Paying It Foward

Finally, a warm, sunny day in the city of Chicago after an unusually cool, rainy Spring.  The fireworks the night before were watched through a low layer of clouds on a dreadfully still summer night, but the threatening rains never came.  Today, though, had been sunnier, brigher, and a wonderful day to enjoy the beach.  The July 4th crowd was large but manageable, and most were returning home to get ready for the evening's activities.

Philip noticed the other gentleman not much older than himself as he was returning his Catamaran to it's rightful spot on the beach.  The other man had just returned his kayak to its slip and was loading his car with beach supplies.  As he finished loading the car, he slammed the back hatch door of the car, turned to walk away, but suddenly collapsed to the ground in a heap.

He didn't move.

Seeing the strange sight, Philip ran to his aid.  The fallen man was lying there with eyes staring skyward, not blinking.  His lips and ears were turning bluish as the tall man shouted at him.  He didn't respond.  Philip checked for a pulse: nothing.  Others were circling, curious as he positioned the man face up on the nearby asphalt.  The onlookers looked confused, amazed at what they were witnessing.  He began pressing on the lower part of the man's chest.  Again, again, and again.

He looked up and shouted as calmly as he could, "Call 911." The bystanders, still dazed, reached for their cell phones as fast as they could and dialed.  By now the attendants at the sailing shack had noticed what had happened and had radioed for help, too.  The AED and oxygen were at the swim beach, about a quarter of a mile away.  A young 16-year old lifeguard, his first day on the job, ran to the scene and reached in to his fanny pack to remove the facemask and worked with the tall, fit man doing CPR.

"Hang in there, Bill!  (not his real name)," the onlookers shouted.   "Don't leave us!" he remembered them saying as they stood by in tears hugging each other.  He kept doing CPR.  "They're coming with the AED!" someone shouted.

He could hear the sirens approaching ...

* * *

Twenty five years earlier, he was home with his mother in the kitchen when the girl arrived in their kitchen, bloodied, and wearing a large blue garbage bag as shorts.    "Help me," she pleaded, "I was raped, but I managed to shoot him," she claimed.  The bloodied shorts and two guns she held in her hands seemed to substantiate her claim. She was trembling, aggitated and seemed terrified. "The police are going to find me and think that I'm a murderer!"

"It's okay," the mother said, trying to calm her.  "Sit down.  What's your name?" 

"Laurie," she said.  "Laurie Dann." 

"It's okay, Laurie. You're going to be okay," she said as she tried to console her.  "I can get you some shorts.  The police will understand that you were just trying to protect yourself."  The girl still looked too upset, untrusting.  The son stood watching carefully as the mother left only briefly and returned with a pair of girl's shorts.  "Here, put these on." 
The girl put down the two handguns and went behind the counter briefly to to put on the shorts.   Phil, not turning his back to the girl, quietly managed to pick up and pocket one of the guns.   "Maybe you should call your family?" he asked.  She shook her head in agreement and he handed her the phone.

She took the phone and dialed, still holding the remaining gun.  "Mom, oh my God, I've... I've done something horrible!   He tried to ...  The police are going to get me, Mom!  Oh, God!..."  She broke into tears unable to maintain her composure.  She  handed Phil the phone.

"Ma'am, my name is Philip Andrew and your daughter is here with us.  She is fine, but looks very upset.  She tells us she's been raped and might have shot the man who raped her.  I think you should come over..."  The mother said she'd try to get there as soon as she could, but she didn't have a car.  Phil felt uneasy with the situation, but the girl looked confused.  They tried to console her.

A short time later, the father arrived home.  He saw the girl with his wife and son sitting there, trying to coax Laurie into giving up her gun.  She wouldn't budge.  She rocked too and fro describing the scene, her terror, her anxiety. The family kept trying to console her, explain the rationale for giving up the gun.   Deflecting, they asked, "Maybe you should call your mother again."  They handed her the phone.  She called. 

