JEMS Case of the Month: Dilemmas in Day-to-Day Care
By Mary Newman, MS
On Aug. 22, 2013, Sue Hostler arrives at the Philadelphia International Airport to catch a flight home. A frequent business traveler, she knows her way around the airport and runs to get on an elevator in a remote area of Terminal F, which is used for commuter flights.
A young man reaches and enters the elevator just before her, and the doors close before she can join him.
When Hostler hits the “up” button a few seconds later, the doors reopen and she’s stunned by what she sees: 25-year-old Bob Hallinan lying facedown on the elevator floor and not moving.
Without hesitation, Hostler uses her cell phone to call 9-1-1, thinking maybe the man had suffered a seizure. It was 3:04 p.m.
The 9-1-1 dispatcher asks if the man is breathing. Hostler checks and replies that Hallinan is unconscious and not breathing. She asks if she should begin CPR and the dispatcher immediately tells her to do so. At this point, another traveler, Vivian Nolan, comes along and offers to help, and the two women turn Hallinan over.
Hostler starts CPR within two minutes of the young man’s collapse. She tilts his head back to open his airway and is about to start mouth-to-mouth resuscitation when she remembers hearing that continuous chest compressions—or hands-only CPR—can be more beneficial soon after a person’s heart stops.
She begins to push on the center of the victim’s chest, following the dispatcher’s guidance to compress twice a second to deliver at least 100 continuous compressions per minute.
The dispatcher asks her to count out loud as she gives compressions. At first she does as instructed, but she soon realizes that she needs all her strength to do the compressions.
Confident she’s using the right cadence, she keeps giving rhythmic compressions and repeats the precise location of the incident to the dispatcher, who reassures her help is on the way.
Periodically, she hears the young man gasp—making a snoring sound—but quickly realizes he isn’t breathing on his own and is actually taking agonal respirations.
Meanwhile, Nolan keeps onlookers at bay and stakes out a post near the curb to guide emergency personnel to the scene. Many people pass by, but no one else offers to help.
A police officer arrives and asks how he can help. It seems apparent to Hostler that the officer neither knows CPR nor recognizes the need to retrieve an automated external defibrillator (AED).
Then, at 3:21 p.m, 17 minutes after Hostler placed the 9-1-1 call, a Philadelphia Fire Department (PFD) ambulance arrives on scene. Hostler estimates she administered CPR for at least 15 of those critical minutes.
The PFD EMS crew defibrillates Hallinan twice before packaging and transporting him to nearby Methodist Hospital.
Hostler later learns Hallinan was alive and had been transferred from Methodist Hospital to the cardiac care center at Thomas Jefferson Hospital in downtown Philadelphia.
Hallinan, who had no known health issues prior to this incident, was treated with therapeutic hypothermia and in a medically-induced coma for six days. He then received an implantable cardioverter defibrillator (ICD) to protect him from future life-threatening events.
On Sept. 5, 14 days after he suffered sudden cardiac arrest (SCA), Hallinan was discharged from the hospital, neurologically intact. He was told he can’t drive for six months post-surgery, but after, he will be able to resume his job as an executive limousine driver.
Hallinan’s mother, Mary Hallinan, a nurse and paramedic, and longtime JEMS subscriber, is eternally grateful to Hostler for saving her son’s life. She’ll never forget the day Hallinan suffered his cardiac arrest and got a second chance at life because it was also her birthday.
This was not an ideal response to SCA. If it weren’t for the early recognition of Hallinan’s cardiac arrest and quick, determined effort by Sue Hostler, it’s unlikely the victim would have survived. However, this case demonstrates the effectiveness of early, hands-only CPR, and the potential for saving lives despite a relatively long duration of CPR and delayed defibrillation.1
This case also presented several areas for improvement in the airport’s emergency response system:
- The lay bystander, rather than the dispatcher, suggested beginning CPR;
- With the exception of two willing bystanders, no other members of the public offered to help; a disappointing fact, but one that unfortunately is consistent with the literature on bystander intervention during medical emergencies;
- There are approximately 100 AEDs at the Philadelphia Airport, but airport personnel and police failed to bring one to the scene;
- If the dispatcher had mentioned the availability and location of an AED to the rescuers, they could have sent someone to retrieve one and would have been willing to use it, despite the fact they haven’t undergone training in the use of an AED;
- The police officer who arrived on scene didn’t take charge of CPR or retrieve a nearby AED;
- Although the rescuer repeatedly provided precise, accurate directions to the location of the incident, it took 17 minutes before EMS arrived.
On the positive side, the patient undoubtedly benefited not only from his young age, physical fitness prior to the event and immediate CPR, but also from state-of-the-art ALS, therapeutic hypothermia and ICD therapy.
This case clearly demonstrates the importance of immediate CPR in treating SCA. Early and effective bystander CPR remains the cornerstone in the quest to reverse sudden death.
Early defibrillation is the most effective known intervention for restoring circulation after SCA. For every minute that passes between collapse and defibrillation, survival rates decrease 7–10%.2
The critical importance of prompt AED use is also well-documented. For example, a prospective multi-center clinical trial demonstrated that survival rates increase from 7% to 38% when bystanders provide CPR and use AEDs before EMS arrives at the scene.4 Survival rates in one city, Rochester, Minn., now approach 60%, thanks to rapid use of AEDs by police officers.4
Although widespread deployment of AEDs is a step in the right direction, unless the devices are used quickly, deployment is futile. In this case, improvements clearly are needed in planning and communications between the airport and the 9-1-1 dispatch center, and in training of airport personnel, so AEDs can be retrieved promptly when future emergencies occur.
In addition, it’s vital to continue to raise public awareness about SCA so that more bystanders understand its pervasiveness,5 the importance of immediate intervention, that compression-only CPR works, and that AEDs are safe and effective lifesaving devices that are easy to use.
Mary Newman, MS, is president and co-founder of the Sudden Cardiac Arrest Foundation (www.sca-aware.org). She’s a member of the JEMS Editorial Board and has been a contributing editor to JEMS since 1980. She can be reached at mary.newman [at] sca-aware.org.">mary.newman [at] sca-aware.org.
References1. Bobrow BJ, Spaite DW, Berg RA, et al. Chest compression-only CPR by lay rescuers and survival from out-of-hospital cardiac arrest. JAMA. 2010;304(13):1447–1454. 2. Link MS, Atkins DL, Passman RS, et al. Part 6: Electrical therapies: Automated external defibrillators, defibrillation, cardioversion, and pacing: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation . 2010;122(18 Suppl 3):S706–S719. 3. Weisfeldt ML, Sitlani CM, Ornato JP, et al. Survival after application of automatic external defibrillators before arrival of the emergency medical system: Evaluation in the resuscitation outcomes consortium population of 21 million. J Am Coll Cardiol . 2010;55(16):1713–1720. 4. Snyderman N. (Oct. 22, 2013.) Survival rates improve when police use defibrillators. NBC News. Retrieved Nov. 9, 2013, from www.nbcnews.com/video/nightly-news/53347636/#53347473. 5. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics–2013 update: A report from the American Heart Association. Circulation . 2013;127(1):e6–e2451. More...