“Is the heart surgeon getting an operating room (OR) ready for the bypass machine?” I asked.
“Yes, it’ll be ready in five minutes.”
Now, as we contemplated escalating the resuscitation to the bypass machine, doubts began to surface among some of our colleagues.
“Dr Maffei, how long will you go here? It’s been an hour and thirty minutes. At what pH would you consider stopping?” The pH refers to the amount of acid in the bloodstream—the longer a patient’s tissues are deprived of oxygen, the more acidic the body becomes. And the more acidic the body becomes, the less likely it is that vital organs, especially the brain, will ever recover. In my entire career, I’ve never cared for a child that survived with a pH less than 6.5, and surviving doesn’t necessarily mean surviving with an intact brain.
“We don’t stop until he is rewarmed to 90 degrees Fahrenheit, and I don’t really know about a specific pH but if you want a number, anything less than 6.5 is likely to be non-survivable.”
“His blood gas results are back,” someone called out. I held my breath while the numbers were read aloud. The blood oxygen was far too low, the blood acid level was far too high, and “The pH is 6.504.”
Now what? I thought. While the pH of 6.504 is greater than 6.5, the difference is less than negligible. But the pH wasn’t less than 6.5. I was grateful that a voice inside of me had chosen 6.5 as my make-or-break number because that same voice inside of me had told me we shouldn’t give up, we still had a chance. We prepared Gardell for transfer to the OR, where he would be put on the cardiopulmonary bypass pump. The transfer from the ED to the OR went seamlessly without having to interrupt CPR. The heart surgeon and his team were scrubbed and sterile and ready to go.
I decided we would do one last pulse check and then Gardell would be in the surgeon’s hands for the bypass procedure, which we all knew carried its own significant risks. No machine can mimic the effectiveness of the body’s own heart and lungs, and cardiopulmonary bypass is no exception. Patients on the “pump” are at risk for stroke, bleeding, even further heart damage, kidney damage, infection, and other complications. It was a huge step to take, especially since we didn’t even know if we had a chance for normal brain function after the prolonged drowning and resuscitation efforts.
“Rich, I’ll check his groin artery for a pulse if you check his neck artery. Everyone, please hold on your CPR for a moment while we check for a pulse and heart rhythm.”
“I have a pulse,” Rich and I said confidently and simultaneously. We looked at the monitor. Normal heart rhythm at 70, then 80, then 100 beats per minute with a blood pressure of 78/44—good enough. We again held our breath waiting to see if this could be sustained; we detected no abnormal rhythms, only a stronger and stronger pulse and improved blood pressure each minute.
There would be no hooting or hollering, no slaps on the back, no high fives—only that same spirit of calm determination we had experienced from the beginning, but now with a profound sense of peace and thankfulness. Yet we all knew enough to also feel nervous trepidation of what lay ahead. A beating heart did not necessarily mean a functioning brain.
Little Gardell did not need the cardiopulmonary bypass machine, but there was still much more work to do: fine tuning his breathing machine, slow and cautious rewarming, continued careful monitoring of his core vital signs, medication adjustments, corrections of abnormal laboratory findings, and watchful waiting in the PICU defined our night. After all the stabilization and high-intensity activities, I could finally breathe long enough to begin to meet the family. First, I met with Gardell’s pregnant mother and then, one by one, his six siblings. The little boy’s father, a truck driver, was racing home from Detroit to be with his son. They were all tearful but hopeful. This is a deeply religious family; they pray and turn to God for all things.
I also took a moment to look at some of the scientific literature and data Rich had found earlier in the evening. Not good. Yes, rare cases of meaningful survival after ice-water drowning with prolonged resuscitation do occur, but fatalities or severe neurologic disability are far more likely the outcome. As my own professional experience had taught me, and as that inner voice had told me during the resuscitation, I couldn’t find any reports of a survivor who had an initial pH of 6.5 or lower. What have I done? Have I saved the heart and lungs of a child only to create a vegetative state? What will Gardell’s brain function be like after such an ordeal?