This time, the mother managed to leave the house as Laurie spoke with her own mother.  Her words were disjointed in some respects, calculating in others.  After pleading with her mother to come, Laurie handed the husband the phone so he could speak with Laurie's mother.  He told her about the gun Laurie still had and asked the mother if she might plead with her daughter to give up the gun.  He handed the phone back to Laurie and told her he would not remain in the house to protect her from the police unless she put down the gun.  She still refused, so the man left the house.  As Phil tried to leave, she ordered him to stay. She pointed the gun at him.  He stood motionless, terrifed.

The standoff continued until just before noon and she became increasingly aggitated.  As Laurie saw the police approach, she shot Phil in the chest and gave chase, furious at the situation, but he managed to escape out the back door before collapsing.   She ran upstairs.

As he laid there, he could hear the sirens approaching...

* * *

They slapped the AED pads on his chest and stopped compressions.  "Analyzing..." the screen said.  The device detected ventricular fibrillation and shortly after the device said "Stand clear!" the man jerked.  They resumed CPR for a short time, but in 30 seconds the man started moving.  The sirens were almost upon them now.

As the ambulance crew arrived, they couldn't believe their eyes.  The man who moments ago had had chest compressions administered and an AED shock delivered, was getting to his feet.  They helped him to the ambulance.

"This impressed my crew, my guys, so much …" Wilmette Deputy Fire Chief Mike McGreal said a the recent Wilmette park board meeting honoring the beach staff.



But to Philip Andrew, now a crisis negotiator for the FBI who was on the beach with his wife that day, he'll never forget the sound of the sirens...

... and the emergency responders that saved his life twenty five years before.

"There's something really beautiful about being able to pay it forward," he said.

-Wes

References:

"Wilmette lifeguards honored after July 4 rescue"

Laurie Dann Wikipedia page

How A Sudden Cardiac Arrest Survivor Handles the World Cup

It's a story as incredible as it is incomprehensible: On 17 March, 2012, a world-class soccer player from England, Fabrice Muamba, has sudden cardiac arrest (SCA) on a European soccer field.  The audience and remaining players stand stunned as CPR is initiated (video here).  An automatic external defibrillator (AED) is applied to his chest.  Two shocks from the AED are delivered on the field, another as he was carried to the ambulance nearly five minutes later, and 12 more shocks were delivered on the way to the hospital.  None of them worked.  Ultimately, 78 minutes of CPR were performed before the sixteenth shock miraculously restored sinus rhythm.  He then underwent therapeutic hypothermia, and, just as incredibly, awakened neurologically intact some time later.  He later undergoes implantation of an implantable cardiac defibrillator (ICD) as secondary prevention against future sudden cardiac arrest.

Fast forward just three months later.

Yesterday, England's soccer team reached the quarter finals of soccer's World Cup tournament against Italy.  In a hard-fought match, time ran out after 90 minutes of play with the score tied 0-0.  To advance to the semi-final match, a shoot-out must decide the victor. 

The air is tense.  The world watches in anticipation.  Mr. Muamba, also watching it all, can only sit and watch as his country's players take the field.  So what does he do?

He sends a Tweet containing a joke and a picture of his remote monitoring device for his ICD:

https://twitter.com/fmuamba/status/217002769578590208/photo/1

(No, the device pictured does not "charge" his ICD)

It was the humorous mark of a champion who is indeed happy to be alive.  Sadly, England lost to Italy in the shootout and although we have yet to learn if Mr. Muamba required the use of his device yesterday as a result, we certainly learned a lot about the character of the man and the remarkable efforts of the medical team who made this remarkable story possible.

-Wes

h/t: C.G., a faithful reader.

Tough Guy Does CPR Hard and Fast

While it might not be quite as funny as the Portugese Cardiology Foundation's Big Belly People video which takes a stab at the obesity epidemic, the British Heart Foundation does a pretty good job getting the "hard and fast" message out for "hands-only CPR" using British tough-guy Vinnie Jones in its new TV ad:



Heh.

-Wes

Knowing When to Quit CPR

... using capnography:

White says that before the use of capnography, the only way of assessing blood flow to vital organs was by feeling for a pulse or by looking for dilated pupils. He says those methods are very crude and can fail. Snitzer never had a pulse despite good carbon dioxide readings. Without the information from capnography, he says it would have been reasonable to stop CPR — and Snitzer would have likely died.

