It was 9 a.m., Friday, Jan. 29, and it was time for Eldrid Primm to go home. Finally. A pulmonary embolism had triggered a cardiac arrest in Primm 20 days earlier. He was carried into UAB Hospital on a stretcher, and his survival odds were not great. Only 3 percent of all cardiac-arrest patients in Alabama are successfully resuscitated, and many survivors suffer extreme brain damage.
Primm is an exception to that rule, and on this day he was walking, talking and laughing — practically his old self. But he wasn’t going home until he shook the hand or gave a hug to every physician, nurse, physical therapist and rehabilitation staff member that he had come in contact with during his stay in the emergency room and critical-care units.
|It’s sunny days and big smiles for Eldrid Primm. Primm went into cardiac arrest and underwent therapeutic hyothermia, a technique that cools the body temperature to 32 degree Celsius in an effort to prevent brain damage caused by loss of oxygen.
Primm thanked each person for not giving up on him, for continuing to perform CPR and for administering therapeutic hypothermia — a feeling that he says “is probably like being in the Alaskan cold with no clothes on.”
But it was a feeling that was worth it. It ultimately meant he was going to live. He was going to be OK.
Numerous cardiac arrests
Some of the memories of Saturday, Jan. 9 are sketchy. Others will be etched in his heart and mind forever.
Primm remembers it was hard to move, walk and breathe when he woke up that Saturday morning in his Lincoln home. He remembers blacking out in the ambulance on the way to UAB Hospital. And he remembers waking up as he was rolled into the emergency room and more than 20 medical personnel — led by Marty Vander Noot, M.D., assistant professor in the Department of Emergency Medicine — swarmed to him.
“I remember Dr. Vander Noot telling someone in the room, ‘We witnessed his heart stop, and if we have the ability to treat the cause, we’re not going to let him go yet,” Primm says.
Then everything went dark.
For the next 90 minutes, UAB medical staff worked frantically, pumping Primm’s chest to try and restart his heart. It would begin beating again, only to stop a few moments later — a process that repeated itself time and again.
“I think in my dictation notes I used the word countless to describe the number of times he coded,” Vander Noot says. “But he kept coming back. That’s why we thought we could save him.”
Vander Noot decided that blood clots were the likely culprit. Indeed, clots had formed near Primm’s lungs and blocked the flow of blood back to the heart. Vander Noot administered a high-powered medicine to break the clots apart, and Primm finally stabilized, his heart beating without assistance.
Having weathered that storm, now there was a new issue: Primm was unresponsive.
Vander Noot and his team’s next course of action was therapeutic hypothermia, a technique that cools the patient to 32 degrees Celsius in order to prevent brain damage caused by loss of oxygen. UAB emergency medicine physicians began using the therapy in August 2009. Only cardiac arrest patients whose hearts stop and then restart following CPR or defibrillation are candidates. Primm was the perfect candidate.
“Our nurses were thinking of therapeutic hypothermia before his heart was stabilized,” Vander Noot says. “The cold saline and blankets already were in the room.”
Primm awoke during the treatment, surprising everyone. The medical team reassured him and put him under anesthesia for the remainder of the treatment. It was the first sign that he was going to survive and reinforced the importance of the therapeutic hypothermia technique.
“I think Mr. Primm’s case lets people know three things: First, when there is a witnessed arrest, maybe you should perform CPM a little longer,” Vander Noot says. “Second, if you get the patient back, don’t let their neurologic status at the time influence how you’re going to take care of the patient. And third, the hypothermia protocol should be the standard of care in anyone you code who remains unconscious.”
When a person’s heart stops, oxygen-rich blood no longer is pumped to the brain, causing damage or death of brain cells. While the reasons are unclear, medicine long has known the rapid return of blood to the brain following successful resuscitation carries with it the potential for additional damage to brain cells.
Physicians and researchers also know that cooling the body for a period of time has a neuro-protective effect, and studies have shown that cooling leads to much better outcomes for cardiac-arrest patients.
Therapeutic hypothermia is the new therapy resulting from this research and now is recommended by the American Heart Association as the standard of care for patients who survive the initial cardiac arrest.
Patients are kept in a hypothermic state for 24 hours after resuscitation using cooling blankets, cold IV fluids and icebags. Patients are slowly warmed to normal temperatures during the next two or three days.
“This is being practiced throughout the country in many academic centers like ours,” says Henry Wang, M.D., an associate professor in the Department of Emergency Medicine and director of UAB’s therapeutic hypothermia program. “Once upon a time, people like Mr. Primm were written off as hopeless, destined to die in the hospital or to live life with major brain injury. However, therapeutic hypothermia has given us a new treatment and new hope.”
Larger programs including the University of Pittsburgh and Virginia Commonwealth University have reported success with therapeutic hypothermia treatments. At these centers, almost 50 percent of patients who undergo the therapy after the trauma of cardiac arrest have survived.
UAB has performed the treatment on 25 patients since August, and Wang says his goal to reach a 50 percent success rate.
Achieving that mark depends on many factors, including cooperation from departments throughout the hospital — something that was evident throughout Primm’s treatment.
Critical-care medicine, cardiology, neurology and rehabilitation medicine and emergency medicine practitioners work together in a multidisciplinary effort to make the treatment possible.
“It’s amazing the amount of teamwork we pulled off to make this happen,” Wang says. “When we first started the program, I kept my cell phone turned on 24/7 and came to the bedside for every hypothermia patient. But I wasn’t even in town when Mr. Primm came to UAB. That’s a testament to the incredible teamwork of our program.”
Wang says the therapeutic hypothermia treatments wouldn’t have been possible, however, if Vander Noot and his team had not resolved the cause of Primm’s cardiac arrest.
“Blood clots in the legs and lungs are very common causes of cardiac arrest but are very under-recognized,” Wang says. “Dr. Vander Noot was smart. He picked up on it, and he pushed very sophisticated drugs to get the clots resolved.”
Vander Noot says his team, which had Scott Irvine, M.D., resident physician, and Valerie Snow, charge nurse in emergency medicine, as its leaders, deserves credit for the work they did in the moment as Primm cleared each hurdle.
“I can’t emphasize enough how much this was a total team effort from everyone in the room, and everyone who cared for him in the moments and days after,” Vander Noot says. “Mr. Primm is why we do what we do.”
‘What a miracle’
Primm walked into the Cardiac Care Unit and the caregivers who recognized him were astounded.
One nurse didn’t recognize him at first. When she was told who he was, she said. “Oh, thank goodness. What a miracle.”
Primm smiled, put his arms around her and thanked her for caring for him.
It’s a scene that repeated itself for the next 20 minutes as other medical staff received word Primm has come by to say thanks. He hugged everyone and thanked them again for “not giving up on me.”