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October 12, 2004

BehindTheMedspeak: Why did Christopher Reeve die?

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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."

But no.

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.

2) Soon after, he developed a pressure ulcer, also known as a bed sore, a constant nemesis of paralyzed individuals. These usually occur over the sacrum (tailbone).

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.

Pressure_ulcer

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.

October 12, 2004 at 05:11 PM | Permalink


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Comments

Jackie, I agree. I believe that there was more to the story about his death. It might of been: A. Maybe his stem-cell treatment resulted in his death, and his family decided to keep this information out of the story because they did not want to give any negative publicity to this research. You are right, C. Reeves appearance almost changed overnight-baldness, eyebrows, etc. Somebody in another post mentioned that Reeves was interviewed in Reader's Digest and he said that he had three life threatening infections in the past 12 months. or- B. Maybe Reeves was depressed and committing passive suicide by refusing treatment for this bedsore, or refusing to be hospitalized for sepsis. This would be something that his family would never admit in public.

Posted by: Lisa | Nov 22, 2008 11:28:13 AM

Jackie, I think that you are onto something. If anyone, C. Reeves might of been getting stem-cells, and that might explain his appearance in the last year

Posted by: lisa | Nov 22, 2008 11:14:30 AM

Here's a question abuot Christrpher' Reeves death I wonder abour and no one is asking, As a nurse I notices that his apperance was deteriorating pror to his death he lost his hair on his head and eyebrows almost like he had recieved chemothreapy,was his death of sepsis as a result of a bed sore or a result of experimentation with stem cell transplantation that went wrong? I ask this because inorder for someone to recieve a stemcell transplant at lest the adult stem cell you need to recive chemo to strip your immune system inorder for your body not to reject the new stem cells.

Posted by: jackie p | Nov 9, 2008 2:49:22 PM

Can bedsores be prevented with proper care? Is neglect the reason they develop and get worse? How can this happen? How can bedsores get to the point of open wounds and black, dead tissue when it's supposedly being treated, and was 'caught early'? How can something 'caught early', get to the stage where it neeeds debrided? Why would someone in this condition be pulled up out of bed to do physical therapy? Why wouldn't someone in this condition be 'watched like a hawk', and religiously turned to keep the pressure off? Why would someone in this condition be put in a wheel chair for a minimum of 2 hrs a day for 2 days, not be given a gel cushion to sit on? Shouldn't therapists know these things are necessary? Shouldn't wound care specialists make these things available to the patient/therapists as soon as they are aware of the beginning of a bedsore? How can there be such a lack of communication between hospital personnel when this condition has FATAL consequences?! My loved one was practically tossed out the hospital doors as soon as the debridement was done and taken to a nursing home where an aide thought the foam wedge was meant to go under his knees!!!!Hello? Heart attack, stroke victim! Does no-one communicate?? God help us!

Posted by: Debbie | Sep 5, 2008 10:40:35 PM

it is so sad what happened. i feel really bad. i cant believe what his son is going through or was going through. it is so terrible what that boy has gone through. Now both his parents have died and he is all alone i would be really scared. When i am just a kid too!!! It just saddens me to hear this story!!!

Posted by: Lora | Apr 30, 2008 11:09:58 PM

My son, Daniel, is a 22 year old quad. He has caregivers who often do not show up in the evening to put him to bed, and understandably he does not want to live in a nursing home at his young age. His insurance company (Medicaid) is giving him a very difficult time getting a different mattress that he desparately needs to help with pressure sores. He gets frustrated and angry. Sometimes he doesn't do the best thing for himself and he knows what the consequences could be. He wants to be in charge of his own life and that is his right, which is what I think Christopher Reeve did. Sometimes they can't take going to the hospital one more time. Pease pray for my son.

Posted by: Barbara | Mar 1, 2008 9:16:45 PM

My dad is 81 years old. He had both his legs amputated in 2006. Dad was a joy to be around.
His lost of limbs did not break his spirits. On August 25 he had a major stroke. He was admitted to Pennyslvania Hospital. Sometime in October, while dad was still in the hospital I became aware of the bedsore. Why the doctors and nurses caring for dad did not tell me about the bedsore is still a mystery to me. I think dad got the bedsore from not being cared for properly. All of a sudden dad started getting turned every 2 hours, after the family became aware of the bedsore. Today my dad is in Thomas Jefferson Hospital in Philadelphia. The bedsore had sugical debidement on December 14 (Dad's Birthday). Dad does have other health problems, I think it is so sad that he had to also get this horrible bedsore. I was with dad most of the day yesterday even though he can not speak he still smiles at me. Please keep my dad Thomas Laughlin in your prayers. Thank You.

