When I first saw my wife Friday a bit after the noon meal, she was as lifeless as I have ever seen a person. She had slumped against the hall wall in memory care at Provision Living at Columbia. She was walking hand in hand with the RN director. A nock on the door to our apartment alerted me.
An oxypulse meter showed a steady red bar for pulse. 911 had been called. She was resting in tilted back chair. The pulse meter bar was full and steady. It vanished. It rose a bit. It flickered. It resumed a normal pulse. Her color returned to normal. She opened her eyes.
The ambulance arrived before the fire truck. “She Is coded to resuscitate.” But I had talked her into making that choice at Provision Living after we had our Power of Attorney papers redone a year ago. Were we doing what she really wanted?
When I got to the front door on my way to our car, the ambulance was still sitting in the drive. An EMT person from the fire truck got into the ambulance. I got into our car. All three vehicles headed to the Boone County Hospital, 5 miles away.
My wife’s heart monitor in the ER showed irregular normal pulses and others that were covered with fur. Her heart beat ranged from 50 to over 200 in the emergency room. Over the next 12 hours the fur disappeared completely.
The EMT person stopped by the ER to say that a defibrillator had been used in the ambulance before they headed for the hospital. Another pang of conscience. Were we doing what my wife wanted? How will she be after resuscitation?
One copy of our directives and POA would not download from a secure vault. Another would not show directly on the screen. Another could not be located on the Internet or on my computer. Boone County Hospital printed out copies dated 2004 (12 pages) and 2015 (5 pages).
Monday afternoon we were home again. The director of Provision Living explained to me that my wife did have defibrillation to convert her heartbeat from a none blood pumping flutter to normal. Her heart had not totally stopped pumping. A do not resuscitate (DNR) order would have had not effect as she had a shockable heart rhythm.
Although defibrillation is used in resuscitation the process is only called resuscitation if the heart has stopped beating, but may still be fluttering a bit. This requires a judgment call. Current emphasis is no longer on getting the blood flowing again, but to also result in little or no brain damage.
The main factor seems to be time. Defibrillation within about 5 minutes yields good results. This happens in the hospital on monitored patients. (My wife hit the CODE button Sunday and 6 people plowed through the door in about 2 seconds in preparation to do resuscitation if conditions warranted it and a DNR had not been posted.)
Missouri joined a majority of other states in 2007 in using an OUTSIDE THE HOSPITAL DO-NOT-RESUSCITATE ORDER (OHDNR). This recognizes the fact that what may be successful in a hospital may not be outside the hospital. The novelty of the order is that the last paragraph allows the person or representative to cancel the order at any time.
Defibrillation is not resuscitation (but can be a part of the process If the heart has stopped). Defibrillation is now part of modern medicine inside and outside the hospital. If defibrillation is delayed too long it becomes resuscitation, when blood flow is sufficiently reduced long enough.
The DNR order then applies only when the heart and brain have been severely stressed to the point that brain damage can be expected.
The following now begin to make sense. I will change my choice on resuscitation at Provision Living to DNR. It will take the assistance of our family doctor to change my wife’s choice to DNR.
“Electrical therapy for the purpose of this guideline encompasses all care necessary for defibrillation during cardiac arrest on all patients with ventricular fibrillation (fast irregular beat) or pulseless (fast regular beat) ventricular tachycardia (that yield little or no blood flow or pulse).” (AARC Clinical Practice Guideline, 1995, Defibrillation during Resuscitation)
A Critic's Assessment of Our Approach to Cardiac Arrest
“”What we do know is that untreated ventricular fibrillation will deteriorate to asystole (no discernible electrical activity on the ECG monitor, “flat line” on monitor) over a period of minutes, and probably more rapidly in patients with more advanced cardiac disease.”” Gust H. Bardy, M.D. N Engl J Med 2011; 364:374-375January 27, 2011DOI: 10.1056/NEJMe1012554 (The relative value of CPR and defibrillation makes for interesting reading.)