Editor's Note: J. Brent Myers, MD, conducted a JEMS.com webcast on Prehospital Hypothermic Resuscitation in April 2009. Watch the archive.
For a 49-year-old man recovering from a heart attack that stopped his heart seven times and landed him in a coma for days, Randy Hodgdon is feeling pretty lucky.
Lucky because when he collapsed without warning in early May, a nearby friend knew CPR. Lucky because EMTs from the Pittsfield Fire Department showed up within minutes to shock his heart into rhythm and restore blood flow to his brain. Lucky because a Concord Hospital cardiologist was waiting for him to unclog the blocked right coronary artery that was causing the problem.
But Hodgdon, of Pittsfield, also had the good fortune to have his heart attack just after the hospital added a new treatment option for patients like him. Doctors wrapped him in pads filled with cold water, put his saline drip on ice and cooled his body down to 92 degrees for a day after his heart surgery. "They call me the ice man," Hodgdon said.
The treatment, called therapeutic hypothermia, has been shown to improve comatose heart patients' chances of a good outcome from about 26 percent to about 49 percent. Without the treatment, Hodgdon might still have woken up from his coma, returned home to his family, and been walking, talking and driving. But probably not. "The chances of them leaving the hospital neurologically intact doubles," said Dr. Kenneth Deloge, the cardiologist who helped bring the new treatment to Concord.
Doctors don't exactly understand how cooling the body prevents the brain damage that often comes after a heart attack, but studies have shown it can make a lifesaving difference. When the heart stops beating, the brain's supply of oxygen is cut off. Doctors used to think it was the loss of oxygen alone that explained why many patients who lost consciousness would often die or suffer severe brain damage. Now, they believe the oxygen loss merely sets off a series of other harmful processes.
For hours and possibly days after the heart starts beating again, the body's reaction to the trauma can make neurological damage worse. Cooling the body slows that process down. "Restoring the heart is easy," Deloge said. "Restoring the brain is hard."
Deloge said he expects about 12 to 18 Concord Hospital patients a year are likely to receive the new treatment. Hodgdon was the first. Jamie Thoroughgood, Hodgdon's niece, said the cooling treatment sounded a little weird when the doctors first explained it, but family members immediately approved it. "All we heard was 20 percent or 40 percent," she said.
Before administering the cold therapy, doctors needed to sedate Hodgdon, insert a breathing tube and then paralyze his body to prevent any shivering that might counteract the cooling. Then they began dripping icy saline and turned on the machine that pumped cold water into pads wrapped around Hodgdon's legs and chest.
It's hard to predict the outcome for heart attack patients in comas, Deloge said. Some wake up within hours, some days later, and others not at all. One downside of the cold therapy is that families often have to wait longer to find out how the patient is doing. Because of the drugs used and the time the treatment takes, it is generally a minimum of three days before a patient treated with hypothermia will regain consciousness. It took Hodgdon a lot longer - for eight days a rotating group of 30 family members sat vigil in the intensive care waiting room, five at a time, and doctors told them to expect the worst. "They kept telling us, basically, don't have any hope," said John Hodgdon, Randy's brother. John Hodgdon said they gave up the lease on Randy's Pittsfield apartment and started looking at nursing homes. Their expectations couldn't have been lower when Hodgdon started showing signs of life.
At first, he was confused, and a little mean. He used foul language and writhed around in his hospital bed. "He was thrashing around, and there was a day or two where each nursing shift was an eight-hour wrestling match just trying to keep him in bed," said Dr. Kirke Wheeler, a cardiologist who treated Hodgdon in the hospital. But it wasn't long before the old Hodgdon returned, family members said. He slurs his speech a little and sometimes struggles with his memory, but overall he said, "I feel great."
Wheeler said he originally referred Hodgdon to HealthSouth Rehabilitation Hospital, assuming he'd need help returning to normal life. But by the time Hodgdon went to his appointment, he was so improved that staff told him he could move right back home. "He's home, he's walking around, talking, enjoying life," Wheeler said. "And with these events, we treat the heart attack and then pray and hope they wake up. And if this just gives people more of a chance to wake up and behave normally or close to normally, great."
Studies demonstrating the benefits of therapeutic hypothermia were published in 2002, but it's taken time for the treatment to spread into practice across the country. Deloge said he was encouraged to push for the treatment when he learned that New York City would only let ambulances take comatose heart attack patients to hospitals that used it.
Hodgdon, who used to be a laborer for a concrete company, hasn't returned to work yet, but he hopes he'll be able to soon. Since leaving the hospital, he's moved in with his sister, stopped smoking and started going to church. During the coma, he said, he saw the white lights and "the pearly gates" of heaven. "They told me to go back," he said.