‘No blip-blip-blip on the screen. It was just a straight line’
Normally, “the colder you get, the longer (your heart is stopped), the more difficult it is to get a full recovery — or to survive at all,” he continues. But Giesbrecht does allow for a bit of luck.
“This guy, once he collapsed, he collapsed in a very good place and he was lucky he had a very good friend,” he says, referring to Reid’s frantic search.
“And when he got to the ER, he had a medical team that didn’t just pronounce him dead.” Kingston General Hospital Just before 8 a.m. on that Friday, two paramedic teams had finished separate calls that brought them to Kingston General’s emergency department when their dispatcher called.
Jonathan Andreozzi and partner Andrew Liersch bolted in their ambulance, racing to the pier in just over a minute. Julie Socha and her partner, Lise-Anne Lepage-McBain, followed. The police were already there, speaking to Alex Reid.
Andreozzi found Jafar had no carotid pulse. No breathing. He and Liersch began a rapid assessment, scanning for obvious signs of death: rigor mortis, stiffness in the muscles, lividity in tissue. None were apparent.
“How long was he down without a pulse?” Andreozzi says. “For all we know, it could have been hours.”
As they quickly began CPR and moved Jafar to a stretcher, the paramedics all had the same thought: a hypothermic patient isn’t dead until the patient is warm and dead.
Liersch and Lepage-McBain shared CPR duty. Andreozzi and Socha pulled the stretcher across heavy, crunchy snow and loaded Jafar into the lead ambulance. Socha started a saline solution intravenous in Jafar’s arm. Andreozzi suctioned vomit from Jafar’s mouth and cleared his airway. A heart monitor was attached: no heartbeat.
Lepage-McBain took over CPR while Liersch drove the ambulance the 900 metres to Kingston General’s emergency department.
The hospital doors whooshed open. Staff was ready. Liersch had radioed: 21-year-old male, VSA.
Jafar was whisked into the resuscitation room. Andreozzi gave a verbal report while the emergency team began its work.
Chest compressions continued as Jafar was wheeled in. His wet clothes, a thin T-shirt and pants, were cut off. He was intubated for assisted breathing. A heart monitor replaced the paramedics’ gear. Epinephrine shots were prepared. Two more IV lines were inserted. Saline solutions were being heated to 43 C — fluid to warm body cavities. A rectal thermometer read: 20.8 C.
“The lowest temperature I’d ever seen was 28 C,” says nurse Jane Lewis, an emergency department veteran who was “scribe” that day — the chronicler of all the “organized chaos” in the room to chart patient treatments. “I’ve never seen anybody that cold.” Jafar was also “asystole.” “That’s what people call a flat line,” says Dr. Joey Newbigging, one of the emergency department physicians working that day.
“There was no blip-blip-blip on the screen. It was just a straight line.”
Calm but aggressive teamwork continued to, essentially, manually warm the man found on the pier.
The heated saline flowed into veins in Jafar’s arms. It was also cycled into his bladder through a catheter; add, drain, repeat.
Newbigging cut into Jafar’s chest, just under his right armpit. The incision was to insert a tube “through which we could flow warm fluid into his chest (to) bathe the right lung and right side of his heart, which would warm his blood,” the physician says.
There were as many as 15 on the team to help Jafar; doctors, nurses, respiratory therapists, support staff, aides running bags of saline into the room.
“Everyone was pretty invested in this case because it was a young person,” Newbigging says.
The emergency department staff also knew the patient had likely tried to end his life.
The team pushed to buy Jafar time should he be deemed a candidate for the next stage of resuscitative measures. Chest compressions, a physically exhausting manoeuvre performed for at least an hour, were as vital as any other act that day to force oxygen-carrying blood to the brain.
“With the CPR, it’s trying to make the blood vessels squeeze to get more blood to his brain because that’s really what we’re trying to preserve and rescue,” Newbigging says.
Soon, a critical question arose: was Jafar suitable for a procedure called extracorporeal rewarming, which could quickly raise his core temperature closer to 37 C? Using the cardiopulmonary bypass system, the procedure takes circulation outside the body so blood can be warmed and oxygenated then returned.
One way to determine Jafar’s suitability was through a blood sample drawn for a serum potassium test.
Upon death, human cells break open and spill their potassium stores into the bloodstream. Those salty spills can be measured. High readings from a serum potassium test would suggest Jafar was too far gone — dead too long — to be saved. He needed a result of less than 10 milliequivalents per litre to be considered for the next round of last-ditch resuscitation efforts on the cardiopulmonary bypass machine. Jafar’s test result was 7. “That, basically, is the green light,” recalls Newbigging at seeing the lab result. The quick decision in the ER: “Let’s try.” Still, other things needed to line up. A bypass machine and a cardiac surgeon had to be available, along with support teams and technicians.
