Tae 6 - Cardiac Arrest

Dedicated to Alan McKendree - hope you like it.

The truth about CPR.

I've performed CPR [based on a modest estimate] on nearly five-hundred people in the past six years as an EMS [you all know what it stands for] provider. I'm also an instructor, and train others to perform CPR. In these classes, we tell people that heart disease is the number-one killer of people in the 40-60 year old age range, we also tell them that performing CPR on a person is one of the neatest things one person could do for another.

Let's look at a typical cardiac arrest:

A late-fifties male gets up in the morning [wife's still sleeping] to go to the bathroom. He's overweight, smokes like a chimney, and is now grunting away - trying to push out the pound of steak he ate for dinner last night. While he's doing that, the pressure he places on his bowels produces a sudden drop in his heart rate, with a corresponding drop in blood pressure. This is known as 'vagal-ing out' - as the vagus nerve responds to such stimulus by dropping the heart rate. The man gets dizzy, and falls off the can in mid-shit. This is what I call the classic 'Elvis' presentation: man on bathroom floor, boxer-shorts down to his ankles, flopping around and leaving skid marks on the floor so wide you'd have thought a 747 landed nearby.

Now his heart *could* at any moment increase it's rate - but since his heart is soooo tired after all those years, it decides to pump at this rate for a while - 'catch a breather' so to speak. Ironically, since the heart isn't pumping enough to circulate blood and oxygen efficiently, the heart itself does not receive enough blood and oxygen to continue beating - so it quits altogether.

Anywhere from several minutes to several hours later, this man's wife wakes up - and follows the 'I had steak for dinner last night'-smell to the bathroom, where she finds hubby. Naturally, you'd think her first reaction is to dial 911, to get some help for him. Noooo, wrongo. You may pick from the following options:

1) She yells "Ralph - wake up."
2) She notices his boxers down to his ankles, and pulls them up.
3) She splashes cold water on his face.
4) She yells "Ralph - wake up" again, just in case he didn't hear her the first time.
5) She genuflects, makes the sign of the cross, and throws in an 'Our Father' for good measure.
6) She calls the family doctor - to ask what to do.
7) She calls the family priest - to ask what to do.
8) She calls another family member - to ask what to do.
9) She does all of the above - _then_ dials 911.
10) Any combination from above.

By the time an ambulance gets dispatched to a cardiac arrest, things look pretty dim. The fire department usually gets there first, and they either: start CPR on an obviously dead person, or withold CPR on a person who just dropped, to see if we want them to start CPR on the person when we arrive.

If the fire department _does_ initiate CPR on a person, they invariably compress the _stomach_, not the chest, providing all responders with visual confirmation of the man's gastric contents and last meal. By the time we get there, there is usually feces, urine, and vomit [the unholy trinity] all over the floor. If the woman has chosen to do any or all of the options provided above, then he is also soaking wet, and there is a priest standing next to the body, playing with his beads. The phone usually rings - the doctor returning this woman's frantic page. And let's not forget the woman's extended family - all barrelling into the house - all trying to get into the same little bathroom we're in. If the fire department also tries to ventilate the man using an 'ambu' bag, and doesn't have a good seal of the mask against the face, then the vomitus is sprayed down the sides of the mask. If by some chance a good mask seal is obtained, but the head of the patient is positioned improperly, then the esophagus - not the trachea, is open. With every squeeze of the ambu bag, more and more vomitus gets p-u-s-h-e-d down the trachea, and into the lungs. If by some miracle of God, and the alignment of the moon and stars, the patient survives, the only thing he'll have to fight is a nasty case of aspiration pneumonia.

ObAside: Most CPR training mannikins have a little tube that runs from the mouth to a squeeze bulb. The idea is that this squeeze bulb can be filled with warm pea-soup, and when an unsuspecting CPR student has their face over the mouth, and someone does a improperly placed stomach compression, the instructor [me] can squeeze the bulb full 'o soup into the face of CPR student. They never make the same mistake again. Used to be that when I put a can of green-pea soup in my backpack, my roommate would say "Teaching CPR today?"

The medic that opts to intubate the patient usually gets a face full of cheesesteak regurg if he/she hasn't told the firefighter to stop compressions while he/she makes the attempt. After re-directing the firefighter's hand over the chest, the next compression usually breaks the sternum - partly due to calcification of the cartilage in the sternum, partially due to the depth of compression needed to produce a palpable compression-pulse. The sound of the sternum and ribs cracking is like a Knuckle-Crackers Anonymous convention in full-swing. Ironically, cracking the sternum makes it easier for subsequent compressions, and results in less fatigue when performing long periods of chest compressions - so most of us try to break the ribs in the first few.

The other medic starts an IV, and performs a 'quick-look' with the cardiac monitor. In most cardiac arrests, there isn't enough time to place chest electrodes on the patient - so we pull the 'paddles' and place them on the chest - a classic 'Johnny 'n Roy' manuever.

AnotherObAside: Does anyone remember the old 'Emergency' series? The story of two Los Angeles County fire department medics - Johnny Gage and Roy DeSoto? It's amazing how many people in EMS were compelled to enter this field of work because of this show. Anyway, part of the opening montage shows Roy at the scene of some accident: he pulls two parts of a large syringe from his med box, and flicks the yellow caps off of them with his thumbs - another classic 'Johnny 'n Roy.' One of my very first calls as a medic - I pulled a 'Johnny 'n Roy' with the syringe: flicked the caps off the syringe - one of which hit a cop in the eye as he stood over me. Got me so nervous that after I connected the syringe together, I expelled the air - and half the contents of the syringe, onto the ceiling. Nothing beats having some medication drip, drip, drip onto you from the ceiling as the family stares at you. 'Trust us - we're professionals.'

The advent of new technology now provides us a choice when performing a 'quick-look.' There are now self-adhesive pads which you can stick onto the patient's chest, and connect via cables to the monitor. Not only can you monitor a patient's cardiac rhythm with them - you can also provide a 'hands-off' shock to him as well. It's really great - when it works. The adhesive sometimes grabs on to the dead flaky skin of an unwashed body - and comes right off. This usually happens in mid-shock, and a large blue electrical discharge arcs from one pad to another. The smell of ozone and singed chest hairs come to mind.

Just a reminder - all this takes place in the first five minutes of the call.

I could go on - but it's time for my medication.

If you like the first five minutes, I'll post the next five at a later date. Thorazine makes me sleepy ...

Seizures! (see ya) - Tae

[Whew! It finally loaded - been trying for the last week. Shitty school acct]


(Originally posted on Tue, 28 Jun 1994)