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Resuscitation Success Improved with Cooling


Joseph Ornato, MD, FACP, FACC, FACEP, launched a paramedic program in 2008 to help treat cardiac arrest patients and increase their survival rates. The day that led Ornato to make a change in his prehospital paramedic program began with a simple kiss on the cheek.

Learning Fast
At the time—1974 to be exact—Ornato was starting a cardiology fellowship at New York Hospital’s Cornell University Medical Center in New York City when he was “volunteered” to run the hospital’s fledgling paramedic program. “New York Hospital had started one of the first paramedic programs in the country, the only 24/7 program in Manhattan at the time,” he says. “I found myself in charge of running a paramedic program that served Manhattan at a time when most laypeople and physicians had no idea what paramedics were all about.”

But he learned fast. When calls came in, Ornato would hop on a rig and ride with the medics. During downtime, he helped them perfect various medical skills, including how to effectively intubate, start IVs more proficiently and work as a team to treat severely ill or injured patients. The paramedics paid close attention, and the results soon proved that all the hard work had been worth it. “Within a very short period of time, we had our first survivor from out-of-hospital cardiac arrest,” Ornato says.

A 60-year-old woman was brought into the hospital still comatose from her cardiac arrest. In the field, using many of the medical skills and techniques that Ornato had taught, the medics had intubated her and gotten her heart  restarted. The next morning, Ornato brought the group of paramedics into the coronary care unit to see her. She had already been extubated and was sitting up in bed eating her breakfast. “They couldn’t believe it was the same woman,” he says. “Within a couple of minutes, there were tears in our eyes, joyous that this woman had been saved from a condition that, in 1974, was virtually lethal—an out-of-hospital cardiac arrest in New York City.”

The patient expressed profound gratitude to the team for saving her life, particularly because her daughter was about to give birth to the patient’s first grandchild. She motioned for Ornato to come over to her. “I thought she was going to whisper something in my ear that she didn’t want the medics to hear,” he says. “Instead, as I leaned over the bed, she gave me a kiss on the cheek. I realized that this was a woman who, in 1974, had almost no chance to be alive from what had happened to her. And here she was, because of what I had taught paramedics. It was essentially a miracle.”

Advancing the Program
Joseph P. Ornato, MD, has come a long way since then. Today, he is professor
and chairman of the department of emergency medicine at Virginia Commonwealth University Medical Center in Richmond, Va., and operational medical director of the Richmond Ambulance Authority (RAA) and Richmond Fire and Emergency Services. He also now belongs to a rarified and small group of physicians who are board certified in internal medicine, cardiology and emergency medicine. But despite his journey, his thoughts are never far from that patient in 1974. Nor are his roots far from prehospital care and the desire to see it become the best it can be.

This focus has led to one of his latest achievements: helping to start an advanced and comprehensive postresuscitation program for central Virginia. The program was instituted in 2003. By 2008, it was focused on five goals:
1. Delivering continuous chest compressions using AutoPulse devices;
2. Spending a shorter time on airway management by inserting a King airway device if an endotracheal tube could not be inserted successfully on one attempt;
3. Spending a shorter time to first drug administration by inserting an intraosseous catheter if an intravenous line could not be inserted successfully
on one attempt;
4. Initiating therapeutic hypothermia as soon as possible by administering cold saline in the field during resuscitation; and
5. Delivering patients who experience return of spontaneous circulation (ROSC) preferentially to Virginia Commonwealth University Medical Center.
The medical center began functioning as a regional comprehensive post-resuscitation care center for an approximately 100-mile radius service area for its three regional medical helicopters surrounding the city. RAA’s supervisors respond to a cardiac arrest along with a fire first responder and paramedic crew.

The supervisor’s initial job is to initiate cooling by administering iced saline via the IV or intraosseous line. “The result is we can get a half a liter on average into the patient before their heart restarts,” Ornato says. “By the time they hit the door of our regional post-resuscitation center, the medics have administered about 1.5 liters of cold fluid on average. The patient’s body temperature is already down to about 35°, so we are already halfway or more down to our cooling target.”

On hospital arrival, the endovascular-cooling catheter is directly placed into the femoral vein, allowing providers to hit the target temperature of 32–33° C more quickly and to control the temperature precisely during 24–48 hours of cooling and during rewarming. “We also have the ability to place patients on full extracorporeal life support, which has provided some “miracle saves” in our program,” he says.

Effective Strategy
Ornato believes the program is the first to initiate cooling during resuscitation but acknowledges that EMS in such places as Seattle, North Carolina and New York City have similar prehospital cooling protocols that typically begin after the heart restarts. “In mid-central Virginia and North Carolina, it’s become very prevalent,” he says. “Virtually all of the counties surrounding Richmond, and many of our rural areas, are part of our program.”

Data on the effectiveness of cooling after hospital arrival is sound, and there’s no evidence of harm by cooling earlier. “No one has done the definitive study of therapeutic hypothermia started during resuscitation versus after the heart restarts to see whether it makes a difference,” he says. “But every bit of evidence we have from experimental and human trial data suggests that the earlier you begin to protect the brain the better the odds of survival neurologically

Since the inception of the program in 2003, Ornato and his team have successfully provided therapeutic hypothermia to more than 500 cardiac arrest patients and his hospital’s regional post-resuscitation center now provides therapeutic hypothermia and other advanced care to about 80 patients annually. “Our prehospital return of spontaneous circulation rates have increased significantly and, for patients who survive to be treated with endovascular cooling in our Advanced Resuscitation Cooling Therapeutics and Intensive Care (ARCTIC) post-resuscitation at Virginia Commonwealth University’s post-resuscitation center, our overall survival to hospital discharge is now over 50%,” he says.

The program provides a full range of organized post-resuscitation services,
including a multidisciplinary team approach to post-resuscitation care, therapeutic hypothermia, goal-directed management, continuous encephalogram (EEG) monitoring, admission to a specialized coronary intensive care unit with care provided by specially trained attending physicians and nurses and a minimum 72-hour moratorium on withdrawal of life support, after admission, to allow adequate time for accurate prognostication. “We conduct a two-hour battery of neuropsychiatric tests before discharge and an eight-hour panel of comprehensive cognitive, neurological and psychological examinations on patients two months after discharge to fully evaluate their recovery,” he says. “Our traumatic brain injury team provides rehabilitation care when needed.”

A Kiss
On occasion, Ornato finds himself thinking about the woman his medics saved back in 1974. It was a day, he says, that literally changed his life. “I realized at that moment that I wanted to dedicate my life and my research to improve prehospital cardiac care,” he says. “That’s what led me to go beyond cardiology into a career that’s been a blend of cardiology and emergency medicine, with a strong focus on prehospital care and research into sudden death and resuscitation.”

Ornato also thinks about the cardiac arrest patients who don’t survive, and the effect their death has on surviving family members and friends. “I told myself very early on,” he says. “When I go out to talk to a cardiac arrest patient’s friends and family, instead of telling them that their loved one has died or would never awaken, if I could instead tell them that they were going to be OK, it would be worth every ounce of effort I could put into improving emergency cardiac care.”

The many cardiac arrest patients that have survived under Ornato’s leadership and protocols couldn’t be more grateful. Some say thank you. Others simply give him a kiss on the cheek.


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