Straight to the ‘Heart’ of the matter

Erich Segal had written a very readable book called ‘Doctors’ some years ago. For those who have not heard of this great writer, he is the chap who authored ‘Love Story’, its many sequels and other books like ‘Class’. In the opening chapter, the medical school dean is addressing a new class of wannabe doctors and he concludes his speech thus – Gentlemen, I urge you to engrave this on the template of your memories: there are thousands of diseases in this world, but medical science only has an empirical cure for 26 of them. The rest is ……..guess work. Segal wrote this in 1988…

I think the figure is pretty much the same, even today. Research doctors strive to find cures, Medical consultants & surgeons meanwhile work on brilliantly applying known cures while treating symptoms and ailments. When I repeat this story to people, few believe it. Try thinking about it rationally and you will realize that it is indeed quite right.

Medicine has always fascinated me, being a doctor’s son had many advantages & disadvantages, having been around surgeries, hospitals, having witnessed major surgeries first hand and being part of other medical events; I must say I understand a wee bit of what is going on!!

So, this time around, I thought of writing about the dreaded cardio world. While some people have come back from the land of the dead with astounding stories (From the land of the dead - read the ending para – a report), think about the normal happening - the common man in a medical emergency (typically accidents, cardiac issues & critical incidents like shooting) end up with a cardiac arrest and if not quickly resuscitated, becomes brain dead, and move on to the next world…….Finito.

So what happens actually?? This has been the belief and definition…

Cardiac arrest is the sudden, abrupt loss of heart function. The victim may or may not have diagnosed heart disease. It's also called sudden cardiac arrest or unexpected cardiac arrest. Sudden death (also called sudden cardiac death) occurs within minutes after symptoms appear. Brain death and permanent death start to occur in just 4 to 6 minutes after someone experiences cardiac arrest. Cardiac arrest can be reversed if it's treated within a few minutes with an electric shock to the heart to restore a normal heartbeat. This process is called defibrillation. A victim's chances of survival are reduced by 7 to 10 percent with every minute that passes without CPR and defibrillation. Few attempts at resuscitation succeed after 10 minutes. Brain death is defined by medical authorities as irreversible cessation of all brain activity. Simply stated, this means that the brain is no longer alive and cannot be brought back to life. A "dead" brain has never been known to recover, even though heart and lung function as well as kidney function can be maintained by artificial means for many days and sometimes two or three weeks.

In the last few years, a number of research projects have been going on, trying to analyze what actually happens between the two events defined above. The original intention behind the research was to gain time for medical intervention e.g. if a guy has a stroke at home, it does take time for paramedics or ambulances to arrive. Every minute is critical until brain death occurred, or so they thought.

The idea they started with was based on an established cooling process in the industrial world (Ice slurry cooling was used since 1976 in the Fishing industry & modern a/c chillers). Forced cooling or induced hypothermia of the body is what it is termed. Put simply, inject saline-ice slurry into the blood circulatory system to rapidly cool the body and you have possibly another 10 minutes of time to work with formal resuscitation and patient revival, thus delaying brain death. A good USA today article linked here provides many a detail, of the method. More formal articles like this from Logos, or Dr Becker’s comments, or the AHA advisory is available for ‘really interested’ people. This may very well become an accepted practice. Industrial support came from companies like Argonne.

How many of you know that the human heart is indeed stopped with ice during a conventional Cardiac Bypass surgery? And that it is restarted a few hours later? And believe it or not, I have seen it all – 7 hours of a complex bypass performed by a famed cardiac surgeon, standing right next to him – but that is another story!

But this recent Newsweek article adds a new insight to the layman. Suggestions are that the future may not be favor rapid revival with electric shock and oxygen after a cardiac arrest. When the body stops breathing, the cells in the body do not immediately die, as medicine has supposed, but instead goes into a form of hibernation for up to an hour. They die only when oxygen is pumped into the body, typically at the ER.


Here is what Dr Becker states - “What we found when we studied oxygen deprivation in cells astounded us,” explained Becker. “When cells are deprived of oxygen for an hour there is only 4% cell death. After four hours, cell death is only around 16%. Both of these numbers are low. The amazing thing was once we re-introduced oxygen to the cells they died off rapidly to almost 60% cell death. This re-oxygenation injury we termed reperfusion injury. We concluded that the re-introduction of oxygen must be handled carefully for the majority of cells to survive. Our studies will be concentrating on ways to prepare cells deprived of oxygen for the re-introduction of oxygen.”


