I was saddened on both a personal and professional level by the news that Reeve died Sunday.
Back in May, 1995, immediately after he suffered his life-and-cervical-spine-shattering injury, he came to my hospital – the University of Virginia Medical Center, where I was on the anesthesiology faculty.
It was a media circus.
After a month at UVA, he stabilized enough to go home.
Subsequently, his unflagging focus and determination to walk again served to jump-start the field of spinal cord regeneration and take it to the next level.
My own interest in paralysis and problems associated with spinal cord damage started long before Reeve’s injury.
It was during my anesthesiology residency at UCLA Medical Center when, on my first (of two) obstetric anesthesia rotations, I was assigned a pregnant quadriplegic patient.
First of all, everyone was amazed she was pregnant: apparently no one had ever encountered such a thing.
But there she was, happily married and about to give birth.
She also suffered from a potentially lethal condition known as autonomic hyperreflexia.
This is a neurological dysfunction associated with paraplegia and quadriplegia in which stimulation of the autonomic nervous system – completely unperceived by the patient – can lead to sudden lethal hypertension, stroke, and cardiac arrest.
Such things as bladder overdistention can be inciting factors.
I read everything I could on the syndrome, then proposed to provide an epidural anesthetic for her delivery.
Now, she was numb from the mid-chest down, so it wasn’t a matter of controlling her pain as the baby descended.
Rather, it was to blunt the autonomic reflexes set off by cervical distention and the compression of intra-pelvic structures.
At the time I was early in the second year of my anesthesia residency.
Since after a few nights in the library, I knew far more about autonomic hyperreflexia than anyone else involved in her care, I became de facto chief of her case.
Long story short: I put in an epidural, gave her anesthesia which I controlled and regulated by monitoring her blood pressure (since the usual measuring stick – pain – was not applicable), and she delivered a healthy infant without incident.
I wrote the case up for the leading journal in the field of anesthesiology.
It was accepted for publication and appeared in December of 1979.
Here’s the reference, for those of you who find bookofjoe too basic for your tastes:
Stirt JA, Marco A, Conklin KA: Obstetric Anesthesia for a Quadriplegic Patient with Autonomic Hyperreflexia. Anesthesiology 51: 560-562, 1979
Back to Christopher Reeve.
I was sure that there would be, somewhere among this morning’s papers, after a day to digest the news, a story about exactly why Reeve died.
But there wasn’t, not in the New York Times, the Washington Post, The Wall Street Journal, The Financial Times, USA Today, or the Charlottesville Daily Progress.
That’s a lot of high-priced journalistic talent above: you’d thing someone would’ve gone beyond the “what happened” to “why.”
The Washington Post had the clearest account of what happened:
1) As of a week ago – October 5 – Reeve was apparently fine, well enough to speak at the Chicago Rehabilitation Institute on behalf of the institute’s research program.
3) The sore became infected, and the infection spread from the localized site into Reeve’s bloodstream. This is referred to as “sepsis” or “septicemia.”
4) Reeve was undergoing treatment for his sepsis at home in Pound Ridge, New York. This consists of at least one and usually two powerful, broad-spectrum antibiotics given I.V.
I have no doubt Reeve was receiving the finest medical care money can buy.
Susan Howley, executive vice-president and director for research at the Christopher Reeve Paralysis Foundation in Springfield, New Jersey, said, “He had extraordinarily good state-of-the-art care, which is not necessarily something available to everyone who suffers a spinal cord injury.”
Still, it would appear to me that Reeve was a victim of what I have referred to before as “V.I.P. Medicine.”
The reason sepsis is life-threatening is the associated symptom complex that accompanies it.
Most important, sepsis can cause low blood pressure and septic shock.
That’s why septic patients in the hospital who are unstable are always in the I.C.U.
5) Reeve was at home when his heart stopped beating. The Washington Post described it as a “heart attack,” but trust me, it was a cardiac arrest, resulting from low blood pressure and subsequent poor perfusion of the heart muscle itself by the coronary arteries.
Home is not the best place to be if you’re septic.
For one thing, the vast array of pressor drugs and real-time blood pressure monitoring by an indwelling arterial catheter are unavailable.
6) He lapsed into unconsciousness and coma at home
7) An ambulance transported him to Northern Westchester Hospital, where he remained comatose and died Sunday.
John Schwartz of the New York Times wrote the best overview of the enormous medical challenges facing paralyzed patients: his story follows at the very end of this post.
But before we go there, I’m going to tell you why Reeve died.
1) The pressure sore that started the cascade of ultimately lethal events should not have happened.
By definition, a pressure sore = poor patient care.
This was pounded into my head during my internship at Los Angeles County-University of Southern California Medical Center by Dr. Margaret McCarron, chief of the hospital’s Jail Ward – yes, it was a locked ward, taking up one entire floor of the hospital, staffed by doctors, nurses, and sheriff’s deputies who checked their guns at the elevator.
All patients were prisoners, some shackled to their beds, others not.
Dr. McCarron, a great teacher and clinician who’s probably been dead for years, was adamant about making sure every patient on her ward was treated with the care and respect the most famous and important patient might receive.
To that end, she made it clear to us interns, just weeks out of medical school – was I ever that young and naive and innocent? But I digress – that we were responsible if one of our patients, however sick he or she might be, developed a bedsore.