Posted by: Roseann Laughlin | Dec 17, 2007 3:58:57 PM

I was very sad to here that Christopher reeves died. He was hero to me to and I wish he was with us today now.I have enjoyed his movie superman I've watche the like Three times now and I was soory to hear he died form the passage above spinal cord injury and from A little bed sore.

Posted by: Anthony | Nov 2, 2007 8:44:07 AM

DR. I am young brasiliam boy and I had a medular leson (C6), can you help me? I need drink a 4-aminopyridine? I am pacient in brasil of Doctor Tarcisio eloy peesoa de Barros. if need I go to US for clinical search.

Best regards

Rodrigo

Posted by: monteiro Rodrigo | Oct 5, 2005 9:25:52 PM

I am so glad I found this article finally! I, too, had been wondering why Christopher Reeve let a pressure sore get so bad and why he was not in a hospital sooner for his infection. My son broke his neck in 1995 also and thank God we have not had a pressure sore. I think Starr was right on though, Reeve was a very stubborn workaholic and could very well have brought on the pressure sore by thinking it 'couldn't happen to him' and he needed to get so much done. I do, however, have another theory about his death. I believe it was passive suicide. I really think he was just tired of living as a vent quadriplegic and decided not to fight anymore. I also think (now don't get offended everyone) the timing was to make a political statement right before the election. Reeve was soooo anti-Bush, he probably figured his death might push Kerry over the edge to win the election and what better sacrifice for his stem-cell research cause than to give up his painful, tired life?

Posted by: Diane | Feb 6, 2005 2:50:29 AM

I think everyone needs to stop blaming the medical staff taking care of Chris Reeve and back off a bit from inferring that they were somehow incompetent. He had a working mind and (stating this with the highest degree of respect for the man), an iron, stubborn will.

If he refused to have treatment in the hospital that was his choice and I believe his family respected his wishes. Maybe he should have been in ICU for his septicemia, but do his doctors and care givers have a right to force him to do this? Unfortunately, no.

There is a lot of "gloss" out there about how good natured he was but let's face it, he was also a workaholic. Ever seen "Rear Window"? The character wasn't just invented...Chris Reeve's persona was invested in that role. I can easily see him shooing away his caregivers because he's "in the middle of something"...sitting or lying in one position longer than he should because he's on speaker-phone with the umteenth VIP. (Just one more call!)

He might have been aware of the seriousness of his pressure ulcer(s) to a certain degree but was notorious for pushing the limits in everything regardless of risk. Notice how he was transferred to hospital once he went into arrest? A man unable to speak can't argue. They were able to get him where he should have been. However, it was too late.
I believe that the medical personal probably tried their hardest to attain his compliance but in the end, he made the choices.

Ironically, while he was able to make choices that may have resulted in his untimely passing, he was unable to receive any benefits of stem-cell research. I think that rather than point fingers at his caregivers, we need to be looking at the real issue....the gov'ts denial of the ultimate form of medical relief...the ability to choose to be part of human research. Chris Reeve had the right to deny forms of care but had no right to undergo procedures which may unlimately have saved his life.

Posted by: Starr | Jan 26, 2005 9:43:57 PM

I agree with you entirely, except for the part about all bed sores (or pressure ulcers) being a result of poor care. Christopher Reeve was immobile for nine years. He couldn't move and no amount of turning, rotating, wet heat would have prevented some kind of pressure ulcer from happening.

But you are right - there are ways to stop it from progressing, and it certainly should not have (if he had been getting the level of care that we expect) turned into a stage IV ulcer that went septic. Nor should they have treated the sepsis from home.

It's just a tragedy all around.

Posted by: miss fitsandstarts | Dec 22, 2004 5:03:33 PM

Why can't doctors use massage-like chairs to constantly move the pressure around? It would seem to be a cheap and very effective way to avoid bed sores.