So Dr Becker says - we should aim to reduce oxygen uptake, slow metabolism and adjust the blood chemistry for gradual and safe reperfusion. One method – Cool the patient - Hypothermia with Ice slurry!! How about turning up the a/c? Why not? They even have ‘coolcaps’ for babies, following the same principle!!

Heart attack – Some Words of advice – Warning signs of a heart attack include the following:
Uncomfortable pressure, fullness, squeezing, or pain in the center of the chest that lasts more than a few minutes or that goes away and comes back
Pain or discomfort that radiates to other areas of the upper body (e.g., one or both arms, shoulders, back, neck, jaw, or abdomen)
Shortness of breath (may occur prior to chest pain, may accompany it, or may occur without it)
Lightheadedness or fainting (may occur with or without chest pain)
Cold sweat or paleness (may occur with or without chest pain)
Nausea (may occur with or without chest pain)
So, don’t wait, get to a doctor. Try these steps

First aid
If possible, raise the legs up 12 to 18 inches to allow more blood to flow towards the heart
Immediately place the palm of your hand flat on the patient's chest just over the lower part of the sternum (breast bone) and press your hand in a pumping motion once or twice by using the other hand. This may make the heart beat again.

How is the heart stopped & restarted during cardiac surgery?The body temperature is cooled down to 28 degrees Centigrade and injects ice-cold (about 4 degrees Centigrade) potassium chloride solution. This stops (arrests) the heart in a relaxed state (diastole). This step is done to protect the heart by transforming it into a “hibernating” state. This is one of the advances in cardiac surgery that makes it a lot safer procedure compared to, say, 15 or 20 years ago. When all the anastomoses (“hook-ups”) of the grafts to the coronary arteries are completed, the patient is rewarmed to normal temperature, and the heart is perfused (supplied with rewarmed blood) through the new grafts. This invariably restarts the heart. Occasionally, the heart needs to be “shocked” to restart its beating. This “electrical (shock) defibrillation” is not harmful to the heart or the patient

BTW Don’t believe everything you read- An internet memo on coughing ‘How to survive a heart attack when alone’ has been around for many years. AHA does not endorse it though there are some doctors like Tadeusz Petelenz who say it is quite OK. On the other hand, it still is a real technique (especially in cases of arrhythmia) used in hospitals for certain situations, but its use as a CPR is urban legend!!

Tail note - For ages, the usage ‘He is big hearted’ has been around. Is it good? Well, athletes have big hearts, but in a normal man, if the heart gets enlarged, it could mean major clinical issues & problems. A
detailed article.

BTW – Newsweek beat me by publishing a detailed article on
all this yesterday. I had been keeping this blog in abeyance for 3 months!!

Comments

Nanditha Prabhu said…
this was an informative post though it came a day later than the news week!
i surprised to know about the use of ice!you have a first hand knowledge of all this?
Maddy said…
yes, nanditha, I observed one of those marathon 7 hr bypass surgeries from start to finish, standing next to the surgeon!! but I do not have first hand knowledge of ice slurry & modern techniques

after the surgery the doc asked, what do you think? this is a lot different from your engineering right? and i said yes. the great doc went on to say that what he did was just glorified tailoring!!
Anonymous said…
Two years ago, i had a heart attack. M.I.

Morning at around 9AM, when I was taking bath, it started. At first I thought it may be muscle sprain or something like that.

As I had to go to office at any cost, I didn't care about it much. In the office, though I was somehow able to do my job, I was feeling very very uncomfortable. I thought it may be stomach problem. So I took my bike, went to a nearby medical store and had some Digene.Still not getting better. Pain in the shoulder, radiating to other parts etc etc.

At around 4 pm I left the office thinking that some rest at home may make me feel OK. Nothing happened. So I took my bike, went to a nearby hospital and did an ECG.

The technician asked me looking at the report " did u come alone?". I said yes. Then i went to the doctor, he advised me to visit another doctor. That doctor, asked me to go to a hospital where cardiology facility. I took an auto and reached the hospital. The second doctor had called the doctor at the new hospital and told him that a patient is coming.

I showed him my ECG. Doctor asked me " where is the patient with this ECG?". I said " doc, I am the patient"' The doctor looked at me with total total disbelief.

Then I was admitted to ICU...2 days there. One week in hospital and one month total rest.

