CPR training

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Contemporary medicine brings with it ethical problems that human beings have not faced before. With the advent of modern resuscitative techniques, issues arise of when to start and stop cardiopulmonary resuscitation. In the 1950s, doctors in hospitals often carried a scalpel that was used when a patient went into cardiac arrest–the chest would be opened, and the heart massaged directly. This method saved the lives of many surgical patients as well as generally healthy pregnant women who had reactions to the anesthesia then routinely given during labor and delivery. It is still used today on trauma victims and on some heart attack victims. In 1960, William B. Kouwenhoven and his associates published an article in the Journal of the American Medical Association on closed-chest heart massage, which is still taught to the general public in CPR classes today. In the early days, doctors would sometimes work on a patient for over an hour, and some of these patients recovered without significant brain damage. Over the years, many other patients suffered severe, disabling brain damage. As CPR spread beyond drowning victims and victims of cardiac death due to a medical condition (such as a myocardial infarction, a “heart attack,” debates over when to use it intensified. CPR might, for example, bring back briefly a dying cancer patient, but what would be the point (unless the patient was waiting for a family member he wished to see before he died or another personal reason)? “Do-not-resuscitate” forms came into vogue, in which the patient or a proxy could let his wishes be known on whether he should be given CPR. I have had several relatives and friends die in peace because they did not go through CPR and advanced cardiac life support after cardiac arrest.

But what about the following scenario: a young woman collapses while jogging at a marathon. CPR is immediately started, along with advanced cardiac life support by the ambulance crew, and the patient is taken to a hospital. It is twenty minutes after her cardiac arrest. Doctors immediately pronounce her “dead on arrival.” This is an actual case; I am leaving out the names of the marathon, the city, and the hospital. What troubles me is that even today some doctors do not give up after twenty minutes, and patients do recover after an hour of CPR and ACLS. Some of these patients fully recover, physically and mentally. Why pronounce a young woman dead twenty minutes after cardiac arrest–maybe her heart only had an electrical glitch that, with treatment, could be controlled, or she could be given an implantable defibrillator and live for many years. We would not know–but twenty minutes seems so short in a decision that guarantees that the woman is dead.

One reason I feel strongly about death being pronounced so quickly in such a case is that my mother suffered a cardiac arrest. Doctors worked on her over two hours (and she did have some times in which her heart would beat off and on during that time), and eventually put one pacemaker line in that did not work; the second line did. She recovered without neurological effects and received a pacemaker and implantable defibrillator.

It seems that too many CPR decisions, both by paramedics and by hospitals, are more based on triage than on what could help patients (albeit a very small percentage of patients). I once asked a PA student who had worked at a hospital whether doctors would work on a trauma patient in cardiac arrest (which they sometimes do if the patient had signs of life at the scene). He replied it depended on how much time they had. I wonder if this is the same for patients in medical cardiac arrest. Now some of these patients may have had a DNR order that was discovered, so when the newspaper says someone was pronounced dead after a short ride to the hospital the DNR is the real reason. But when I read in the paper about drowning victims who were in the water less than five minutes being pronounced DOA twenty minutes later, this is troublesome. Would not there be a moral obligation, in a life or death situation, to try a bit longer, especially given the existence of some successes in the past? If a fifty-year-old man has his first MI, a witnessed arrest with bystander CPR, is twenty minutes’ effort enough for him? I am sure doctors mean well and are looking at “evidence-based medicine,” and studies that say the success rate of ACLS after 20 minutes is extremely low. Because of such studies, paramedics are calling codes over after 20 minutes of CPR and ACLS in the field. In an unwitnessed arrest, this may be justified. If the arrest is witnessed with no CPR given before the ambulance arrived, it may be justified. I am not so sure if the arrest is witnessed.

In the case of trauma, I know of at least two instances, one in Tennessee, the other in North Carolina, in which paramedics said that a patient was dead–and the patient was not. I can understand triage at a trauma scene; the chance of CPR and resuscitative thoracotomy (opening the chest and massaging the heart directly, which is done with some trauma victims) have such a low chance of success with trauma victims) is almost nil (although, contra most articles, there have been survivors of blunt traumatic arrest who fully recovered–check out Woodbury, Minnesota). So if the number of paramedics is limited and someone else with a pulse and severe injuries needs to be treated, in those cases it is acceptable to consider the person in cardiac arrest dead. Otherwise, outside of severe head injuries with brain matter, obviously broken necks, obvious severe bodily trauma, and clear signs that too much time has passed, why not try CPR? Sometimes trauma victims swallow their tongues or get debris in their mouths, and they arrest due to asphyxiation. What is wrong with clearing the airway, trying CPR for a few minutes, seeing if there is any rhythm on the monitor. If not, what harm does it do? It doesn’t harm the patient. And a life might be saved.

I realize that physicians will say, “You’re not a physician and have no right to say anything about these issues.” No, I am not a physician; I volunteered as an EMT-Basic for eight months, but the knowledge from the training is extremely small compared to a physician’s. But I can read articles in medical journals, I can use a dictionary, and I can interpret the data and cases I read. I do know that there is a difference between someone with a shockable rhythm and someone whose initial rhythm is PEA or asystole, and that death will be pronounced more quickly in the latter situations unless a readily reversible cause of the arrest can be found. But the clincher for me is that my mother would have died if the doctors had given up on her. Thank God for them, and for my brother, who pushed the doctors to continue CPR even after they had considered giving up. It is too bad that other patients do not have such an advocate.