When Not To Quit: Man Revived After 96 Minutes
m.npr.org
m.npr.org
I hope the new technology makes it into the hands of EMTs quickly so that more lives can be saved.
Given the increasing prevalence of capnography use in the field, I expect the next few years will see several studies into how it could be used to improve patient outcomes.
The nurse "called the emergency room doctor, who told him that I was dead and that they should walk away," says Snitzer. "And he hung up and he said to the rest of the people in the room, 'Is anyone else here uncomfortable with walking away from this?' And they all said yes. And it was at that point that he called Dr. White."
Then they probably had to make a key decision between keeping an emergency team busy for 90 minutes for every case where death was probable, just in case there's that less-than-1% chance of revival, or dismissing the team and freeing the resources for patients who have a higher probability of survival, and increasing the probability of survival of those due to faster response times.
This is the problem; today everything is a cost/benefit analysis.
This seems like a very grim economic calculus, but following a disaster or disease epidemic doctors must make such decisions many times a day, sometimes with only minutes to evaluate patients. Likewise, those who run hospitals (especially public hospitals) have to balance the probability of a successful outcome against the cost of leaving other patients untreated.
The problem with applying linear mathematics to human issues is that it's a gross oversimplification of a complex problem. Couple that with the relative weight of values (i.e. every person placing a different value on life) and it's clear that rather than being a more objective measure, it is in fact firmly grounded in subjectivity. I think that the objective illusion only serves to calm the conscience. A more objective and fair way of doing this, which also calms the conscience, would be to flip a coin.
The other issue is that the line of thinking you have described is the same one used to justify horrendous actions. Sacrificing someone who is seemingly less deserving of effort (again, by our completely subjective criteria) for someone more deserving is the logic used to justify locking people up in prisons, burning witches, gassing Jews, it's all the same - those "less deserving" are sacrificed for those who are "more deserving". And all that with a subjective metric.
I think that the root cause of this irrationality is that even the most rational people tend to miss the fact that perfecting one's logic is not enough. After that point, assumptions are everything. Logic is merely a tool for transforming one set of assumptions into another. If you use shit as the input, you'll get an equivalent output.
I'd rather live longer, with more friends and family who live longer, in the cost-benefit community.
I'd say the opposite [everything is NOT a cost/benefit analysis]. [As evidence of this,] We spend vast amounts of money prolonging the life of people who we know in advance are extremely unlikely to generate quantifiable benefit. How do you suppport what you've said [that everything is a cost/benefit analysis]? [The evidence shows your position to be incorrect, therefore my position that life is more valuable than cost/benefits indicate is true.]
This argument fails to show that when it comes down to it, there's more than one person and their associated who get affected by the decision to invest those resources. The benefits to one person come at the expense of another in current healthcare situations.
But unfortunately medical errors kill a lot of people: http://www.bbraunusa.com/index-A3866CA8D0B759A1E395A615A2C00...
I recently got certified in CPR and defibrillator use. Turns out that CPR guidelines keep changing as scientific research advances our knowledge of what is actually going on. One of the reasons why a first responder should keep getting re-certified every year or so.
.) Yes, it is fascinating to see how the emergency-medicine tech evolves over time... I mean, keeping a man "alive" for that long outside of a situation room, wow!
.) Plus: as always, the ppl actually handling those emergencies, deciding what to do on site. "Life over Death" with a clear head... wow^2
This is interesting: "Now, during good CPR, this is probably going to be around 25 — if you keep this up in that 25 range, then there's circulation still going on. ... That's where you're going to get a positive outcome,".
So essentially, if CPR is working, you don't need to die even if your heart and lungs aren't working on their own. CPR is doing their work well enough, for the moment anyway. If they keep at it all the way to the hospital, you may survive.
Of course, if you'd seen Lindsey brought back in Abyss, you'd already know this is possible :-)
Depending on local laws, US emergency services field providers usually don't officially declare legal death, though there are protocols for either not commencing or for ceasing resuscitation efforts.
These don't involve electroencephalography.
Factors input in this decision and these protocols vary, but can include evidence of insufficient structures for maintaining life (eg: decapitation), absence of vitals, rigor, lividity (blood pooling), absent electrocardiogram, rescuer exhaustion, and (for cases involving cardiac) failure of defibrillation and advanced cardiac life support where applicable. These factors are usually used in combinations; you need more than one of these, and no vitals.
Contraventions can include hypothermia, which may have been a factor in the cited case, and cold-water drowning.
Many of these cases can and do involve a consultation with the patient's physician, or with the emergency physician
Emergency transport of patients that are presumed dead is not without risks to members of the community and to the EMS crew; these can include vehicular collisions with emergency vehicles, as well as simply not the crew unavailable for another call. Funding also applies, as survival to discharge is (in various studies) not expected in cases where pre-hospital advanced cardiac life support (ACLS) has been administered, and has failed. (If ACLS didn't work in the field, it's equally unlikely to work after a five or fifteen or half-hour transport to an emergency facility.)
I'm not aware of any US emergency services field providers that are using electroencephalography for this nor any field equipment for this, nor even any discussions of its applicability in the field.
On the other hand, capnography has been a subject of various discussions for some years now among emergency physicians and hospitals and field providers, including its use for assessing correct placement of breathing tubes, and waveforms for differentiating various respiratory dysfunctions.
A paramedic I know failed to revive an elderly woman who'd collapsed at home. The rescue attempts were watched by the woman's (panicked) daughter, who was a nurse. The daughter later threatened to sue, saying he was negligent for not performing a procedure that she thought was necessary. Paramedic was called before some lawyers, at which point they found out he'd actually done a lot more than protocol had required in those circumstances, and the case was dropped.
