A day and a night in the CCU -- out-of-hospital cardiac arrest

In the evening, we were called from the ER to say that the ambulance was bringing in an "out-of-hospital cardiac arrest". What does that phrase mean to us? To give you an idea, I quote from a review article:

"The circumstances of cardiopulmonary resuscitation (CPR) can affect prognosis after a cardiac arrest in terms of both survival and quality of life. In one study of out of hospital cardiac arrest, 44 percent of patients receiving CPR survived initially, 30 percent were alive at 24 hours, 13 percent at one month, and only 6 percent were alive after 6 months. The duration of CPR significantly correlated with outcome; no patient who required more than 15 minutes of CPR survived more than 6 weeks. (Bereke et al, 1997).

This 70-something lady had spent the day shopping with her daughter, after enjoying a good breakfast. In the evening, she went to visit her husband who was recently transferred to a nursing home because of severe dementia. The two of them were visiting in his room. There was no one else there at the time. What happened next is surmised from the stories of others. The nurse and CNAs at the desk heard the nursing home resident room alarm go off. Apparently, this alarm is triggered to go off when the resident moves his back away from the chair. At first, since they knew his wife was in the room with him at the time, they thought she would help him.

When the alarm did not stop, they went to the room to check up on him. They found him leaned forward in his chair trying to hold up his wife who it appeared, had passed out. They could detect no pulse. The woman was put on the floor and the nurse and CNAs began CPR while someone called for the ambulance. The ambulance techs arrived and hooked up to an AED (Automated External Defibrillator), which advised a shock to the patient. Over the next 40 minutes during which CPR was continued, the patient was shocked again en route to the hospital. By the time she got to the ER, she was intubated, on a ventilator, but her heart was beating on its own. The ER doc was relieved to hand me the chart and the patient as she placed a hand on my shoulder and said "Good luck!"

We moved the patient to the unit (CCU) and got her stabilized. During the course of a very long night, she began to have tonic-clonic seizures. I had the responsibility of talking with the family and explaining the dismal outcome we expected, given this ominous sign of anoxic brain injury.

Last night, I had to have similar conversations with two different sets of families. In both cases, I was telling children of the patients that their mother was not expected to survive, although they were alive at the time. I had to explain that although their heart was beating and the ventilator was helping them breathe, they would never be the same. The patients in both cases were unresponsive. There was a strong possibility of severe injury to the brain from the lack of oxygen in the time it took to rescucitate them.

You know, some nights, after a conversation like that, I am actually grateful if my pager goes off and I can leave to the next emergency where I have to focus on a task at hand and not think about the meaning of the conversation I have just had.

A single event like what happened to this patient can change one's life for ever -- even end it all. And such an event is not predictable, although its occurence may be inevitable in the setting of some kinds of heart disease. Bottom-line: carpe diem -- seize the day!

Addendum, next afternoon:

I visited the CCU to find out how the patient was doing. I was informed that given the poor prognosis and predicted quality of life, the family chose to withdraw support. That meant stopping the ventilator. The patient died shortly after that was done.