Contemplating life.

Paul’s Story

At a recent training night, I had the pleasure to listen to a victim and consequent survivor of cardiac arrest. I was really taken by his story, so, with Paul’s permission, I am quite excited to be allowed to share his story with you:

A few months ago, I was riding home on my motorbike, when I pulled up at a truck stop for a rest and to fill up with fuel. I was about to set off again, when I accidentally overbalanced the heavy bike – first it fell over on to the ground with a heavy thud, then I followed with a painful ouch. I was more than just a little miffed – not only had I scratched my bike, but I also managed to land on my bike, landing with my sternum on the handlebar, resulting in quite a sore chest. A little winded, but more embarrassed than anything, I heaved the bike back up and headed back home.

The chest pain never quite went away. It was really quite annoying. A few days later, I was sitting at home, watching TV with my wife, and it still had not improved – in fact it had become worse throughout the day. “I must have cracked a rib”, I told myself. It was progressing from annoying to painful – the pain being in the top of my sternum. The wife (probably sick of my complaining) offered to drive me down to the hospital to get some decent pain relief, as the Panadol wasn’t helping anymore.

I should probably mention that I actually work at the local (country) hospital as an orderly, and have done for quite a number of years now – I know the procedures, I’ve seen a fair deal going on, but I wasn’t too worried about myself. I was also a volunteer ambulance officer for 35 years – and knew my presentation did not reflect the classic signs or symptoms of cardiac related chest pain. All I wanted is to get this bloody pain sorted out so I could get back to the telly, followed by a good nights sleep. As I approached the triage desk, the nurse on duty eyed me up, cocked her head to one side and said: “What are you doing here Paul, you’re on you’re days off! Can’t get enough of us, can you?”. I tried not to laugh too much (ouch), and explained the situation. “You know the protocol for chest pain Paul, we have to follow it!”. And so I was placed on a bed, wheeled in to the emergency department, a 12 lead ECG was applied, blood samples were obtained and sent off to the lab.

I felt a little silly to be honest, lying in the emergency department where I normally work. Instead of seeing people lying on the bed looking up at me, I was now that person in a hospital gown looking up at others from the bed! I was sure it would be over soon. My wife was sitting on a chair next to me, the 12 lead had not revealed anything, the doctors and nurses told me I was probably right about me having a cracked sternum. The blood samples had just come back, with all results within normal ranges. But just to be on the safe side, the x-ray technician had been called in to give me a chest x-ray.

Damn sternum. That bloody bike, silly me for letting it drop, and for me falling on to the…gee, what a roaring in my ears, and my head is spinning like mad…

– ~ –

I open my eyes. I am lying on my back, in the resuscitation bay of the emergency department. Normally, only the sickest patients are placed here. I’m not quite sure what’s going on.

I turn my head around to try and make sense of it all. I am attached to a few more devices than when I remember last, and surrounded by a few more machines. What really catches my eye (and worries me) is the big white board to my right – it is full of scribbles: times, drug dosages, interventions and oucomes. That white board only gets used if someone was really sick.

That someone was me.

The staff quickly realise that I have regained consciousness, and are glad to be able to talk to me. “Paul, what where you thinking, you scared the crap out of us all!” I am mockingly scolded. Apparently that fast beeping I had picked up was my heart going in to Ventricular Fibrillation – followed by a hectic effort to bring me back to life. I received the full ACLS workup; vigorous CPR was performed, I was defibrillated multiple times, drugs were administered. All written up on that white board. I was lucky to be alive.

Two hours had passed since my heart had decided to fibrillate uncontrollably, and continuing efforts were underway. The coronary care unit in the main city had been contacted, and a bed had been reserved. The Royal Flying Doctor Services (RFDS) were en route to our little airport to fly me up. I hardly had time to get my thoughts sorted when the paramedics walked through the door. “Paul, what have you been up to?” Everybody knows everyone in country towns…

I was loaded in to the ambulance, transported to the local airport, and transferred on to the  aeroplane. The flight was alright, although I still knew in the back of my mind I was in a critical condition. Quite often, the RFDS will fly with a nurse on board only – I had two nurses and a doctor escort me on this flight. Once landed, I was loaded in to another ambulance, and the paramedics took me to the coronary care unit that was already waiting for me. I had one stent put in place the next morning, and was kept in hospital for two days for observation. After the staff were happy with my progress, they sent me on my merry way back home! I was stunned how fast everything happened. Sunday night I was in cardiac arrest 400km from the nearest cath lab, Monday afternoon I already had a stent in place, and Wednesday midday I was being discharged, with a letter to my GP and a specialist follow up appointment in six months time.

After arriving back in town, my colleagues at the emergency department were really glad to see me. They admitted to feeling rather bad after I had gone in to cardiac arrest, and had spent quite some time reviewing and deliberating over my ECG, sharing it around and asking for expert opinions. Still no hint of my impending doom, and another review of the blood work did not show up anything either.

I am incredibly happy to be alive today, and it goes to show how such an atypical presentation (nil shortness of breath, ‘obvious’ history of chest trauma) should not be underestimated, as the consequences could be dire.

And I thought it was my sternum.

RINSE and repeat.

The service I work in has very recently began collaboration in a pretty cool (pun intended) trial – the RINSE Trial (Rapid Infusion of Normal cold SalinE).

Why: Current guidelines only support the use of therapeutic hypothermia post ROSC (Return Of Spontaneous Circulation) – see the Australian Resuscitation Council (ARC) guidelines or the International Liaison Committee On Resuscitation (ILCOR) advisory statement. The RINSE trial was initiated to find out if there is any clinical benefit in commencing therapeutic hypothermia during resuscitation efforts by paramedics.

Background: Basically Therapeutic Hypothermia (TH) aims to slow the rate of metabolism down, reducing the body’s consumption of O2, and also lessening the chemical reactions that lead to reperfusion injury (reference). For a even more info on TH, visit the ever excellent Life In The Fast Lane and EMCrit.

How: Paramedics will be inducing TH by means of IV chilled Normal Saline, checking temperature via tympanic thermometers.

Who: This study is currently running in three states in Australia, by the three statewide Ambulance Services and a participating university in each of those states:


Please check out the link for more and in-depth information!

RINSE trial


Has your service implemented TH for cardiac arrest?

Adrenaline: Curse or Cure?

An issue I have with adrenaline that I have never heard brought up before (I may have missed the argument) is the danger it causes to motorists.

Picture the scenario: Call to very old person, unresponsive, witnesses state patient collapsed >20 minutes ago, but ‘may have had a pulse’. Nil information when patients pulse and breathing ceased. CPR is initiated by paramedics, the attached ECG shows asystole.

This patient has is not likely to survive; they are already clinically dead. If, by some freak of nature, this patient miraculously survives, the quality of life would equal that of seaweed, but costing society much more, and giving relatives false hopes.

CPR on its own would be massaging a lifeless heart – but CPR plus adrenaline (a drug where we are still awaiting confirmation if it actually improves outcome) translates in to a heart beating in an unsustainable rhythm, which usually translates in to transporting a patient to hospital under priority conditions. I’m sure many of your services out there follow termination guidelines similar to those described here.

What to change – drug administration protocols, or transport decision protocols? Evidence on the efficacy of adrenaline in cardiac arrest may take a while to produce, whereas we already know that CPR in the back of a moving ambulance is ineffective, dangerous, and the above mentioned scenario, pretty worthless.

Whatever happened to allowing people to die?