I finally pray, “Lord, help this child and his family—be with them. Stay with me, as I felt your presence during his resuscitation.”
It was now 2 am in the PICU. I was in the unit watching over our nearly frozen toddler and gently, quietly, speaking to his family. “We will do everything we can for Gardell. We may not know for days what the extent of his recovery will be and indeed even his survival is still in question.” The family left the PICU to get some rest on the chairs and floor of our waiting room.
At 3 am the tube in his artery that was providing blood pressure readings malfunctioned. That could have been bad news. I hoped it was just a mechanical problem that required some troubleshooting rather than requiring the replacement of another tube. I went to the bedside to check on it and I did a double-take, and then a triple-take. Was he trying to open his eyes? I called to the bedside nurse, “Did you just see that?”
“Amazing,” she replied, “amazing.”
A short time later, he again opened his eyes and looked straight at me. I called his name and he grimaced. “Gardell, do you want to see your mommy?” I asked.
He nodded, an unmistakable “Yes!” We called his family in immediately, including his father who has arrived just in time to witness his baby’s remark-able and stunning awakening.
After only eight hours since his pulse had returned, Gardell was now answering questions. Word spread fast: every doctor, doctor-in-training, medical student, night nurse, aide, and respiratory therapist stood around his bed dumbfounded and overjoyed. As we all looked at Gardell, his family, and each other, there was again a spirit of calm and peace in the room, now with an aura of awe.
“Do you want to play trucks when we go home?” his father asked Gardell. He smiled around the tube still in his throat. I stood back and thanked God.
A day later, Gardell was liberated from the breathing machine and, a mere three days after being pulled, frozen and dead, from an icy stream, Gardell went home from the hospital. His mom sent me a beautiful video showing Gardell running and playing with a balloon his siblings gave him.
Gardell went on to make a full recovery.
I often stop to think about how we got from an hour and forty-one minutes of CPR to a happy and beautiful little boy who can bounce a balloon with his brothers and sisters. I reflect on the more than fifty people whose complete and total devotion to saving this child did, indeed, save him: the neighbor who searched far down an overflowing stream to find him facedown in the water, stuck on a branch; the incredible first responders who knew not to give up on their CPR; the dedicated physicians and nurses at two hospitals who orchestrated a phenomenal resuscitation. Calm, but determined heroes, every one of them.
Most of all however, I am left with the overwhelming sense that divine guidance enabled us to resuscitate Gardell. Many of us have since remarked that there was never a feeling of desperation or hopelessness throughout the entire resuscitation. It was as if we were hearing from above, “Do your job and I will take care of the rest.”
1http://www.cnn.com/videos/tv/2015/03/20/lead-pkg-darlington-toddler-revived-after-near-drowning
.cnn
2http://www.nbcphiladelphia.com/news/weird/Toddler-Survives-CPR-Pennsylvania-Icy-Creek-29695
4871.html
3http://www.mirror.co.uk/news/world-news/miracle-toddler-who-fell-stream-5377435
4http://fox8.com/2015/03/20/toddler-dead-for-101-minutes-is-now-alive/
5http://abcnews.go.com/
Health/video/pennsylvania-toddler-revived-after-having-no-pulse-for-hours-29781706
Date of event: January 2009
The Miracle of Teamwork
Paul A. Skudder, MD
Late afternoon on a Monday, I was visiting the cardiac intensive care unit (ICU) and had to introduce myself to the nursing staff; I’m not in the cardiology department and they did not know me. I asked a few questions to locate a patient who did not expect to see me.
There were several family members at his bedside, concerned but looking ever so much more relieved than when I had last seen them. Far more relieved. And the patient, in his late sixties, was smiling, sitting up, a bunch of tubes coming from various body locations, cheerful and speaking with his family. A new man, a new lease on life. Wow.
I began, “Do you recognize me?”
“No . . . should we?”
“Well, maybe, maybe not. It’s a bit out of context,” I answered.
