other people's emergencies: random thoughts of an urban paramedic

For more than twenty years I've worked as a paramedic for the city of Boston, Massachusetts. The opinions expressed in this diary are mine alone, and do not represent the views of Boston EMS. Names, dates, locations, and physical characteristics have been changed to ensure patient confidentiality.

Friday, May 01, 2009

Winning the Battle, Losing the War

The inhaler said it all.

It lay there on the carpet, just a couple of inches from the patient's outstretched hand, right where it had fallen when he collapsed during his asthma attack. It was supposed to keep him alive, to open the bronchial passages and allow him to breathe. But it was too late. First he'd stopped breathing, and then his heart had stopped, and now a firefighter was pumping on his chest, while an EMT forced oxygen into his mouth and nose.

My partner hooked him to a cardiac monitor. The EKG looked surprisingly good. "Somebody check for a pulse," my partner said. Hands reached for the man's neck and arms. "I've got one," said one of the EMTs. "It's fast, but I can definitely feel it."

As if on cue, the patient took a deep breath. Then another. Soon he was breathing deeply and regularly. One moment he'd been dead, and the next he'd come back to life.

This doesn't happen often. Producers of movies and television shows would have you believe that CPR can save almost anyone. A character collapses, a hero performs CPR, and a few minutes later, the victim comes back to life, good as new.

But in real life, it doesn't work that way. Not without medications, anyway. CPR doesn't often bring people back from the dead. Its purpose, really, is to keep oxygen flowing through to the brain, to prevent neurological damage until the heart can be started again.

Sometimes that requires defibrillation. Sometimes, medications. But CPR alone almost never causes a silent heart to start beating again.

When the heart stops beating because of an oxygen shortage, however, and not because of a blood-clot-induced heart attack, CPR can make all the difference in the world. This is one of the few circumstances in which CPR can restore a heartbeat without any other intervention. And that's what seemed to happen this time. The patient had suffered an asthma attack, and when his heart ran out of oxygen, it stopped beating. Once the flow of oxygen was restored, the heart started beating again, giving him blood pressure and a pulse.

We lifted him to the stretcher and wheeled him out to the ambulance. He was breathing quite well by this time, though his eyes remained closed and he made no attempt to move. This troubled us. The problem had been corrected, and he hadn't been in cardiac arrest for more than a few minutes. Why wasn't he waking up?

His condition didn't change on the way to the hospital. Every so often I'd squeeze his fingertip, hoping to elicit a response to the pain. But the man never flinched. His heart was alive, but we couldn't be too sure about his brain.

"Maybe he's got a bleed," my partner said as we brought him into the emergency department. "The way he's breathing, he looks like somebody bleeding into his head. There's something about his breathing that looks like a neurological problem. If they do a CT on him, I'll bet they find a bunch of blood in his brain."

I had to admit that he was breathing like patients I've seen with ruptured aneurisms. It's funny, but after you treat enough critically sick and injured patients, you begin to identify certain conditions more through hunches than anything else. And most of the time, those hunches prove correct.

This time, though, it really didn't matter. The man had died, and we'd brought him back to life. Maybe it was a ruptured aneurism that was preventing him from waking up, or maybe he'd suffered permanent brain damage during the brief period of cardiac arrest.

But who really cares? Nobody's going to care about the cause if he spends the next forty years in a nursing home somewhere, existing in a vegetative state. His family won't care, and the patient certainly won't care. It's not the heartbeat that matters, but the brain function.

Because if we bring him back to life, but he never wakes up again, then we've won the battle, but lost the war.

15 Comments:

Anonymous Anonymous said...

Great piece, TS. CPR is one of those things that are a must however. I'm amazed at how many people lack that basic knowledge.

CPR may not save everybody, it might not save 1/3, but as the old saying goes, it's better to win some of the time than to not try at all.

Matt

12:40 PM  
Blogger TS said...

Thanks, Matt.

1:37 PM  
Blogger mommy-medic said...

Just found your blog- Thanks for all the good reads! Off to bookmark...

7:50 PM  
Blogger TS said...

Glad you like it!

10:30 PM  
OpenID medicblog999 said...

Interesting post TS, did you manage to follow up and find out what happened to him?

5:38 AM  
Blogger TS said...

He was admitted. Unfortunately, that's all we could learn. Boston EMS has a nurse who follows up with the hospitals on all cardiac arrests, however, and evantually she'll be able to tell me the end result.

6:34 AM  
Anonymous Anonymous said...

TS,

Once you EMS liaison RN finds out what happened, could you posr that in this section?

Thanks!

9:51 AM  
Blogger TS said...

I will.

9:26 PM  
Anonymous Jeff said...

We have a very safe community with a very large elderly pop., so an outright "save" seems wishful. I've never had a successful CPR but I have gotten pulses back long enough for family to say goodbye, and the few times it's happened it has meant a lot to the family. Gives me another reason to keep those compressions deep and quick when it looks like a lost cause.

1:56 PM  
Blogger TS said...

Jeff:

Great point. Thanks.

9:50 PM  
Anonymous Joy said...

Did you hear about the nurse who died after giving CPR? She was at a softball game and the coach collapsed. She administrated CPR and he was revived and is doing alright.

But the nurse fell to the ground right after she stood up, was rushed to the hospital but died in route. This was in Santa Clara, CA and here is a link.

http://www.channel3000.com/news/19341850/detail.html

How sad but I am glad the coach is alright.

10:46 PM  
Blogger TS said...

Joy:

That's just bizarre. Thanks for passing it along.

9:33 AM  
Anonymous Joy said...

Have you ever heard of this happening?

I mean, I've never heard of someone dying after doing CPR. Of course there must of been an underlining problem, undetected before this happening.

12:14 AM  
Blogger man-nurse said...

I still remember when dawned on me, before my career, that CPR is not even really meant to save people, but rather to preserve for further action.

I agree about the breathing patterns. I don't often get a morning report as a tech in the ICU, but just hearing someone's breathing already gives me a feeling about whether we're dealing with a brain bleed or infarct. And then there's all the people blowing off CO2 or whose obstructive apnea comes out after sedation.

We kind of blew off (pun intended) breathing pattern assessment in our nursing assessment class, since it doesn't seem as important as auscultation, but I think it should be emphasized a little more.

5:50 PM  
Blogger TS said...

Man-Nurse:

Great points. Thanks.

11:21 PM  

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