Nice way to say thanks for trying to save your mom.
That's a whole lot more paperwork than "Confirmed asystole in 3 leads, see attached strip"
Me? I build websites. If something blows up it can always be fixed. New hardware can be bought. Back ups restored. Apart from some downtime, everything is as good as new.
Them? Turn up on a job not necessarily knowing what to expect. Some times they'll find a situation they can literally do nothing about and, oooops, someone's dead.
Someone dying in front of me is an incredibly bad day at the office i'll never forget. Watching people die as an emergency responder is kinda part of the job description.
The worlds aren't as far apart as you might think... While the stakes (and the pace) are obviously different, I think I enjoy both of them because of the challenge they present. My favorite part of the development process is troubleshooting (either new code or old... doesn't really matter). EMS is really all about troubleshooting. _Something_ is causing whatever this patient's issue is, I just need to figure out what it is and mitigate it to the best of my ability.
This new finding should influence laws and procedures in the future.
Death isn't a single nor simple event; it's a progression.
Hypothermia, for instance, has seen changes in training and protocols.
Changes in geriatric procedures and medicines, too.
Laws, too, change. Sometimes positively. Sometimes not.
Medical practice? That too changes.
These practices and these legal areas all tend to move slowly and sometimes seemingly too slowly, and with considerations beyond a single survival. With caution. Sometimes with consideration of the equipment costs, of patient outcomes, of training costs and a number of trade-offs all apply. Sometimes not.
One of the problems for emergency services can involve competing requirements for time and training. Various of the the "great ideas" that are around, and that become standards or sometimes legal requirements. Cases which involve training requirements for events or situations or patient conditions that field providers will likely never encounter, but for which training is required. Or cases where the same training has been repackaged by some other entity, mandated, and whole organizations has to go through what is effectively the same training all over again.
And then there are the inevitable politics.
If this stuff is running "correctly", it's based on evidence and on the needs of the local community. But it's all a compromise. It's sometimes messy. And everybody eventually dies.
Presence of CO_2 in the alveoli signs the presence of a blood flow, regardless of the nature of the pump (heart vs CPR).
If the blood flows, the organs (including the brain, which is the most sensitive to oxygen deprivation) are properly fed and viable (assuming CPR started soon enough).
Another fun fact: CPR is more efficient if you use a plunger to perform the chest compressions, because you can push and pull it, thus not only pumping blood out of the heart (through the arteries), but also actively sucking it back in (from the veins).
As a consequence, at the end of a cycle, there is more blood in the chest to be pumped out on the next one.
See http://www.ncbi.nlm.nih.gov/pubmed/21251705 for the details.
One note aside, it's not uncommon for a resuscitation to go on for 1 or even 2 hours, it depends on the circumstances, the patient, the medical situation and most importantly, the timespan that elapsed before cpr was first administered, which was obviously quite fast in this example.
No, it has nothing at all to do with a pulse. It has to do with a much better indicator: blood flow through organs.
The goal of compressions in CPR is to keep blood flowing so organs (especially the brain) can get "fresh" (oxygen-rich) blood and get rid of their CO2 buildup. Because blood "naturally" goes through the gas exchange of the lungs during its travels, CO2 output is a very good indicator of blood circulating correctly, and therefore internal organs having a chance.
As long as the CO2 output is good, the brain (and other organs, but mainly the brain) can be considered protected (alive) and the patient can be saved if whatever went wrong is fixed (generally the heart restarted or arrhythmia managed)
The problem of checking the pulse is that it's a very bad indicator of whether your compressions are working: it does not indicate anything about them, it just tells you if the heart is beating strong enough to generate a pulse. Even though CPR might be keeping the patient alive with a stopped heart.
It looks as though it's been replaced with the actual headline now anyway, though I don't think that highlights the most interesting part of the article.
If it did, then the LHS and RHS would be functionally identical, or nearly so. But they aren’t, because you can’t rewrite “New use of existing technology” to “man revived after 96 minutes w/out a pulse” in many contexts, or vice-versa, without a change in meaning.
English uses “is” for simple identity, but not as often as it uses it for other things.* Indiscriminately replacing “is” with “=” or “==” is usually only going to confuse any math or programming person trying to take it seriously. And if you don’t mean it to be taken seriously, using “==” for an equally long and much more ordinary word is just silly.
* For example, copula: http://en.wikipedia.org/wiki/Copula_(linguistics) . This is the form of “is” in “Denver is south of here”. Clearly Denver is not equal to to predicate of relative southernness, or I could say “San Diego is Denver”.
Medicine needs to send truthful messages about what can and can't be done.
Expensive? Probably. "Wasteful"? "Selfish"? Not your call, thankfully.
I routinely ask patients their 'code status' and articles like this give them false hope and false belief. Instead of: "do you want us to do cpr if your heart stops and/or intubate" ... I should be saying, "do you want your last dying moment to have someone beating on your chest breaking all your ribs while another person shoves a tube down your throat as you get pumped full of drugs."
You will never forget the first time you push on ribs and feel the crunch, watching the half-dead eyes look up at you as they live their last moments, and wondering if they are feeling their veins burn with drugs being pumped in.
Never mind that the article makes it sound like resuscitation efforts are grand. They aren't at all. The statistics are dismal.
Oh ACLS drugs? Yea, they don't really work to well... even as far back as 1998.. there are newer studies showing that ACLS training is helpful, but the actual drugs make little to no difference. http://www.sciencedirect.com/science/article/pii/S0196064498...
Less than 18% (!) requiring resuscitation survive to discharge. http://www.nejm.org/doi/full/10.1056/NEJMoa0810245 http://www.sciencedirect.com/science/article/pii/S0300957203...