"The lesson that I certainly learn from this is you don't quit, you keep trying to stop that rhythm as long as you have objective, measurable evidence that the patient's brain is being protected by adequate blood flow as determined by the capnographic data," says White.

-Wes

How to Catch a Perp

... thank him for saving someone's life:

"He administered CPR until paramedics arrived and then left. We just want to identify him and thank him. It's nice to know that people are there to help."

Police released a photo of the man in the store.

But Wright said the man "also committed a crime at this convenience store, but we . . are not releasing any of this information at this time."

Gee, I wonder if he'll step forward...

-Wes

Super Sexy (Adult) CPR

Employment Alert: While there is no frank nudity, viewing video might be best done after hours.

Although this ad for lingerie might not be sanctioned by the American Heart Association, I'll bet you'll never forget CPR after seeing it:



Yeah, I know: I'm a dog. And the ad doesn't use the latest no-breath CPR technique.

Still, you have to admit...

... it beats the heck out of the Bee Gees...

-Wes

Can a Website Teach CPR?

The American Heart Association, in conjunction with a $1 million dollar grant from the Medtronic Foundation, thinks it can, especially if schools can win a thousand bucks for their effort promoting the idea:

Through the Be the Beat campaign, the Medtronic Foundation is providing $1,000 grants for school staff to help fund CPR and AED training outreach programs within their school or community. The deadline for application is January 15, 2010. More information is available in the “Teachers and Administration” section of the Be the Beat Web site, BetheBeat.heart.org/schools.

BetheBeat.heart.org engages 12- to 15-year-olds to learn the basics of cardiopulmonary resuscitation (CPR) and how to use an automated external defibrillator (AED) through interactive games, videos and songs on the Web.

Sadly, the music selections that play at 100 beats/minute, (like "Stayin' Alive" and "Another One Bites the Dust") aren't available for download, but a expanded list of songs that play at that rate is included. Songs like U2's "I Still Haven’t Found What I’m Looking For" or Simon and Garfunkle's "Cecilia" (yep, "Celilia, you're breakin' my heart, I'm down on my knees, beggin' you please, to come home, to come home!" made the list. This alone is sure to be a source of endless entertainment, though I'm not sure about the appropriateness of singing ABBA's "Dancin' Queen" during CPR...)

And while the games kids are expected to play on the website are right up there in challenge level with the first iteration of "Pong," the concept of getting a broader, younger demographic to even think thirty seconds about CPR and how to use an AED is a novel one.

-Wes

A New iPhone App for CPR

Yeah, it's out. But $3.99? Hardly a way to promote wide distribution.

But then, I wonder if it plays "Stayin' Alive" for you, or lets you switch to "Another One Bites the Dust?"

-Wes

Doping Doctors

It's a move that will make even Major League Baseball's Roger Clemens and Andy Pettitte take pause: doping doctors.

It seems there is a "crisis" afoot in America's hospitals: in-hospital cardiac arrests. According to the American Heart Association (AHA)'s National Registry of Cardiopulmonary Resuscitation (NRCPR) investigators and now rocketed to the media to increase the fear factor:

In-hospital cardiac arrest is a major public health problem. During 2005 and 2006, more than 21 000 in-hospital cardiac arrests were reported to the AHA NRCPR from approximately 10% of the hospitals in the United States. The principal finding of this study was that survival to discharge following in-hospital cardiac arrest was lower during nights and weekends compared with day/evening times on weekdays, even after accounting for many potentially confounding patient, arrest event, and hospital factors.

In an amazing move to justify their existence, the investigators' cardiac arrest database has identified the obvious: hospital wards staffed by the lowest numbers of individuals who have received the short-straw of night and weekend duty because of their junior status have poorer outcomes during cardiac arrests.

Well no kidding, ace. We needed a study to show this?

It seems so. Bureaucrats need to find things to "improve" in their ever-expanding quest to raise the cost of providing healthcare to our sick and injured while securing their fitful place in the Quality Assurance Hall of Fame.

