When Not To Quit: Man Revived After 96 Minutes

http://m.npr.org/news/front/139670971?singlePage=true

by raleec • 15 years ago

276 61 15 years ago

m.npr.org

raleec2• 15 years ago

My first thought is how many people were abandoned because of a reliance on the incomplete picture that the old tech bundle provided.

relix• 15 years ago

I like to believe this would be less than 1%. Medicine is science, and I hope while designing modern CPR guidelines they did tests to see if pursuing CPR even while all signs suggest death, for long periods of time, would revive more people.

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.

rokhayakebe2• 15 years ago

Then they probably had...increasing the probability of survival of those due to faster response times.

This is the problem; today everything is a cost/benefit analysis.

jhamburger• 15 years ago

Given those numbers, you'd have a statistical expectation of one life saved for every 150 hours spent. Say $100/hr for salaries+bennies for two parametics, 15K per life saved. I think it's worth it.

bh42222• 15 years ago

I like to believe this would be less than 1%.

But unfortunately medical errors kill a lot of people: http://www.bbraunusa.com/index-A3866CA8D0B759A1E395A615A2C00...

bahman2000• 15 years ago

Medicine is science and as such is always evolving.

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.

pointernil• 15 years ago

.) Well, yes the new method is better than the prev. tech available, still it is as well only providing an estimate of the true situation... so, not all of the prev. abandoned ppl had a 100% chance to recover as in the described case.

.) 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

gaius• 15 years ago

Well, I just refreshed my EFR cert, and can tell you that the official statistic is that only 5% of those requiring CPR survive, and that's what all the assumptions are based on.

yarone• 15 years ago

It seems that his heart was beating, although irregularly to a degree that they couldn't detect a pulse. Is the article saying that estimating the CO2 output via this new method is a more modern / sensitive way of detecting a pulse?

pygy_2• 15 years ago

No, it detects the release of CO_2 from the blood to the pulmonary alveoli.

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).

sp3322• 15 years ago

Well, the heart still has to be in more-or-less the right "shape", right? If the valves are messed up, blood won't circulate through the lungs and back to the organs properly. http://en.wikipedia.org/wiki/File:Heart_diagram_blood_flow_e...

derwildemomo• 15 years ago

the most common phenomena that leads to that kind of heart activity without any actual pumping result is a ventricular fibrillation, which looks like this: http://www.ecglibrary.com/ecgs/VFNORWCH.gif, compared to a regular rhythm looking like http://www.grundkurs-ekg.de/definition/ekg1_neu.jpg. This is ( likely ) the underlying problem. What's described here is the fact that the medical personel was able to determine whether their actions ( CPR ) where effective enough to maintain blood circulation. there are, of course other metrics, like o2-saturation levels etc, but this one seems to be especially suitable.

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.

masklinn• 15 years ago

> Is the article saying that estimating the CO2 output via this new method is a more modern / sensitive way of detecting a pulse?

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.

csomar3• 15 years ago

There is an important thing missing: In order to prove that someone is dead, you must do electroencephalography. This will detect the brain electric charges. Normally, since the patient isn't dead, there will be brain pulses, which will prove he is alive.

carbocation• 15 years ago

In which country is it required that a physician perform an EEG prior to declaring death?

csomar3• 15 years ago

I don't know. I'm a medical student in Tunisia. Here, in order to claim that a patient is dead you need to show its' EEG graph. Well, what's happening is something else.

sp3322• 15 years ago

Maybe when the person is already on life support, and you're trying to make a decision about whether the person is "dead" even if most of their organs are alive.

typicalrunt• 15 years ago

Then what about the wave of death [1] that happens to people? The body can still release pent up energy well after brain death, but it doesn't necessarily mean the person can be brought back to life.

[1] http://news.discovery.com/human/near-death-brain.html

csomar3• 15 years ago

The wave described in this article is actually atypical brain activity. This confirm that the brain is unstable and the person may be facing his last minutes. This actually make the EEG more precise.

Hoff2• 15 years ago

There are differences among the laws and norms of local and national jurisdictions, and among pre-hospital and hospital providers.

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.

goatforce52• 15 years ago

I've had paramedics tell me they'll go beyond what the protocols say to try to resuscitate people because they won't the extra paperwork involved in dealing with a death.

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.

Shorel• 15 years ago

You are talking about current laws and procedures, designed with decades-old knowledge in mind.

This new finding should influence laws and procedures in the future.

Pyrodogg• 15 years ago

I know that this article is mostly about the medical tech related to this case but I still get a warm fuzzy feeling knowing this happened in my hometown; that it was a crew of volunteer firemen and others that kept the vital CPR going for 96 minutes.

I hope the new technology makes it into the hands of EMTs quickly so that more lives can be saved.

Alex3917• 15 years ago

Every time I get my VO2 max taken I feel like I'm dying anyway, so this is only a fitting use of the technology.

thedjpetersen• 15 years ago

I don't know if anyone else noticed this but when I see '==' I think comparison not assignment.

takeoutweight• 15 years ago

It really should be logical implication '⇒', shouldn't it.

raleec2• 15 years ago

This. I'm usually pretty pedantic about this sort of thing, but don't submit very often, and wasn't aware of the 80 char limit. Forced to pare a more descriptive headline and get back to work, I made a mistake.

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.

cmontgomeryb• 15 years ago

I think that was the intention: (tech == man revived) returns true :)

celoyd• 15 years ago

I don’t think it does.

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”.

JshWright4• 15 years ago

Capnography is actually required for all intubated patients in many areas (and intubation is a standard step in the management of pre-hospital cardiac arrest patients). This is because (properly interpreted) capnography is one of the most definite ways to verify that the ET tube is headed for the lungs, not the stomach.

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.

sidwyn• 15 years ago

Non-mobile version here: http://www.npr.org/2011/08/22/139670971/when-not-to-quit-man...

mv2• 15 years ago

ugh. This is exactly what drives up the cost of medicine. People hear crap like this, and then come in demanding that 'everything be done' for their 95 yo grandmother in a coma in the ICU. Sadly technology can keep this type of person 'alive' for a very long time. Expensive, wasteful, selfish.

Medicine needs to send truthful messages about what can and can't be done.

JoshTriplett• 15 years ago

Says someone who is almost certainly not 95 yet.

Expensive? Probably. "Wasteful"? "Selfish"? Not your call, thankfully.

mv2• 15 years ago

You misunderstand, it isn't selfish to want it for yourself, but it is selfish to keep someone else alive in a vegetative state. It is so easy to choose 'life' as the correct and right thing when in fact 'death' is the natural and moral thing. Society needs to think about their end of life plans. If your plan is to be fed through IVs, have a foley, breath through a machine, have a butt tube, and foley catheter in for the last 10 years of your life be my guest. Just please don't use any of my tax dollars for that! The sad thing is most people don't chose this for themselves, instead they have a stroke or suffer another handicap and while they are unable to make decisions (probably unable forever) the family chants 'do everything you can'! Medicine can do a lot, but mostly at the end of life it just prolongs misery.

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...

troymc• 15 years ago

Does this mean that the "Flatline" (See http://tvtropes.org/pmwiki/pmwiki.php/Main/Flatline ) will have to be relegated to TV and movie history?

d2• 15 years ago

My favorite paragraph:

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."

stretchwithme• 15 years ago

That is a fantastic use of technology.

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 :-)

maeon3• 15 years ago

Imagine all the people that could have been saved if only the doctors knew what action to take. I imagine people stuck in a coma, listening to everything going on around them saying: "keep doing what you were doing, it is working", and instead watching them decide to give up.

When Not To Quit: Man Revived After 96 Minutes

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