I thought, Like really way out of context. All they see is another doc in a white coat and a tie, in a big hospital where docs in white coats and ties are a dime a dozen. I’ll bet they’ve seen so many docs in the past two days they couldn’t recognize half of them.
But they wouldn’t remember me from the hospital. It was before all of this. Before the helicopter. Before there was hope.
They looked at me some more. I reached into my pocket, the pocket of my white coat that usually holds my stethoscope. I pulled out a baseball cap with a logo on it. I put it on slowly. I adjusted it and I smiled.
Stunned silence.
* * *
Back to two days earlier. It’s frigid, just a couple degrees above zero. Crystal clear, visibility from here to everywhere. A busy Saturday in the ski industry, a mountain full of enthusiastic customers enjoying a “bluebird day,” the kind where the snow is fluffy and soft, the air is crisp and cold, and your skis seem to turn effortlessly. At the summit of the mountain, in the old wooden shack, those ski patrollers who are not out scanning for the injured, cold, or lost are warming up last night’s leftovers in the old microwave with the broken handle. It’s time for lunch, and the homemade wooden table is surrounded by familiar faces, relaxed, going over the last few days’ challenges, pondering how long the weather will remain clear and cold, and wondering who was on duty next weekend. Generally just “chewing the fat” as they say. The desk is manned by the dispatcher. There are two phones, two radios, and a logbook full of scribbles nobody could really read. The dispatcher turns to me and barks over the crackle of a radio:
“Hey Doc, they are starting CPR (cardiopulmonary resuscitation) on the snow in front of the mid-mountain restaurant.”
Red coat on quick, helmet buckled. Turn on my two-way radio hustling out the door. Yell something about “Somebody be sure the portable de-fib is on the way.” That’s the defibrillator machine we use to restart stopped hearts; you know, the “paddles.” Snap, snap into my skis. Push hard away from the shack, over the little hump and point them down. Don’t turn, don’t brake. Just go, go, a mile and a half to go, just go. Wind whistling by, biting and cold, freezing exposed skin. Chatter on the radio. Others coming, gathering, different skills assembling. Turn hard, staying on the shortest path between two points. Around the corner, avoid the customers, don’t cause another problem. Over the last hump, and there they are, the first of our highly trained team to arrive, red coats, white crosses on the back of each one, bent low, on their knees. Around him.
The group makes room for me. CPR chest compressions (pumping) underway, bare chest, defibrillation pads are already in place. It’s cold, maybe four degrees Fahrenheit, his bare skin is blue, lips blue, face ashen, his whole body bouncing on the snow with each compression. A breathing mask held over his nose and mouth, attached to a bag squeezed regularly, pushing oxygen from a small green torpedo tank into his lungs.
Too many spectators; scared family, curious onlookers. “Get crowd control! We need room to work!”
“We can talk to family later.”
“Everybody clear!”
The defibrillator fires. “Shock delivered!”
Compressions again. Shock again. No response. He needs meds, he needs meds. Medicines are crucial for resuscitation of a heart attack patient. Continue compressions. Trade off, somebody else give compressions. He is cold. Maybe that’s good, they use hypothermia (low body temperature) inten-
tionally in intensive care units after heart attacks, protects the brain and other organs. He’s cold. Stay on it.
More noise, a roar, a gasoline engine, smells like an outboard. The crowd parts. Snowmobile skids in next to us. Meds have arrived with licensed personnel. Open the box, root around, find the meds we need, draw them up in a syringe, push them in the vein. What vein? They are all collapsed, it’s freezing. Veins collapse in the cold. Nobody can find a vein; too cold, too constricted. Where is the biggest needle? Gotta find a really big vein. His neck, look at the neck, find the “landmarks,” the jugular vein will be there even though we can’t see it. “Stop compressions!”
“Why? No! He needs compressions!”
“Stop, I can’t go for the jugular with the man bouncing like this.” Without meds he’ll die. Stillness. One pass, straight into the jugular. Yes, we have an IV line! Start pumping again, CPR compressions. Where are the meds? Here, here, push them in here. Epinephrine (aka adrenaline) pushed into the jugular IV. Compressions. Shock. Repeat. Epinephrine. Compressions. Shock.
