardiac arrest, and altered levels of consciousness are often inaccurately portrayed in the media, and I wanted to clarify a few misconceptions 

First of all, when someone is brain dead, they are, for all intents and purposes, dead. Death is defined as brain death and/or cardiopulmonary death. If Odom were brain dead, he could not wake up. If he really woke up, he was never brain dead. Brain death = legal and biological death. Brain death means that the person has no function in their cortex (upper brain, which produces consciousness) OR in their brainstem (the “rudimentary” brain, so to speak, which controls functions such as breathing). When someone is brain dead, their entire brain is permanently functionally damaged and can never return to a functioning state in any way.

brain2

The way that we as doctors assess for brain function is first by clinical exam. First, we make sure to minimize factors confounding the exam (for example, turning off medications, or warming someone who had been hypothermic).

If someone is awake, alert, and conscious, they are demonstrating that they have at least some cortical (upper brain) function. When someone has altered levels of consciousness (for example, they are somnolent) The exam then aims to answer “how good is their cortical function?” — can they speak? Can they interact or express themselves in some way? Can they visually track? Can they follow simple commands?

People who are unconscious can sometimes have spontaneous movements (such as abnormal posturing), but they will not have purposeful movements or meaningful interaction with their surroundings.
When someone is unconscious, we want to see if they have some “lower brain,” or brainstem function. We start by examining cranial nerve reflexes. Cranial nerves are peripheral nerves that have their roots in the brainstem, and they control head and neck functions such as facial expressions, facial sensation, and pupil dilation and constriction. Reflexes mediated by cranial nerves include pupil constriction upon stimulation with light, blinking upon touching the cornea, and gagging when the back of the throat is stimulated (such as with a q-tip). Someone without brainstem function (i.e. a brain dead person, or equivalently a dead person) has fixed dilated pupils, will not react to stimulation of their corneas or throat, and cannot breath on their own, as the brainstem controls the respiratory drive.
What does it mean to “pull the plug” or remove “life support” from a brain dead person? Often, brain death is declared on a person who is intubated and on a ventilator—they have a tube (an endotracheal tube, named because of its position within the trachea) down their throats, and this tube is connected to a machine called a ventilator that moves air in and out of the lungs using positive pressure. The drive to breathe is located in the brainstem, so a brain dead person will not breathe on their own if the breathing tube is removed (if they are extubated). Once they experience respiratory arrest, their heart will soon stop beating and pumping because it is not being supplied with oxygen (the heart’s drive to beat is actually independent of the brain, but without oxygen the cardiac muscle will stop functioning). So, someone who has experience brain death will, inevitably, if left untouched by medical devices, swiftly experience cardiopulmonary death.

ventilator

Keeping a brain dead person on a ventilator is not “keeping someone alive”—it is oxygenating and perfusing a corpse. The medically appropriate next step after someone is declared brain dead is to extubate them within a reasonable amount of time (eg. sometimes a few hours to a day, to give the family time to process). There are situations, however, where a person is  NOT brain dead, but they are breathing with the help of a ventilator. Sometimes, based on the patient’s prior wishes, his or her durable power of attorney (often a spouse, a parent, an adult child) makes the decision to extubate them and let nature take its course.

Why does the heart keep pumping if the brain is dead? That is because the heart beats independently of the brain. The heart has its own pacemaker, and the heart will continue to function (if it is a viable organ) for as long as it continues to receive oxygen. A viable heart removed from the body would continue to pump if it received adequate tissue oxygenation. When a person dies naturally (i.e., when they are not intubated and on a ventilator), however, both brain death and cardiopulmonary death occur (the heart stops once breathing stops, and breathing stops once the brain dies. Sometimes, the heart dies first, and then the brain dies because it is not getting oxygenated blood flow).

Cardiac arrest occurs when your heart suddenly stops. Cardiac arrest is not the same as a “heart attack,” or myocardial infarction, which is when a coronary artery (vessel that brings oxygenated blood to the heart) gets blocked, such as by a clot that gets stuck in a plaque (plaques often form on vessels, narrowing of the vessel). A heart attack COULD lead to cardiac arrest, but there are several other events that can also cause a cardiac arrest. Also, the majority of heart attacks do not cause cardiac arrest.

Coronary artery anatomy
Coronary artery anatomy

Sometimes, however, a person can have serious brain damage and can be in a coma for days, but can still have brain function and a chance for some sort of meaningful recovery. I recently saw two patients around the same time who had experienced cardiac arrests. One died, and one is alive and interactive. Both received CPR at the scene, and both were brought to the hospital and their bodies were cooled (therapeutic hypothermia). Both were intubated and on ventilators, and unresponsive for several days. Bill had his eyes open, was at first not visually tracking, but was withdrawing to pain, and was moving his arms on the bed spontaneously. Tim was completely unawake, with eyes closed, not moving, not responding to pain; however, he did have cranial nerve reflexes. We did a test called somatosensory evoked potentials (SSEPs), which showed that Bill had some cortical activity, while Tim had only brainstem function. Neither was brain dead, but Tim had a very poor prognosis based on clinical exam and SSEP; Bill’s prognosis was at that point unclear. After a few days, however, Bill started tracking our faces with his eyes. He started following simple commands (at first, he would blink and shut his eyes on command. Next, he would squeeze hands on command. Then he became able to give a thumbs up, lift his legs). Soon Bill passed spontaneous breathing trials and he was extubated. He was very disoriented, not knowing where he was or what year it was, but he could verbalize, and he could tell me his name, his wife’s name, his hometown. Day after day, he continued to get better. He still has serious neurologic deficits, but he is awake and alive. Tim, on the other hand, did not get better. Each day, he looked the same as the day before. His family decided to extubate him, and he eventually passed.

Cardiac arrest is a serious event, and most who experience it die. However, like my patient Bill, there are some who do survive. However, most who survive a cardiac arrest are left with serious permanent neurologic deficits. Only a very small fraction, however, return to their baseline functioning. Someone might return to baseline–for example, if he or she were were young and healthy at baseline and received effective CPR right away.