I have written before about the beneficial effects of cooling the brain on survival and neurological recovery after a cardiac arrest. It has been shown that the sooner the cooling is started and the sooner the target temperature is achieved the better the outcome.

I have started intravascular cooling in the Intensive Care Unit on multiple occasions. If started in the ICU, then the cooling is may sometimes be delayed by more than an hour and the benefit of it is likely greatly reduced.

Starting cooling as early as possible, ideally, at the scene of cardiac arrest should be out ultimate goal.

Realizing, of course, this is easier said then done. Imagine paramedics trying to intubate the patient, perform CPR, establish peripheral access, transport the patient at the same time and, somehow, initiate cooling.

It could only be done if the induction of cooling was easy to perform on the field and efficient enough to have a measurable benefit on survival.

One of the methods is to start infusing cold saline through a peripheral IV. This could be done by paramedics and continued in the Hospital.

A novel technique, which we previously described, is to use a rapidly evaporating substance to cool the mucous membrane inside the nose and throat of the cardiac arrest victim.

The proximity of the nose to the brain and the shared blood supply between the nasopharynx and the brain makes it an “ideal” candidate for induction of hypothermia.

A recent study published in the Critical Care Medicine Journal compares two cooling methods (nasopharyngeal cooling vs. cold saline infusion) in porcine model of cardiac arrest. Both were initiated at the start of CPR.

The study concluded that nasopharyngeal cooling (NPC) initiated at the start of CPR significantly improved the resuscitation rate when compared with cold saline infusion.

After all is said and done, your nose might become a “vital organ” to save your life if you ever go into cardiac arrest.

The other day I was sitting outside a patient’s room waiting for the hospital employee to finish taking orders from the patient for meals for the following day.
The patient had to decide between chicken, beef and fish for lunch.
Once the orders were put into the computer, I stepped into the room to see the patient.

The patient was an 87 year old man with a widely metastatic cancer. His condition was terminal and no further treatment was offered by his oncologist. My plan was to discuss two issues with the patient -- pain control and resuscitation status. It’s good practice to decide if the patient wants to be resuscitated in the case of cardiac arrest. It is also a good idea to make this decision when things are relatively stable and the patient can take the time to think about it.

As I was talking to the patient, I couldn’t help but think that my conversation is no different than the one the patient had had earlier with the cafeteria employee. The options were different, but that’s about it;
“What do you want us to try for pain control?” was my question.
“We can try some vicodin or percocet. How about some morphine to get things under better control?” I asked.

The conversation regarding code(resuscitation) status went the same way:
“If your heart stops, do you want us to put you on a breathing machine and perform CPR?” The patient paused for a minute and as if picking items from a menu, stated that he is Ok with CPR but does not want to be on a machine. At that point I realized that the patient had very little understanding of what resuscitation meant and what the possible outcomes were. Performing CPR without providing adequate blood oxygenation will have limited effect, and vice versa, putting somebody on a breathing machine and not doing CPR will have no benefit in the case of a cardiac arrest.

It is our responsibility to help the patient to make the decision regarding life support by providing education and counseling on end of life issues. Sometimes, you, as a physician, will have to make that decision and communicate to the patient why CPR should not be performed. We do not offer patients surgery or a procedure if there is no benefit from doing it. Why should we offer CPR if the patient is unlikely to benefit from it and could, actually, develop complications related to CPR.

I strongly advice against resuscitation in the following circumstances:

When cardiac arrest will likely happen as a result of a severe and irreversible metabolic and physiologic change. At that point, performing CPR is futile since you cannot reverse the condition leading to it. The example would be a severe multiple organ failure and Acute Respiratory Distress Syndrome due to overwhelming sepsis. If patient’s lungs are so damaged that there is not adequate oxygen delivery and that causes the heart to stop, doing CPR is not going to bring the patient back. Of course, all the treatment options for the underlying condition should be exhausted first.

