Thursday 18th June 2020
Figures for 17th June
UK COVID Deaths 184 / Total 42,153
James Cook Hospital – Total COVID deaths – 251
All COVID cases within South Tees Hospitals Trust – 12
James Cook Critical Care COVID cases – 2 / 2 ventilated
James Cook Critical Care non-COVID cases – 39 / 21 ventilated
Today I was back on one of the ICUs again. One of our patients was admitted following an out of hospital cardiac arrest two days ago. The elderly gentleman has a long history of heart problems and his cardiac arrest was most likely caused by an abnormal heart rhythm related to his heart disease. The arrest occurred outside his home and resuscitation was started by someone nearby who had witnessed what had happened. When the paramedic crew arrived he was in ventricular fibrillation and was defibrillated twice with restoration of a pulse after a total of 20 minutes. He was brought into hospital deeply unconscious and intubated and ventilated before being taken up to the ICU.
We have spent the last few days stabilising his condition and waiting to see whether he has suffered any brain damage during and around the time his heart had stopped.
The emergency services in the UK attempt resuscitation following out of hospital cardiac arrests in approximately 30,000 patients each year. 80% of these arrests occur at home. Sadly, the survival rate following these cardiac arrests is about 9%. Even in survivors the lack of oxygen delivered to the brain during the arrest can cause significant brain damage. This is more likely if you are older, have underlying health problems, do not receive immediate resuscitation, suffer a prolonged arrest or have a type of arrest that will not respond to defibrillation.
Of course, your chance of survival is improved if you happen to arrest in front of sometime trained in basic life support and if you have appropriate equipment like a defibrillator nearby. I remember a few years ago, seeing a patient who had suffered a cardiac arrest whilst out walking in the Moors with his wife, miles from anywhere. She started resuscitation but obviously feared the worst, given their remote location. Fortunately there was a National Park Ranger nearby who, to her amazement, was carrying a defibrillator and was able to use it to quickly restore a pulse. The gentleman subsequently survived and made a good recovery. Sometimes you just get lucky! The funny thing was that the Ranger’s colleagues had laughed at him time and time again for wanting to go hiking with such a bulky piece of medical equipment and kept telling him to leave it in the Land Rover.
Unfortunately, television, movies and the media often portray an unrealistic picture of cardiac arrest survival, especially those occurring outside hospital. I guess a realistic portrayal doesn’t often make for enjoyable drama. Everyone prefers a success story, don’t they? When members of the public are asked what the survival rate is following cardiac arrest, they often report figures well in excess of 75% for cardiac arrests occurring in hospital, whereas the true figure is in the order of 22% for cardiac arrests occurring in the ICU.
It can be notoriously difficult to try to predict whether a cardiac arrest patient has suffered significant brain damage. It often takes many days to form a clear picture of what damage has been done and this can be agonising for the patient’s family. Investigations like CT and MRI scans, brain wave recordings (EEG) and some blood tests can help but neurological examination once the sedation is turned off a few days later is often the most helpful tool.
The day before when we had turned off our patient’s sedation to see how well he woke up, he started shaking and making some movements that could indicate a significant amount of brain damage. We put him back off to sleep, fearing the worst, but when we tried again today the picture was much more promising. After a few hours his movements appeared more purposeful and by the end of the day he was obeying simple commands like sticking his tongue out when asked. This is very encouraging and we will await further improvement over the next few days.
The early afternoon was taken up performing a tracheostomy on a young patient who had developed a pneumonia following a drug overdose and has spent some time in ICU recovering.
Later we visited one of our two COVID patients in one of our isolation rooms. The gentleman, in his 40’s has been improving to the point where he was probably ready to be woken up and have his breathing tube removed. However, he had been very agitated and was remarkably intolerant of the breathing tube unless heavily sedated. Waking him up before had not gone well. Rather than resorting to performing another tracheostomy we attempted to reduce the sedation to the minimum required to stop him becoming unmanageable, ride out the period during which he became squirmy and remove the tube. We would then turn off the rest of the sedation, hoping he would be calmer once the tube was out and would then wake up more relaxed and compliant. This plan worked, sort-of, but he was initially drowsier than I would have liked.
Over the next few hours he started to wake up slowly but still looked fairly calm. When I left I was beginning to feel that there was a chance that he could stay off the ventilator. I apologised in advance to my colleague Lucasz, who was taking over, in case my plan turned out to be too optimistic and he was left to pick up the pieces. My guilt assuaged, I headed home on my bike in the rain.