If you have heard about the incredible story of the man who survived a cardiac arrest in part by receiving 96 minutes of cardiopulmonary resuscitation (CPR), you might be wondering how I feel now about our position on termination of resuscitation/stopping CPR after 30 minutes or if I have second thoughts about the comments I made in a recent blog on protocol recognition and another on starting and stopping CPR.
First, if you are unfamiliar with the story, check out some articles online. from USA Today is pretty good. If you want more detail and you have the time, check out the unedited interview with Dr Roger White below. He was the physician who advised the practitioners in the field and also attended to the patient in hospital. In it he talks in great detail and even shows printouts from the monitors used during the resuscitation.
Essentially, a 54 yo man had a witnessed cardiac arrest in a small town in Minnesota (MN). CPR was started promptly and was continued by “dozens” of locals, all taking turns in shifts. They defibrillated him 6 times. An advanced life support (ALS) team arrived at about 40 minutes into the resuscitation. They intubated him (placed a breathing tube for ventilations), gave IV drugs and defibrillated him 6 more times. Defibrillation established a regular rhythm for very brief periods of time after some of the ALS shocks. It wasn’t until he was given a large, out of protocol, repeat dose of the anti-dysrhythmic amiodarone that he remained in a rhythm that produced a sustained pulse. He was then transported the 30+miles to Rochester, MN, for a heart catheterization and other treatment. He left the hospital after 10 days feeling tired and sore but apparently with his intellect and other body functions intact.
Dr. White admitted that he and the ALS crew questioned the wisdom of continuing in the face of the recalcitrant dysrhythmia. In the end they chose to continue in large part because they were able to confirm the continuous production of carbon dioxide via one of their monitors. In essence, this indicated that the CPR was effectively perfusing the lungs, evidenced by the measurable amount of carbon dioxide produced there. This indirect measure of global perfusion gave them hope and thus made it hard to stop.
This gentleman survived because of an extraordinary confluence of circumstances and people, including the online, real-time advice from a “…leading expert in cardiac arrest…” Take any one or more of those away and the result would have been different. Most if not all of the capabilities described would be unavailable and/or unrealistic in a wilderness or remote setting in a harsh environment. This was the quintessential chain of survival.
Bottom line: As amazing as this story is, our CPR protocol still makes sense.
This resuscitation demonstrates that good quality CPR can make a difference. However, maintaining good quality CPR is not simple. Fatigue would have set in much more quickly for a significantly smaller crew. CPR quality and therefore perfusion worsen with rescuer fatigue and maintenance of perfusion is what gave him a chance. Fatigue in a remote and harsh environment can also put rescuers at risk. And this success took more than good quality CPR. Even the AED proved to be of little use without more advanced capabilities. In the end, the experienced practitioners involved are not sure how or why they succeeded.
Remember too, this was caused by a heart attack with a potentially fixable rhythm and not from trauma or a prolonged submersion.