Cardiologist-in-a-Box

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By Eli S. Chesen On a light news day, there might typically be a feel-good special-interest story in the local rag about a child who was found, motionless, out in the lake, saved by an alert young fisherman, who pulls the victim out of the water and promptly and successfully performs CPR on him. The kid coughs up some water and begins breathing, just after which the rescue squad arrives. The EMT person peruses the situation and announces that, in another 30 seconds, the child would have died! The Samaritan receives kudos from the mayor, enjoys a free lunch at the Rotary Club and is the beneficiary of a $50 gift certificate, good at any Nike Store. Or, there is the story about the man who is out at the mall, let’s say, waiting for his wife, who is in Victoria’s Secret. Suddenly, he falls to the travertine and a fast-thinking shopper, who has seen countless episodes of Grey’s Anatomy, grabs a handy Medtronics AED, rips off the man’s shirt and gives him the 350-joule shock of his life. The impromptu patient comes back to life, asking the question, “Did I leave the refrigerator door open?” He is reassured by the EMTs, who are now on the scene, that “the food did not spoil.” (AEDs are automated external heart defibrillators, which can in fact restart an arrested heart through the administration of one or several electrical jolts applied across the chest. These devices are now as ubiquitous in the mall as Old Navy and GAP.) A media-savvy dermatologist, who also happens by the scene, opines on the 10:00 news, “Yes, in another 30 seconds we would have lost him.” Don’t get me wrong, these devices can work and can occasionally prolong life. AEDs are equipped with allegedly foolproof microchips, which hopefully prevent the device from causing a cardiac problem rather than fixing one. There is something dramatic about the act of defibrillating someone. It is, under the most ideal of circumstances, a kind of electronic resurrection. Countless movies and TV shows now include defibrillation scenes, which, along with hovering helicopters, convey life histrionically on the edge. I would guess that being defibrillated, while in a helicopter, must be the ultimate trip. In a the recent James Bond movie, Casino Royale, Bond is both “shaken and stirred” and saves his own life as he is actually seen defibrillating himself… His especially equipped Aston Martin, of course, has an AED in the glove compartment. Given car-buyer demographics, I predict, here and now, that Buick will be the first to offer the defibrillator option in next year’s Century Limited. Yes, this device has reached the echelon of techno-necessity, just like the iPod or the cell phone that takes pictures in IMAX format. AEDs cost anywhere from $1,000 to $3,000 and if Medtronics has its way, there will exist one of these little shockers in every home, shopping mall, McDonald’s and Starbucks. This will put a new meaning into the concept of the espresso double shot. In actuality, so many testimonials of 30-second races against the Grim Reaper are, in reality, difficult to impossible to substantiate. I would contend that most bystanders witnessing someone’s collapse to the floor at the mall have no idea whether the fallen has merely fainted, might have been intoxicated, suffered a stroke, manifested a seizure, cataplexy, sustained an insulin reaction with a very low blood sugar or, on the other hand, suffered a heart attack (a myocardial infarction) or a cardiac rhythm disturbance. It would only be the latter, which might be helped by the use of an AED and/or a lower tech resuscitation. Lore would have it that you should zap first and ask questions later, since the AED is electronically omniscient… It “knows” whether or not it is needed: Everything to gain and nothing to lose, right? Then there is the issue as to whether everyone who falls to the floor at Radio Shack should be resuscitated. And there is the question as to what is the likely outcome for someone who is resuscitated by, say, conventional CPR as compared to the use of an AED, with or without traditional cardio-pulmonary resuscitation. It is not unlike compiling statistics on lightening strikes. While it is difficult to tabulate the usefulness of AEDs, it is well known that many, many people, post-resuscitation of any kind, soon experience another significant cardiac event and have a very high mortality rate in the near term. In fact, if a person falls at the mall as a result of a hypoglycemic (low blood sugar) insulin reaction, the use of an AED might waste valuable time during which the person might have benefited from the simple administration of sugar by mouth or by IV. Given that we have equipped malls with AEDs, should we not likewise equip shopping centers with prefilled syringes of glucose and blood sugar monitors with handy instructions on how to operate this equipment as well? Should we add to the kit fast-acting anticonvulsant drugs and TPA (the gene-spliced miracle drug given in the acute stage of stroke)? And with so many people, from boy scouts to knitting guilds, learning CPR, should we likewise be recommending courses in the treatment of low blood sugar, high and low blood pressures, the management of gran mal seizures and stroke? In an ideal world, all shoppers would be ER nurses or board certified internal medicine physicians. There is, in fact, no great outcry by the medical profession, the boy scouts, pre-med clubs, book clubs or other good Samaritans for people to learn how to manage the varied and numerous causes of falling … into a state of altered consciousness. Unencumbered by worrying about the varied causes of collapse, the user of the AED simply follows the brief instructions, operating with the illusion that the victim is being evaluated, automatically, by the Medtronics-Cardiologist-in-a-Box. I would suggest that the shopper wielding an AED is even worse off than the proverbial mechanic who possesses only a screwdriver. He attempts to fix the car, the air conditioner and the lawn mower with his screwdriver to little avail. We tend to use the tools at hand, staying within our knowledge base. On General Hospital, we are likely to see a good defibrillation every few episodes or so. Having become familiar with this procedure, the public can relate to using this handy “screwdriver” to save lives. I feel that, as we walk into The Mall, a Wal-Mart-type greeter should offer us the option of a “Do Not Resuscitate” sign, which we could pin to our shirts on the way into Brookstone. Thanks to AED technology and TV, I think many people have come to visualize the fallen as now having a kind of reset button, which can be pushed in the event of an emergency. Anyone who has taken part in an in-hospital resuscitation realizes that the procedure is anything but “push button.” In hospital resuscitations, an IV line is started with infusions of sodium bicarbonate; monitors are connected; the patient is intubated; blood sugars, electrolytes and other lab tests are drawn; cardiostimulatory medications are administered. The patient might be wheeled over to the cardiac cath lab or to the operating room. During such an exercise, there is always a team leader; everyone knows their job. Specific protocols are utilized with changes only at the discretion of the team leader. In a hospital “Code Blue” there might typically be 150 years of medical experience hovering over the patient. Even with this kind of experience and discipline, the near-term and intermediate-term results of these heroic efforts are fairly poor. And this does not even address the issue as to whether a code should have been called in the first place versus having let nature taken its course. So, back to our good Samaritan at the mall. He or she will now be more frequently armed with a break-glass-in-case-of-fire defibrillator, with which he or she might experiment. While the odds of near-term, intermediate-term or long-term success with this device are abysmal, there is generally no harm in giving it a try. On the other hand, I wonder if there might be better things on which we might spend our medical dollars in this age of spiraling health-care costs. It seems to me that many of the people promoting AEDs have a paucity of knowledge about human physiology, which reminds me of an old Sanskrit saying: “He who says does not know… He who knows does not say.” As a species, humans seem to rail against allowing nature to take its course. Am I against defibrillators at the Dairy Queen? Not necessarily. Take a swing, give it a try… Who knows, you might make it on the 10:00 news.

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