Because it was incumbent upon us, if we had a patient who was bedridden, to turn that patient onto his or her side every day when we made rounds to check for skin breakdown.
So it is inconceivable to me that “the extraordinarily good, state-of-the-art care” Reeve was receiving should have led to this end.
2) Reeve had no business being treated for sepsis at home. What ridiculous hubris, to deal with such a life-threatening condition as if it were some minor ailment.
He belonged in an I.C.U. until he was stable, then in the hospital until he was off I.V. antibiotics.
Now, here’s the New York Times article, from this morning’s paper.
- With Paralysis, Challenge Goes Beyond Walking
The death of Christopher Reeve illustrated something that those who live with paralysis know all too well: the challenges go far beyond the inability to walk.
“Walking is the least of it,” said Donna Messinger, who is 43 and has been paralyzed since an automobile accident in her senior year of college.
Mr. Reeve died of cardiac arrest on Sunday.
He had previously been treated for a severe systemic infection that was, in turn, caused by a pressure wound, the medical term for a bedsore, a common complication for people who are paralyzed.
Mr. Reeve was, in fact, one of the lucky ones.
Though his injuries were among the most severe possible, he also had the resources to get the best treatment.
“He had extraordinarily good state-of-the-art care, which is not necessarily something available to everyone who suffers a spinal cord injury,” said Susan Howley, the executive vice president and director for research the Christopher Reeve Paralysis Foundation in Springfield, N.J.
Infection is perhaps the biggest enemy for people with such injuries.
According to the Infectious Diseases Society of America, some form of infection is the No. 1 cause of death among patients who are paralyzed from the waist down.
Mr. Reeve’s own problems with pressure sores show how difficult they can be.
Patients who cannot move for themselves must be shifted and turned regularly during the day and often must have 24-hour nursing care.
And even when expert full-time care is available, as in Mr. Reeve’s case, it is no guarantee.
“After nine years, it takes its toll, that continual pressure,” Ms. Howley said, with “proclivity to skin breakdowns that comes from sitting or lying in one place day after day, month after month, year after year.”
For those patients who cannot breathe on their own, lung infections are also common, said Dr. Kristjan Ragnarsson, chairman of rehabilitation medicine at Mount Sinai Medical Center in New York City.
Patients get treatment to keep mucus from building up in the lungs, but the airways can still become fatally plugged, he said.
Another risk is that blood clots that form in the legs or abdomen can travel to the heart and lung, resulting in a pulmonary embolism, or blood clot in the lung.
And any infection, in the skin, in the lungs, in the kidneys, can get out of hand, with bacteria pouring into the bloodstream, producing septicemia.
Beyond infection, paralysis is associated with a host of medical problems that deeply affect patients’ quality of life.
Many people with spinal cord injuries deal with chronic pain and muscle spasms, and the body can lose its ability to regulate blood pressure and temperature.
There is often loss of bowel and bladder control.
Those who rely on artificial ventilation through a tracheostomy tube are prone to pneumonia and infections related to the tube.
Cardiovascular illness is another leading cause of death in people who have become paralyzed over the long term.
“These are the kinds of things that I don’t think the average person generally thinks about when they think about spinal cord injury,” Ms. Howley said.
The course of Mr. Reeve’s illness was not unusual, experts say.
Dr. John McDonald, the director of the spinal cord research center at the Kennedy Krieger Institute at Johns Hopkins in Baltimore, who treated Mr. Reeve, said that “people typically die from common complications” associated with their injuries, “each one accumulating over time, making you more vulnerable to the next one.”
Research is able to address some of the common symptoms with varying degrees of success.
For example, Dr. Ragnarsson said that muscle spasms could now be effectively treated with medication that is taken orally or through the use of a small drug pump implanted within the body, and some doctors have treated spasms effectively with Botox.
And while the most common cause of death for people with paralysis used to be kidney failure from recurrent infections, Dr. Ragnarsson said, “this is no longer so,” because of advances in treatment.
“The life expectancy of people with spinal cord injury has been increasing every year for the last 50 years,” Dr. Ragnarsson said.
Dr. Wise Young, the chairman of the department of cell biology and neuroscience at Rutgers University and a friend of Mr. Reeve, said that combination therapies, including the transplantation of stem cells to repair damaged nerves, are showing promise in animal studies and are generating excitement for possible future treatment in humans.
“What makes me so sad is Christopher Reeve did not live so long as to see the fruits of this – not only for himself, but for others,” Dr. Young said.
Treating the infections and other medical problems that accompany paralysis was a large part of Mr. Reeve’s work as an activist.
And though Mr. Reeve is most closely associated with his work on behalf of stem cell research, he also pushed to expand research on improving the quality of life for people with spinal cord injuries.
Once patients get past the initial shock and emotional blow of paralysis, Dr. Ragnarsson said, “the majority of people with spinal cord injury say they have made an adjustment, and have relatively high quality of life.”
Ms. Messinger said this was a lesson of Mr. Reeve’s life for many people: giving the impression of living a normal, independent life.
“Life does go on, and you can accomplish a lot,” she said.
She completed a master’s degree after her accident and now works in the litigation department of a pharmaceutical company.
“It’s a lot of hard work to make it look easy,” Ms. Messinger said.