Doctor later told me that I was simply risking my life. A silent heart attack could be fatal...

So my advice is, when in doubt, consult a doctor immediately.

(pardon me for being anonymous)
Nanditha Prabhu said…
Glorified tailoring! yes indeed....i think it is an apt description.
my grandfather too walked into a hospital by himself and straight entered the ICU....similar to what anonymous said!
Guru said…
Heart attacks seem to occur when people least expect it. The fatal victims include cardiologists and heart surgeons. Dr Christiaan Barnard
the pioneering heart transplant surgeon reported died of heart attack in 2001.
Talking about the heart attacks, how many of us know about "Nuclear Cardiology" that can assess to a certain extent, the risk faced by the heart? A study of the distribution of a radioactive tracer called 99m Technetium labeled SestaMIBI in the heart muscle is made after the injection of the radio-pharmaceutical at stress (after doing a Treadmill for eg)and at rest. Use of Radionuclide tests for management decisions in patients with known disease include : 1. Deciding the need for cardiac catheterisation
2. Assessing “borderline” stenosis
3. Deciding the need for CABG (Bypass graft)
4.Deciding the need for angioplasty
5. Risk stratification following MI
6. Risk stratification before non coronary surgery
7. Evaluation of the results of therapy.

While a coronary angiography gives details of the vessels and the blocks within them, if any, Myocardial Perfusion Scintigraphy tells us whether the blocks are significant or otherwise and the consequences of the block. The scintigraphy (scanning) tells us whether the muscle in the affected is viable or not. Thus it helps the cardiac surgeon in deciding about the future course and management of the patients. If done at appropriate times, many of these investigations can either prevent or at least postpone the major event of "Heart Attack".
diyadear said…
medicine n doctors n hospitals make me dizzy.. i get soo uncomfortable.. though im sure having a fair knowledge of all this will be excellent, i cudnt make myself to read ur article fully :(
Pradeep said…
Very interesting one, esp that ice part... didn't know actually
Maddy said…
thanks Dr YNI, thanks Pradeep, Diya & anonymous...There is a new type of angiogram in US these days, it is called 64 slice CT which is very accurate & provides a nice & accurate color 3d picture of the heart and the adjoining arteries...also a calcium count, pretty good i am told and in many cases better than the invasive angiogram that is done these days!!! The invasive one is of cours better for certain cases!
harimohan said…
dear maddy
nice blog new things for me will have to read up
medicine is a changing science like all
so lets hope things are beter in future
bye
harimohan
Blog was really interesting. Being a Bio student, I am interested in stuff like this. Could you write more? Human Anamtomy interests me so much, The Heart, The Brain, they are not as simple as I think...they are fascinating. For me, Bio is not bi-hearting words like "Coronrary Thrombosis". I am sure I shall go through every word if you write about Medicine.
Maddy said…
lakshmi - I did not know that these are of such interest, but it does seem to be, so i will pen some more interspersed with other blogs, so please visit often. I plan one on a bypass, one of these days, have to edit a rather lengthy story written earlier, down to a blog..

Hari - you and others like you are our hope to prove Erich Segal wrong..

Guruji - even though earlier reports stated that Dr Barnard had died of a heart attack, an autopsy revealed that he died of an accute asthma attack!!
Guru said…
I think you referred to web articles,
which do not usually have provenance.
Working at that time in Vienna, I watched the the symptoms described by his wife on the TV. For many, it sounded like cardiac arrest.
Maddy said…
Guru - surprising that you made a diagnosis based on his wife's TV interview. Autopsy reports & press statements confirm he died by the pool side following an asthma attack.

Reconfirmed by various newspaper reports.

http://www.hri.org/news/cyprus/cmnews/2001/01-09-04.cmnews.html

http://www.dispatch.co.za/2001/09/05/southafrica/ABARNARD.HTM

http://www.cbc.ca/world/story/2001/09/02/barnard_doc010902.html

An autopsy earlier yesterday confirmed that the former heart surgeon had died of an asthma attack after swimming in his Pathos hotel pool.

Speaking at a press conference at Pathos Central Hospital after the postmortem, Dr Eleni Antoniou said the autopsy showed Barnard's heart was in excellent condition, "similar to that of a newborn baby".
She said the cause of death was a bronchial blockage brought on by the attack.

"It appeared that he had an intense asthma attack and was not able to locate his inhaler. He had reportedly suffered several bad asthma attacks the previous evening during a dinner function.

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