Posted by: josh | Dec 17, 2004 3:23:46 AM

Thank you so much for doing this article! I was looking for this information for my own blog and have provided a link to this for my students to follow up on and see for them selves. Infection awareess and risk reduction is something I have incorporated into my OSHA bloodborne pathogen training, infact, I call it Biologicals now because the picture has gotten so much bigger.

For this reason as well, I have become very vocal supporter for patient advocacy. People must become more diligent about finding and teaching family or friends what to watch out for and to ask about!

Posted by: Cynthia Anderson | Oct 22, 2004 2:09:25 AM

I was a fan of Christopher Reeve. When I heard what he had died from I thought about my miracle. I too, was hospitalized with life-threatening septicemia(a systemic infection) along with life-threatening pancreatitis in 2003. I had a fever of 108 degrees and was in the intensive care unit of a hospital fighting for my life. My doctors and nurses told me and people continue to tell me that is is a miracle that I'm alive today. I survived because alot of people prayed for my recovery. I believe that I survived so that I can continue helping others. My mission is to continue visiting and comforting the sick, elderly, and homeless and to spread the message of peace and love in the United States and throughout the world.

Posted by: Ms. Pennsylvania 2004 Maria Frisby | Oct 17, 2004 3:29:17 PM

thank you for the interesting insight and info. i have searched google in order to find further info about what led to Reeve's heart failure in addition to cnn's Dr. Sanjay Gupta's explanation....and in all pages from different news org. etc. there was the same superficial explanation given in a rather broad outline, until i "bumped into" this one! appreciate your time Dr.(Mr. anaesthetist).
...and.... god bless the advent of the internet....

Posted by: sharon | Oct 17, 2004 12:40:04 AM

Instead of sitting at our computers reading these articles, we should stop and put to reason why we are more happy for his life instead of being sad for his death. Christopher Reeve gave us many things. I can remember when I used to watch Superman movies like there was no tomorrow, I can remember them all; I remember when he was on Live with Regis and Kathy Lee. I remember when they showed his favorite past time with horses. This man had passion! He had it on the set, he had it when he was at home, he had it in his 'chair'. God Bless his family
Amen

Posted by: Steve | Oct 16, 2004 8:27:47 PM

It is terrible for a family when they lose a loved one. I hope god will be with Mrs. Reeve and her children as they suffer from the loss of their loved one. Christopher reeve was a wonderful man. He had a terrible accident that changed his life forever, but he did not let that get him down in his spirits. May god be with his family. You are in my prayers.

Posted by: Kacey | Oct 16, 2004 6:00:51 PM

It is sad to know that This fine man died from something that could have been prevented. Maybe if someone would have taken him to the hospital he would still be with us today.

Posted by: Lisa | Oct 16, 2004 5:56:23 PM

I am glad Christopher Reeve died becuse now he can stop having to go through all the pain. I am also very sad that Chritopher Reeve died on Monday I think it was because he was a hero to all of us . He will always be remebered. Our 8 grade class of Silver Lakes Middle read a story of Christopher. We learned he attended the cermony for raising awarnece to keep his comitment that he promised befor the accident. He has a beutiful wife and I am not sure if he had any children. We learned more but this is a small page so I can only write so much. If I could meet Mrs. Reeve I would tell her I knew so much about him and I felt like I new him even though didn't. I am writing thisbecause I know what it feels like. I might not have what he had but I have vitiligo. Christopher Reeve will be in the books within the next year, I WILL make shure of that. :)

Posted by: Baylee | Oct 16, 2004 3:28:42 PM

I have been searching for this type of article since Monday. It just sickens me that Christopher Reeve died because of a stupid bed sore! I have been a quadriplegic for over 20 years, and every person with a spinal cord injury hears the same thing over and over again in rehab--do your weight shifts! Check your pressure areas religiously! We know that routine well. Christopher Reeve knew better--that is what is so frustrating about this! And yes, the medical staff caring for him should be ashamed. Have you read Reeve's recent interview with Readers' Digest? Christopher said that he has had 3 life-threatening infections this year because of pressure wounds--how does that become commonplace? He also stated that one of his sores was an abrasion from his exercise bike. What a cruel irony...

Posted by: Cheryl Overturf | Oct 14, 2004 10:44:02 AM

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