Summertime in the City – Why does hypothermia have to be therapeutic?

brrrrrrr…

“Coldest winter I ever spent was a summer in San Francisco” – Mark Twain

“Don’t believe everything you read on the internet” – Abraham Lincoln

“Quotes are stupid” – Some idiot

 

Summertime is here and I for one am glad.  Glad that I get into my car in the high 70s and get out in the City somewhere in the high 50s.

At home it’s shorts and flip flops, at work it’s jackets and glad we wear wool pants.  When I return home, however, to temps in the 90s we rethink the wool.

In a recent conversation with a respected hospital administrator the term “therapeutic hypothermia” was tossed around rather freely, as if saying it for the 500th time would win them a set of steak knives.  It seems the powers that be are interested in bringing some active cooling measures to the only recently mostly dead.  This was the result of a series of meetings I somehow never made it to.  Laziness one possibility, apathy another, or I could have been reading charts and yelling at people.

In our discussion of the merits of the term “therapeutic” we wondered if having to mention a treatment is good in the title is a red flag we’ll look back on in the future.

“Try this therapeutic oxygen, it’s amazing, but avoid that passive oxygen, it’s no good.”

Making people cold can apparently help them recover from a cardiac arrest.  I guess some papers have been written and some friends looked at it and agreed so it became the thing to do.  Trouble I have is the recommended window of initiation of treatment.  It seems that if we can get their heart beating on it’s own again, then make them slightly cold within 4 hours and keep them there for 12-24, we can improve their chances of survival.

4 hours.

Our average transport time hovers in the teens and tack on a few minutes to get pulses back…let’s call it 1 hour.

One full hour, 60 minutes from when the heart stops to when we hit the doors of the ED with pulses and a BP.  That leaves 3 hours to initiate CONTROLLED cooling in a CONTROLLED environment.

My conversation with the hospital rep then turned to the process that will be used to monitor the cooling efforts.  Thermometers perhaps?  Maybe, we’ll see.

On a side note, we also have a problem with a little something called passive hypothermia wherein Erma Fishbuscuit drops a few tenths of a degree just by sitting in her drafty bay window, then we carry her out to the rig on a cold chair with a single wool (wool again!) blanket.  Then we have to get her all tucked in and cozy warm.  Makes sense.

But for her the hypothermia is not therapeutic, had she suffered cardiac arrest, then yes, but late for her dialysis, then no.

So what to do?  Hypothermia seems to be the next big thing, but I’m not sure the effects it will have in my system.  Could we get more people leaving the hospital without deficits from cardiac arrest if we focus on the weakest links of the chain of survival?  Bystander CPR, Public Access Defib and ED CPR quality? (See how I threw that in there?)

 

The conversation ended with a desire to see all policies and protocols require footnotes showing the research that supports the contents.  Then we realized half the manual would need to be discarded and laughed.  It wasn’t a triumphant laugh, but more the kind of laugh when you realize your car was stolen.

As Clinical Supervisor I am tasked with ensuring my crews follow established policy and protocol while acting in the best interests of their patients.

But Justin isn’t sure what kind of an impact making the recently deceased shiver will have.  On a cold summer’s day in the City we could probably just leave the blanket off and get good results.

 

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5 thoughts on “Summertime in the City – Why does hypothermia have to be therapeutic?”

  1. That’s why The Borg doesn’t do it. t can safely be deferred until hospital arrival. When it is used, the improvement in neurological recovery is very impressive, but thus far there is no hard data to show any benefit to doing it prehospitally.

    We do have a policy of transporting our ROSC patients to a facility that uses therapeutic hypothermia over those that do not, even if closer, provided such a facility can be reached within 15-20 minutes.

    1. Our system is designing jsut such a policy.  Currently there is no delinitation between a post recus with a BP and signs of spontaneous respirations and a CPR in progress. “closest facility” still reighns supreme.  Maybe why we’re at the save rate we are…thanks Kelly.

  2. Maybe your system is different, but one of the reasons we started doing it was that the hospitals weren’t. Our medical director at the time went to the major hospitals and told them that if they wouldn’t commit to continuing TH, he’d just direct us to bypass them. Amazingly, they suddenly were able to come up with the funding to buy the equipment.

    Which is one of those things that EMS 2.0 should be doing, pushing hospitals to do things that are good for patients.

  3. The hospital that gets all of my codes (resuscitated or not) seems to have some set of super-secret hypothermia criteria that even the EM residents aren’t familiar enough with to know them without looking it up somewhere other than the trauma room.  

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