Off, everybody off. Check him. He has a pulse. No? Yes! Cover him, get him warmed up. Maybe? Is it better if he’s cold? Where is the two-passenger CPR toboggan? Here it is—great, already here. People are thinking and moving. A team! This is why we practice so hard.
Strong guys, big guys to steer this one down the mountain! He’s a big guy and we need a rescuer on the toboggan with him to squeeze the air bag that’s providing oxygen for him, breathing for him. He’s not conscious. Will he live? Pupils dilated, a bad sign, will he wake up? We don’t know, can’t say. Yes, his pulse is still there. Good. Blood pressure? Yes, he has a blood pressure. No bleeding. Cardiac event. Call air ambulance, this one needs a chopper.
He needs a breathing tube in his windpipe before we can put him on the chopper. Wow, these guys with military field experience are good; in the tube goes, on the ground, on the snow. Putting that tube in can be tough in a hospital, on a bed, with bright lights and all the rest! This is now an ICU in the snow, artificial breathing apparatus, jugular IV lines, meds, all of it!
The chopper is on the way. Skiing down, down, a careful two miles on the snow. Strong skiers pulling, two men in the toboggan, one breathing for the other, keeping him alive. Not too fast, don’t lose control, don’t roll them over, but no time to waste. Air ambulance arrives. Tell the flyers the story, details, what we did, how he is. Load him up, strap him in. Off he goes.
Now the family, ask them about it. Crying; fear; what happened? What will happen? Heart attack? No better explanation at hand, he just dropped on the snow after lunch in the restaurant. They say he was happy all morning, no complaints, no warning signs. Just went down after lunch. Yes, we did our best; we hope he will make it. Do you need directions, how to drive from here to the hospital, almost two hours?
Good luck. God be with you. Best to drive carefully; hurrying will not help him.
* * *
Where were we? Oh yeah. I reached into my pocket, the pocket on my white coat that usually holds my stethoscope. I pulled out a baseball cap with a logo on it. I put it on slowly. I adjusted it and I smiled.
Stunned silence.
Then . . . “Are you one of those guys?!”
The red-and-white logo on the cap read SKI PATROL.
“Yup. One of those guys. The one with the big needle.”
So the visit began, smiles, tears, hugs all around. Memories of an eventful day from different perspectives. Talk of the procedures in the
hospital since then, the diagnosis of the heart attack, and the cardiologists’ good care to ensure a good outcome.
“No, I was not involved in the procedures in the hospital, I am not a cardiologist. I am in a different field of medicine. I did my part the other day. I volunteer at the mountain, part of the patrol, there to help. It’s a really good team.”
Date of event: 1999
A Good Samaritan Repaid
Fred M. Henretig, MD
It was a lovely spring weekend, but it was my lot to be working a Saturday shift as the attending (supervising) physician in the emergency room. The morning had begun with nothing out of the routine for our busy, urban children’s hospital—lots of sick, feverish infants, children of all ages with minor trauma, children with asthma and other chronic illnesses having flare-ups—yet happily, no catastrophic events to confront so far that day. That all changed when we heard the hospital operator on the overhead paging system call “Code Blue,” the emergency code for a patient having a severe, potentially life-threatening heart or breathing problem.
But, rather than the usual location announcement directing physicians, nurses, and technicians to a patient’s room, this call was to the elevator located in the center of our lobby. That was unusual, but even more unusual for us was the patient—a middle-aged adult who was visiting the hospital that day. We don’t often treat adults in our children’s hospital, and I must say it made me more than a little nervous. It had been over twenty-five years since I graduated medical school and entered into pediatrics, and even though all of us in the ER had taken the standard courses in adult life support and cardiopulmonary resuscitation (CPR), this situation was definitely out of my comfort zone! Apparently this man had entered the elevator on the first floor and immediately collapsed when the door opened onto the eighth floor.
Miracles We Have Seen Page 14