But what was truly scary is not the problem; it was their solution proposed to fix this "major public health problem:"

Night staff proficiency in cardiac resuscitation could be enhanced by additional training, such as "mock codes" and cardiac resuscitation simulation training. Chronobiologic scheduling, naps, or use of medications such as modafinil may also improve nighttime staff performance.

That's right. Dope the doctors and the nurses.

These investigators, at a loss to offer concrete staffing solutions, feel the use of drugs is the way to go. They reference two other studies: one in ER doctors and the other from sleep researchers touting the benefits of modafinil. Never mind that this drug prevents fitful sleep. It seems there is a move afoot amongst our clipboard-carrying colleagues to promote performance-enhancing drugs as a means to improve physician and nursing performance in all sorts of arenas.

I can see it now: George Mitchell will soon be hired by the hospitals' Bud Selig look-alike, Richard Umbdenstock, president and CEO of the American Hospital Association. Patients will be aghast at the findings. News media lights will shine. The scandal will be exposed. Performance enhancing drugs will "sully" the very game that is healthcare today. Doctors will be called before Congress, or worse: called to the witness stand to explain their drug-seeking behaviour to a jury of their peers.

Ridiculous, you say?

Not really. It is a sad commentary that there are really bozo's who think that the use of drugs should be condoned to improve outcomes in cardiac arrest.

That, my friends, makes my heart stop.

-Wes

California Chiropractors: Anesthesia Without CPR Training

Amazing that California's Board of Chiropractic Examiners recently adopted a resolution (supported by a defensive news release) stating that "manipulation under anesthesia" falls under a chiropractic's scope of service, while also recently abandoning the requirement for doctors of Chiropractic in California to train in CPR:

“Repeal of Section 356.1, Cardiopulmonary Resuscitation (CPR) Requirement For Doctors of Chiropractic: The Board of Chiropractic Examiners repealed section 356.1, which required Doctors of Chiropractic to maintain current certification in Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) from the American Red Cross, American Heart Association, or “other associations approved by the Board.” The Board no longer requires CPR/BLS certification for applicants and renewals beginning May 1, 2007.”

Anesthesia without CPR training?

"Houston, we have a problem."

If I was Governor Schwartzenegger, I'd think twice about leaving a link to my website on their home page!

-Wes

Hat tip: a faithful reader.

CPR: Bag the Breathing?

The ABC's of cardiopulmonary resusitation (CPR) might get scrambled: instead of "airway-breathing-circulation" as the cornerstone of CPR, maybe we should think "compression, compression, compression" and bag the breathing:

Ken Nagao of Surugadai Nihon University Hospital in Tokyo and colleagues compared how well more than 4,000 adults fared after receiving traditional CPR, the chest-compressions only approach, or no CPR at all until paramedics arrived.

Patients who received only chest compressions had less brain damage than those who got compressions and breaths, the team reported in Saturday's issue of the medical journal The Lancet. Not surprisingly, patients who had no CPR had the poorest outcomes.

The researchers suspect breaths may be detrimental if there is only one person performing CPR, because the mouth-to-mouth breathing takes precious time away from chest compressions that bring blood to the heart and brain.

-Wes

Reference: Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study. The Lancet 2007; 369:920-926. DOI:10.1016/S0140-6736(07)60451-6

In Cardiac Arrest, Higher Defibrillation Energies Are Better

Take any drug, give more of it, then usually you’ll see a bigger physiologic response. Most of us in medical school knew this as a dose-response curve.

As a cardiac electrophysiologist, I have always been interested (but never had the patience to test) why the American Heart Association’s guidelines were always suggesting “start low and work your way up” with defibrillation (shock) energies when a patient has the life-threatening heart rhythm disturbance, ventricular fibrillation. During ventricular fibrillation, the heart is only barely quivering and generates no effective cardiac output or blood pressure. Time is of the essence when correcting this arrhythmia to improve patient survival: without cardiopulmonary resuscitation (CPR) during ventricular fibrillation, irreversible brain injury can begin in just four to five minutes.

