Cooling

"I've got a pulse. He's back."

The EMS tech triumphantly declared as the crew rushed the patient to the Cardiac Room.

The patient was only 18 years old; much too young to die. “Oscar” just wanted to get some extra money for a date with his girlfriend of six months. But he fell off the ladder while at his construction work after a live electric cable rendered him unconscious and stopped his heart. His co-workers had confirmed that he fell onto a tent. There was no head injury but the electric shock caused his heart to go into ventricular fibrillation.

Bystander CPR and EMS CPR gave the patient the chance he needed. Upon arrival to our ER, his heart started beating again, but he remained unconscious. His endotracheal tube and the ventilator ensured that his lungs are relieved of the work of breathing.

The question on our minds: have we saved his life but left him brain-damaged? All those free radicals in his brain needed to stop wrecking havoc on his neurons. We needed to inhibit those excitable neurotransmitters and stop further cell death. As per the latest recommendation, we should cool the brain to reduce oxygen consumption, to give his brain a chance to heal.

Induced hypothermia is an evidence based practice that was fully endorsed by the International Liaison Committee on Resuscitation: Unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32°C to 34°C for 12 to 24 hours when the initial rhythm was ventricular fibrillation (VF). “Cool them” is the mandate.

He was only 18 years old, and we would not let him die. Our hospital was considered the most prolific in New York City; we were gungho about cooling. And since Oscar met all the criteria, we cooled him to give his brain a fighting chance to normalcy, so that he can go to as many dates as he can.

Iced fluids ran through his veins, and the cooling blanket was wrapped around him burrito-style. Target temperature is 34 degrees centigrade. As the nurses monitored his esophageal temperature, they checked his shivering and sedation status. Fentanyl kept him deeply sedated, and there was no sign of microshivering: he was a Zero on the Bedside Shivering Assessment scale. He was to be maintained on hypothermia for 24 hours before he can be rewarmed; that is, if he did not succumb to his injuries, or if we could still save his brain. We prayed that he would not end up to be a “vegetable”.

Oscar was sent to the ICU, still cold at 34. His parents and girlfriend followed him, afraid of the journey ahead; their questions unanswered, his life uncertain. At that point, they were just grateful that his heart was beating again.

A week later, Oscar walked out of the hospital, hand in hand with his girlfriend. Neuro check: alert and oriented x 3. Even if he could just afford fast food for a date for now, he now has a lifetime to plan for more dates.