First, if you are unfamiliar with the story, check out some articles online.  This one from USA Today is pretty good.  If you want more detail and you have the time, check out the unedited interview with Dr Roger White below.  He was the physician who advised the practitioners in the field and also attended to the patient in hospital.  In it he talks in great detail and even shows printouts from the monitors used during the resuscitation.

Essentially, a 54 yo man had a witnessed cardiac arrest in a small town in Minnesota (MN).  CPR was started promptly and was continued by “dozens” of locals, all taking turns in shifts.  They defibrillated him 6 times.  An advanced life support (ALS) team arrived at about 40 minutes into the resuscitation.  They intubated him (placed a breathing tube for ventilations), gave  IV drugs and defibrillated him 6 more times.  Defibrillation established a regular rhythm for very brief periods of time after some of the ALS shocks.  It wasn’t until he was given a large, out of protocol, repeat dose of the anti-dysrhythmic amiodarone that he remained in a rhythm that produced a sustained pulse.  He was then transported the 30+miles to Rochester, MN, for a heart catheterization and other treatment.  He left the hospital after 10 days feeling tired and sore but apparently with his intellect and other body functions intact.

Dr. White admitted that he and the ALS crew questioned the wisdom of continuing in the face of the recalcitrant dysrhythmia.  In the end they chose to continue in large part because they were able to confirm the continuous production of carbon dioxide via one of their monitors.  In essence, this indicated that the CPR was effectively perfusing the lungs, evidenced by the measurable amount of carbon dioxide produced there. This indirect measure of global perfusion gave them hope and thus made it hard to stop.

This gentleman survived because of an extraordinary confluence of circumstances and people, including the online, real-time advice from a “…leading expert in cardiac arrest…”  Take any one or more of those away and the result would have been different.  Most if not all of the capabilities described would be unavailable and/or unrealistic in a wilderness or remote setting in a harsh environment.  This was the quintessential chain of survival.

Bottom line: As amazing as this story is, our CPR protocol still makes sense.

This resuscitation demonstrates that good quality CPR can make a difference.  However, maintaining good quality CPR is not simple.  Fatigue would have set in much more quickly for a significantly smaller crew.  CPR quality and therefore perfusion worsen with rescuer fatigue and maintenance of perfusion is what gave him a chance.  Fatigue in a remote and harsh environment can also put rescuers at risk.  And this success took more than good quality CPR.  Even the AED proved to be of little use without more advanced capabilities.  In the end, the experienced practitioners involved are not sure how or why they succeeded.

Remember too, this was caused by a heart attack with a potentially fixable rhythm and not from trauma or a prolonged submersion.

Materials You Need:

• Download a blank SOAP Notes page here.
  
• Download the list of abbreviations here.

Wilderness and Rescue Medicine Case Study

The story:

A 40 year old female tripped while descending a companionway amidships of a sailboat. Witnesses reported that she landed on her back on a salon table at the base of the stair, rolled onto the floor, and was found gasping for breath. As her companions started their assessment at 1100, the pts. respiratory distress quickly improved and the pt. stated that she had the wind knocked out of her in the fall. The patient complained of lower back pain but had no other complaints. She stated that she remembered tripping and falling and did not think she hit her head or neck. She had tenderness in the left flank but no bruising was noted. The abdomen was found to be soft and non-tender. The spine exam was unremarkable and she had normal CSM in all four extremities. She had no allergies, took no regular medications, and had breakfast that morning about 3 hrs. prior to the fall. Her Pulse: 98, Respirations: 22 and easy, B/P: 122/78, Skin: pale, and she was alert and anxious.

Put the appropriate information from the story above into the correct spaces provided in the SOAP note.

After you’ve completed the Subjective and Objective sections, develop an Assessment for 1100hrs. with Anticipated Problems and an appropriate Treatment Plan listed in the columns to the right.

At 1130, the pt. reported that her pain had diminished somewhat although a repeat exam revealed persistent left flank tenderness with some developing bruising. Her abdomen remained soft and non-tender. Vitals were repeated: Pulse 72, Skin: warm and normal in color, Respirations 14, B/P: 116/76, and her AVPU: AOx4.

Again, transfer any appropriate information to the SOAP note and update the Assessment as needed. Be sure to note the time when you update any information.

Questions:

1.      Do you feel more or less comfortable with your patient at 1130?

2.      If the patient did suffer significant internal bleeding from her kidney injury, what early signs might you notice during your assessment?

3.      If evacuation to shore was delayed for days, what options might you have for dealing with you patients’ potential spine injuy?

Click here for the assessment and plan.

Click here to purchase the Wilderness and Rescue Medicine Workbook by Tom Clausing.