Saleyha Ahsan

At the call of ‘cardiac arrest’, you swing into action – and try until all hope is gone

Posted by Dr Saleyha Ahsan on 1 February 2018 | 0 Comments

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‘Ten years on, no longer a wide-eyed foundation doctor but an emergency medicine registrar, I still get the same adrenaline surge, that same feeling of dread.’ Photograph: Alamy

 

Imagine trying to save someone whose heart has stopped. Cardiopulmonary resuscitation (CPR) with rescue breaths is being delivered to maintain essential oxygen flow to the brain. But the heart has not started beating on its own again. How long should the doctor carry on before “making the call”? When should they stop CPR and announce that life is no longer present in the body before them?

When Hickey, 63, went into cardiac arrest at home in June, his wife, Sue, started CPR with instructions from the 999 operator, buying essential time until the paramedics arrived. After almost an hour of resuscitation efforts, the decision was taken to stop, but Sue begged them to try one more time. Ten minutes later, his heart began to beat on its own again, and he was able to be evacuated to hospital. He is now back at home and living a normal life.

That’s the outcome every doctor hopes for, from the minute we place our hands on the chest of someone in cardiac arrest. I can’t tell you exactly how long we will spend trying to resuscitate a patient. No doctor can. There are too many variables.

One thing I can say about Chris Hickey, though, is that I am not surprised the doctor continued CPR after Hickey’s wife begged them to. CPR is often done with family present, so they can see that everything is being done to save their loved one. And the pleas of family members are not ignored.

I remember my own first cardiac arrest call as a foundation doctor, just after medical school. There I was with all the right kit, but full of uncertainty. It was messy, awkward, clumsy, fumbling – and then it was all over. The patient, an elderly woman with numerous medical problems, did not survive. You walk out of the room, straighten your scrubs and move on to the living.

Ten years on, no longer a wide-eyed foundation doctor but an emergency medicine registrar, I still get the same adrenaline surge, that same feeling of dread. Now, however, there is experience and focus, but you never lose that tightening of the stomach muscles the second you hear the call “cardiac arrest”.

No one walks into such a situation with a pre-set time frame in mind, although you do note timings carefully. You stay and work for as long as it is feasible that you might save someone’s life. The number of times CPR has resulted in saving a life is outnumbered by the times it didn’t. But it worked for some and they are still with us today. And that’s the point.

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 ‘Two years ago, however, this government cruelly blocked a bill that would have made it compulsory to teach first aid and life support in schools.’ Photograph: Justin Sullivan/Getty Images

I remember being on a night shift a couple of years ago. It was 7.30am, only half an hour to go before handover, and I was exhausted. It’s the early mornings when you’ve got to find that second wind, because come they will – the most sick, the dying and the desperate. This morning was no exception.

“Resus” was already busy when a man walked in with chest pain. Nurses obtained an urgent ECG and connected him to a monitor. I went into the cubicle to find the man looking worse. He was clutching his chest, clammy and beginning to look grey. He wanted to sit up and swing his legs around the side of the bed. He was getting agitated. That was a red flag. By 8am I had put out a “peri-arrest” call, which means summoning the cardiac arrest team early to try and stop a full-blown arrest.

And then he collapsed. The colour and life drained from him and he fell into my arms. I shouted for help and heaved his dead weight back onto the bed. I checked for a pulse. None.

The drill – instinctive and immediate – began. Hands clasped together on the chest, elbows straight, push down, repeat. The nurse placed a mask over his mouth and began to pump air into the lungs after my 30 compressions. The team ran in within minutes, although it felt like ages. Anaesthetists, medics, nurses. Suddenly there were 10 people around the bed.

A tube was placed down the patient’s throat to breathe for him and the acute life support protocol continued: cycles of heart-starting drugs, and electricity delivered via the defibrillator. We would repeatedly get a pulse after adrenaline, but it would tail off again and we would restart chest compressions.

The A&E consultant placed an ultrasound probe on the patient’s chest. She wasn’t absolutely sure, but there was a suggestion that the right side of his heart looked enlarged, hinting at a pulmonary embolism – a blood clot in the lungs. The team talked about the next step – should we give a blood-thinning agent, which would then commit us to CPR for a further 90 minutes? The answer was yes.

We had now been working on the patient for around 120 minutes. It was just before 10am. We continued resuscitation for another 90 minutes and got a pulse, but this time it didn’t tail off. Phone calls were made to the intensive therapy unit (ITU) to find him a bed.

At around 11.30am the family were brought in. I watched them as they sat around the bed, willing him to live. A machine was breathing for him. I have sent many patients to ITU after getting a pulse back, but only a few wake up. It becomes a place that gives families time and space to say goodbye, to decide on the next stage and to think about organ donation.

I remember the drive home – the tree-lined streets with their fine greenery making me appreciate life and its fragility. I thought of the family who, in the next few days, would have to start arranging the funeral.

Later that day, I called the department expecting to hear the worst. Instead I heard that he was still with us. Two days on, he was breathing for himself. He survived with only a small degree of kidney injury.

As I said before, there are many factors that influence how long you continue delivering CPR. But a key one is how quickly it was started. For Hickey and my patient, it was almost immediate. My patient won’t remember me, but I’m so glad he had his cardiac arrest in front of me. Had he collapsed elsewhere – at home, on the street, without immediate CPR – the outcome might have been very different.

It is vital that the moment someone goes into cardiac arrest compressions are started immediately. Survival also depends on the appropriate and timely use of defibrillators when the heart is in what we call a “shockable rhythm”. This is why there is a need for defibrillators in the community, and widespread teaching of how to use them. Two years ago, however, this government cruelly blocked a bill that would have made it compulsory to teach first aid and life support in schools. Talk about denying a child the skills they need for life – in this case, for saving one.

 

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