Surgeon Andrew Hamilton was free. He said he’d try, too.
At about 8:48 a.m., Jafar was wheeled from emergency — with a nurse on the stretcher, straddling his stomach, still performing about110 chest compressions a minute — and rushed into the operating room. Newbigging accompanied Jafar.
Jafar’s last core temperature in the emergency department was recorded by Lewis at 22.8 C; a two-degree increase in about 45 minutes, largely from heated saline irrigations and the warming blanket. Extracorporeal rewarming could raise his core temperature by nine degrees in an hour and during that time, perhaps his heart could be restarted. Perhaps.
Another question lingered: would he want to be revived?
The student had attempted to end his life. Now an all-out resuscitation effort was underway. This was not lost on the emergency department team — and that this patient “was a young kid who was obviously unhappy,” Newbigging says.
“If we get them back, are we helping them?” the physician says of patients who arrive with no vital signs. “Because we may not be bringing them back to the state of health that they were in when they first got sick. A lot of people ended up
“The lowest temperature I’d ever seen was 28 C. I’ve never seen anybody that cold.” JANE LEWIS EMERGENCY ROOM NURSE
being quite disabled and never get back to independent living.” Nurse Lewis was blunt. “Did we do him a favour?” Cardiac bypass In the earliest days of heart surgery half a century ago, controlled clinical cooling of the body aided intracardiac surgery. Surgeons had a little extra time to work on an inert heart when circulation was temporarily halted.
Today, extracorporeal rewarming equipment (commonly called cardiopulmonary bypass machines) is so “biocompatible” with living tissue that cardiac surgeon Andrew Hamilton says the hard part “is making the decision to do it. That’s No. 1.”
Extracorporeal rewarming is the only way to effectively rewarm a patient whose circulation has arrested, Hamilton says. That is done by circulating the blood outside the body where it is warmed, oxygenated then returned.
Potential candidates can be rejected if deemed they are beyond saving. Jafar’s low serum potassium count got him on the bypass machine — even though he was still flatlined.
“It doesn’t matter if the heart’s not beating at this point,” Hamilton says.
The surgeon explains that for Jafar’s extracorporeal rewarming, one tube about the size of a thumb was fed up from the groin vein into the venous confluence of the heart, allowing removal of the blood from the body to the machine. Another slightly smaller tube was inserted into a groin artery and was used to return the warmed oxygenated blood back to the body.
A profusionist attended the machine constantly.
Hamilton recalls when Jafar’s core temperature reached about 28 C, he applied external contact pads to the chest and delivered an electric shock of 200 joules. That was likely before 10 a.m.
“He was easy to get started,” the surgeon says, noting the patient had age on his side. “Nice young heart like that? Poof!” Finally, heartbeats. Strong ones. But serious complications flared when the time came to remove Jafar from the extracorporeal rewarming circuit. The combination of the hypothermia and duration of cardiopulmonary bypass had rendered his blood incapable of clotting, explained Hamilton. “In addition, this combination of factors caused his blood’s protective mechanisms to become abnormally activated, leading to, among other things, edema (swelling) of his lungs,” the surgeon says.
Hamilton says extracorporeal circulation can be used for days if needed, “but it’s a very toxic event to have your blood running through an external machine.”
“The longer you’re on the extracorporeal circuit, the more likely that you’re going to accumulate this toxic damage,” he says.
Jafar developed a condition called coagulopathy; his blood could not clot despite an alchemy of medications and adjustments to remedy the issue. Hamilton recalls there was bleeding into Jafar’s chest. Intensive-care-unit nurses Jennifer Bird and Vanessa Holmes recall blood was gushing out of the chest tube incision, too.
Jafar now required massive transfusions. Over his first 48 hours in hospital, Jafar received: 50 units of red blood cells; 32 units of frozen plasma (the liquid portion of whole blood that needs to be frozen in storage, then thawed for use); 20 units of cryoprecipitate — a concentrated component of plasma that contains high levels of clotting proteins — and eight units of platelets.
Dr. David Good is Kingston General’s hematopathology service chief. He wasn’t directly involved in Jafar’s case but reviewed records of the blood components used in his care. “The most common blood component is the actual pack of red blood cells (and) over two days, he received 50 units,” Good says. A red blood cell unit is about 400 millilitres per bag.
“A normal person’s blood volume is about 10 units,” Good continues. “He basically had his blood replaced about five times over the two days.”
Jafar’s blood group is AB positive — rare in Canada and found in about 3 per cent of the population, says Good. People with AB blood are considered universal recipients for red blood cells and platelets (meaning they can get these components from donors of any blood type) but require frozen plasma from an AB donor.