YOU do not know it, but this morning you are going to die. You rise from your bed at 6.15 a.m., your usual wake-up time,shuffle sleepily into the bathroom to wash, get dressed, and eat your breakfast. You put on your shoes, struggling a little as you bend down because, after all, you are not so young anymore and, even with the help of a long shoehorn, slipping into a pair of shoes is a strain and leaves you breathless. You pick up your briefcase and your walking stick at the door. Your wife, as usual, is also getting ready to go and bustles about in the kitchen. You tell her, with suppressed irritation, that yes,this afternoon you would do the errand you had promised her. You are looking forward to later in the evening when you are going to have dinner with a close friend. You stifle a coughbecause you do not want your wife to worry, even though the cough has been tormenting you for a week, if not longer, and the clogging mucus and phlegmgives you a sore throat and makes you nauseous and wanting to vomit. You feel tired from the exertions and did not have a good night’s sleep. You step out of your house.
It is 7.10a. m. At this time your neighborhood is relatively quiet. Beyond your street the city grumbleswith traffic. You walk a few paces forward. You hear the chirrup of a small bird. You are about to cross the road. Suddenly, your legs crumple and you fall forward. Your face hits the concrete pavement. You don’t feel the stones cutting your forehead because, in that instant, your heart has stopped.
A cardiac arrest is an electrical malfunction of the heart and the pumping action is abruptly halted. As blood fails to circulate, your vital organs, especially your brain, are starved of oxygen. Carbon dioxide begins to accumulate. If somebody witnesses the event and reacts quickly, calls emergency services and administers cardiopulmonary resuscitation (CPR), you have a chance. Let’s say a neighbor does see you.She does not know how to give CPR– few people do. Scarcely three minutes have passed but brain cells are already destroyed. Technically, at this moment you are already dead. This state, however, is reversible.
What happens next, whether you are resuscitated and brought to hospital, whether you receive intensive care, survive without or with minimum brain damage, whether you go on to enjoy a normal life, fall into a coma or a vegetative state, or die right there, on the street in front of your house,will not only depend on your physiological condition. Your survival now is also determined by the city in which you liveand the state of your country.
If you are lucky enough to get to a hospital with a heartbeat, your medical emergency will involve collaboration among a team of doctors–you will be received by intensivists and anesthetists in the ERand seen by a range of organ specialists if you progress to the intensive care unit (ICU). The most important and immediate purpose for the team will be to preserve your brain function. This is where therapeutic hypothermia, TH, may be called into play. TH is a relatively newprocedure but has already become a mainstay of advanced intensive care. The aim is to rescue the brain and prevent further neurological damage after cardiac arrest. The body is rapidly chilled to around 32 degrees using a combination of intravenous fluids, ‘ice’ blankets and helmets. In this state of induced coma, the cold thwarts the destructive processes that occur when blood circulation is restored. The process dramatically improves your neurological outcome. After about 24 hours your body is slowly re-warmed to normal temperatures and sleeping medications will be gradually stopped. If conditions are stable, brain function can be tested and, possibly within three days, you could be fully awake. You’ll just feel like death warmed up.
But getting you to this point can be fraught with difficulty, particularly if youhave underlying medical problems. You would also be drawing on massive hospital resources. You will need a mechanical ventilator if you cannot breathe on your own. Another machine might be assisting your heart. You might require a tremendous amount of medication to maintain your blood pressure. Organs could start to fail. You might, for example, need dialysis for your kidneys. Keeping you alive can cost up to half a million dollars.
Here are three random scenarios on how you might fare.
If you live in London, an ambulance should be with you in about 8 minutes. On arrival, CPR would be done immediately and it is likely a pulse would be obtained within 20 minutes. The National Health Service, the NHS, funded by the UK’s stringent taxation system, provides universal medical healthcare. One million patients every 36 hours are treated under this system. You would not need to worry about medical bills. You will be taken to an intensive care unit where you will be assessed against criteria that would decide whether you are eligible for therapeutic hypothermia. If you get through this screening, then the TH process will start. How long you would be kept on life support after your body is re-warmed is determined over a number of hours and against a range of considerations. The first 72 hours are critical. If a poor prognosis is foreseen, care may be withdrawn sooner rather than later.
If you live in a European city, your medical care will probably be partially subsidized by the state and by an insurance policy, the cost of which is determined by the level of your income. As long as you pay your insurance, you would not need to worry about the cost of your treatment. In a small city such as Amsterdam, an ambulance could get to you in 5 minutes. You will undergo TH as a matter of course. After re-warming, doctors will work to stabilize you and can defer prognostication for several days, even up to 7 to 12 days. They will err on the side of caution.
But suppose you live in neither of these cities. You live in Manila where traffic keeps the roads blocked for hours on end. Some major hospitals are able to give you TH. But it is unlikely you will get there in time. If you do, your relatives will need to pay a massive amount of money before you are admitted. Your medical bills will be stratospheric.
Childhood malnutrition, tuberculosis, dengue, HIV, and maternal mortality are,quite understandably,your country’s major health priorities.Keeping a cardiac arrest patient alive with cutting edge techniques such as TH is a luxury, which is available only because there are a few very rich people who can pay for it.
But you are not rich. You are an ordinary person. You will lie on the pavement outside your home. Your neighbors will gather around you and help as best they can. Within minutes of your heart stopping, of your losing consciousness, you will die. It is a banal death. Your wife, your family and your friends will pray that your soul is at peace and say that it is “God’s will” and that it was “your time to go”.
For Dr. P. R. Tuinman and his team at the VUMC, Amsterdam.