
When Not To Quit: Man Revived After 96 Minutes - raleec
http://m.npr.org/news/front/139670971?singlePage=true
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Pyrodogg
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.

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JshWright
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.

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d2
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."

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

~~~
relix
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.

~~~
jhamburger
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.

~~~
chc
But what's the expectation of lives lost due to late emergency crews?

~~~
ohashi
I wonder how overburned most areas are? I had a friend who was an EMT and said
they really liked being called (didn't get the impression they were that busy)
because it was far better to be safe than sorry and people were often too
hesitant about calling for emergency services.

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stretchwithme
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 :-)

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csomar
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.

~~~
Hoff
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.

~~~
goatforce5
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.

~~~
JshWright
I'm not sure what they meant by "more paperwork," but in most locations,
working an arrest will result in a whole lot more paperwork than simply
calling it in the field. All interventions (intubation, IV access,
medications, defibrillation attempts, etc) have to be documented (who did it,
when they did it, etc).

That's a whole lot more paperwork than "Confirmed asystole in 3 leads, see
attached strip"

~~~
goatforce5
I don't know. They might have just been hamming it up for the benefit of the
story. Those guys all have a seemingly weird attitude towards death, often
appearing somewhat blasé about it. They can't take things too personally when
someone dies while they're working on them.

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.

~~~
JshWright
I actually do both. I'm a freelance developer, as well as a Firefighter/EMT
(currently working on my paramedic certification).

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.

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troymc
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?

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yarone
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_
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).

~~~
sp332
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...](http://en.wikipedia.org/wiki/File:Heart_diagram_blood_flow_en.svg)

~~~
pygy_
Indeed, the valves must be in working order, and there must be enough blood in
the vessels to close the circuit and prime the pump. I don't know if it was
confirmed, but while I was a student, there were strong suspicions that blood
in the whole thorax (pulmonary circulation), not only in the heart,
contributed to the assisted flow.

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.

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sidwyn
Non-mobile version here: [http://www.npr.org/2011/08/22/139670971/when-not-to-
quit-man...](http://www.npr.org/2011/08/22/139670971/when-not-to-quit-man-
revived-after-96-minutes)

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Alex3917
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.

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

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

~~~
raleec
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.

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maeon3
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.

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mv
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
Says someone who is almost certainly not 95 yet.

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

~~~
mv
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...](http://www.sciencedirect.com/science/article/pii/S0196064498700319)

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...](http://www.sciencedirect.com/science/article/pii/S0300957203002156)