So it was refreshing to see the results of the effectiveness of out-of-hospital defibrillation with two different energy regimens tested side-by-side by Canadian researchers in this month’s Circulation. They compared fixed lower (150J-150J-150J) defibrillation versus higher escalating doses of defibrillation (200J-300J-360J) in 221 patients requiring more than one shock with a biphasic defibrillator during out-of-hospital cardiac arrest. Their results were predictable: higher energies work better. Much better. 25% vs. 37% better (p<0.035).

The dose-response curve held true: improved success was seen when higher defibrillation energies were applied.

Now the question becomes, why not just start delivering shocks at the maximum output of the defibrillators during cardiac arrest? If a 10% improvement was seen with escalating doses of defibrillation, could additional success be identified using a fixed maximum defibrillation energy? In animals, it has been demonstrated that ventricular fibrillation in the setting of acute ischemia (lack of blood flow to the heart) requires higher energies to achieve successful defibrillation than non-ischemic ventricular fibrillation.

I guess we’ll have to wait for another study for my answer. But for now, dial up those defibrillators when shocking ventricular fibrillation.

-Wes

On the Value of CPR

A truly inspiring story about the value of cardiopulmonary resuscitation (CPR):

"I noticed everybody was standing around him and he was just laying there dead on the floor and nobody was doing anything," DeYoung said. That's when instinct took over for DeYoung, who gets annual CPR training for his Statesville job.

"I don't even remember walking over to him," he said. "I just remember being next to him and starting to do chest compressions."

Meanwhile, a bystander had pulled Edwina away from the blackjack table and pointed to her husband. She rushed over and time seemed to slow down as she saw DeYoung begin CPR.

"It was very surreal, like my own out-of-body experience," Edwina said.

As the scene unfolded, Edwina remembers with crystal clarity that a woman, another partygoer, took a deep breath and said, "Oh my God, it's me" before joining DeYoung at Hal Cowell's side.

The woman was Nancy Flitcraft, who had her own slow motion moment in the instant after Cowell collapsed.

She immediately thought back to the day in 2000 when she and her husband tried to revive a 7-year-old boy who had suffocated in an accident. Flitcraft, a nurse who had performed CPR before on several occasions, had given her husband hurried instructions as they worked over the boy's body, but it was too late. He was gone.

Flitcraft hadn't done CPR since the boy died. Her family had spent years trying to work through their sadness about witnessing the accident and not being able to help. But in the few moments after Cowell collapsed, instinct took over for her, as well.

It's amazing how many people were at this fundraiser, but how few knew (or were willing to acknowledge their knowledge of) CPR.

Although I've seen lots of stories about cardiovascular "saves," this one struck home - perhaps because of Ms. Flitcraft's prior experience with a 7 year old boy. Read the article to see how this story ended.

-Wes

Addendum: Time is of the essence: time to CPR, time to defibrillation, and the time needed to administer advanced cardiac life support (ACLS).

New CPR Guidelines - Better?

Boy, I'm not sure I agree with the new recommendations put forth today by the American Heart Association regarding more manual compressions before delivering a defibrillation during Cardiopulmonary Resuscitation (CPR):

The old guidelines called for repeated shocks along with a pulse check before administering CPR. The new way endorses a single shock followed by two minutes of CPR, the Heart Association said.

In the EP lab where we witness cardiac arrest and all of its excitement first-hand, there is NO QUESTION that early defibrillation works. I have had times where one shock is not enough to resuscitate a patient in our lab setting. If I stopped to first perform CPR before shocking one of my patients during witnessed cardiac arrest, I am sure we would have a higher complication rate in our laboratory. Many of our patients have ischemic coronary disease, and when the heart fibrillates, no effective blood flow is pumped from the heart, cuasing it to be more susceptible to ventricular fibrillation, not less.

I suppose in patients who have collapsed for a while, there might be logic in the AHA's recommendations - circulate a bit of oxygenated blood to the heart first, then try shocking. But certainly in witnessed cardiac arrest, I'm going to shock them more than once every time.

-Wes