When overall life expectancy is poor due to an incurable disease or condition. The patient with a terminal, widely metastatic cancer should not spent his last days on a ventilator.

When CPR could actually cause more harm than good. Performing CPR on a 89 year old female with a severe osteoporosis will like lead to multiple rib fractures and potentially lung damage.

Having said that, it’s almost like a patient’s “right” to get CPR before death and refusing to perform it might have legal consequences. What we need is better education for the public on end of life issues and better protection for the physicians for refusing to provide futile care.

Some things just don’t make any sense. It’s like in the “Red fish, blue fish” book be Dr Seuss: “did you ever fly a kite in bed?...did you ever walk with ten cats on your head?... Think about it. Does it make any sense? No, it doesn’t. What about doing CPR on your patient for two hours straight? Does that make any sense? At that time it seemed like it did. Even though, critical care medicine is inherently chaotic, we don’t like any surprises.
You often know who is “supposed” to die and who is not. A thirty one year old previously healthy man just was not supposed to die. You can’t let it happen.

Just a few days ago he was fine. Later he developed some flu-like symptoms and now he is in ICU with severe pneumonia, full-blown Acute Respiratory Distress Syndrome and multiple organ failure. You’ve tried everything there is to try: maximum ventilatory support, Nitric Oxide and even prone positioning (turning the patient on his abdomen) – nothing is working. Transfer to the outside facility for ECMO (extra-corporeal membrane oxygenation) is simply unrealistic – the patient is not going to survive the transport. And now he is coding (developing cardiac arrest). This is one of those what I call a “Rolling Code”. The patient loses his pulse for five to ten minutes. CPR and ACLS (advanced cardiac life support) is initiated. He regains spontaneous circulation just to lose it a few minutes later. Every time you feel his pulse, you “reset the clock” and start all over again. Remember, you just can’t let him die, so you do it again and again and again.

The family was summoned into the room to witness the code. His parents are sitting quietly in the corner staring into space. Twenty, thirty minutes into the code the silence in the room is almost wicked. Nobody talks. All you can hear is the sound of chest compressions and bag-ventilation. If you believe in afterlife, every time the patient “dies” the soul is leaving his body.

You hold the chest compressions after another round of Epinephrine and Atropine – “yeah, we got the pulse”. Every possible medication is running into his vein to keep him alive. The periods between arrests become shorter and shorter. You check his pupils – fixed and dilated. The patient likely sustained a severe brain damage from the lack of oxygen supply. Now, it’s time to talk to the family again and stop. You have done everything you could and beyond, way beyond. Sometimes, it’s not up to us to decide who is not “supposed” to die.

Have you ever done CPR? Not on a manikin but on a real person. It requires quite an effort. It also is a good exercise – it involves multiple muscle groups: arms, shoulders, back and even abs. I am surprised they don’t have it as a workout technique, something like TotalCPR or TurboCPR. The idea is to push against the chest wall elastic recoil and pump the blood out of the heart in an effort to preserve blood supply to the vitals organs. Providing rescue breaths used to be a part of CPR. That did not work very well in a community. Imagine that you have to wrap your lips over dead stranger’s mouth and blow air into his lungs. Not to mention that the person could have a communicable disease and a questionable oral hygiene. It has been changed recently – just chest compressions are good enough. Rescue breaths were not found to be ”effective” anyway and provider willingness to do it was a “concern”. No kidding!

Does CPR work? Yes it does. Like any good medicine it can save lives when used in the right circumstances. Imagine 50 or so year old gentlemen golfing with his friends and, suddenly, collapses. CPR initiated by his buddies. EMS arrives within minutes. The patient is being defibrillated by the Automated Defibrillator and transferred to the Hospital. He is taken to the Cath lab where cardiologist opens up one of his coronary arteries. The patient recovers completely and doesn’t even remember anything – like it never even happened. This is very good. This is how it is supposed to be.