UAMS Heart Team, Paramedics Save Landmark Man with CPR, ECMO Combo
| As a cable TV lineman and admitted workaholic, Dillon Howard often spent 12-hour days climbing telephone poles, seemingly impervious to temperature extremes. On his off-days, the motocross enthusiast liked to race across rough terrain at breakneck speeds.
To call him a rugged outdoorsman would be an understatement.
Then one night in mid-February, while at home with his wife and 9-year-old son, the 30-year-old adventure seeker’s body suddenly stopped working. He lost all feeling in his legs and became unable to move.
He had been feeling tired for a few days but chalked that up to the flu. Unaware of any serious health problems, his sudden incapacitation startled him and his wife, Autumn.
Within minutes, an ambulance arrived at their home in the Landmark community just south of Little Rock, and Howard was loaded into the back. Then, before it could head for the hospital, his heart stopped beating, and he lost consciousness.
The paramedics began cardiopulmonary resuscitation (CPR) efforts immediately but struggled to maintain a steady pulse. They knew they needed to get Howard to the University of Arkansas for Medical Sciences (UAMS) as quickly as possible for placement of an extracorporeal membrane oxygenation (ECMO) machine, which temporarily takes over the work of the heart and lungs. But UAMS was about 13 miles away, and every minute that lapsed lessened Howard’s chances of survival.
This is when a coordinated effort known as extracorporeal cardiopulmonary resuscitation (ECPR), which UAMS has been using for about a year to revive cardiac arrest patients both inside and outside the hospital, kicked in.
For it to work, CPR must begin within five minutes of a cardiac arrest and be administered continuously until the patient can be placed on an ECMO machine, which includes a mechanical pump, an oxygenator and cannulas inserted into a patient’s vein and artery through the groin. ECMO provides cardiac output and perfusion to the body by delivering oxygenated blood. It buys time by providing mechanical support for the patient’s organs, allowing doctors to diagnose and treat the reason for the cardiac arrest.
The paramedics alerted UAMS, and an emergency room physician stayed on the line to provide medical guidance while the ambulance sped toward the hospital. A mechanical device in the ambulance took over the delivery of chest compressions until the UAMS ECMO Team, quickly summoned in after regular work hours, could place Howard onto ECMO immediately upon his arrival.
Howard survived, thanks to the combined efforts of MEMS, UAMS Emergency Department staff and the ECMO Team. Doctors determined his cardiac arrest was caused by a rare adrenal gland disorder, Addison’s disease, which they then treated.
When he went home a month later, Howard had no brain damage or major physical impairments, despite having gone without a steady pulse for 50 minutes before being placed on ECMO.
Adequate chest compressions can provide enough circulation to sustain vital brain function, which is why bystander CPR in the community is imperative, said Amber Westpheling, RN, an ECMO coordinator at UAMS, adding that it buys time to initiate ECPR and minimize neurological deficits.
Now, nearly a year later, Howard takes daily pills to regulate his sodium and is more conscious of listening to his body, so he doesn’t overdo it physically. He traded in the high-wire lineman job for working at a local cable company doing inspections, enabling him to spend every night at home with his family instead of traveling and living in hotels.
He has also had to re-learn how to walk, talk and eat again.
“When I was working on the pole,” he said, “I was sweating my butt off every day.” The cardiac arrest, he said, “has kind-of changed my outlook on everything. I used to put work first, before family. I was a hard worker and wanted to make a lot of money. Now I can be home every night. Honestly, I’ve not felt this good in a long time.”
Just two days after coming home, he and his wife went fishing with her siblings.
“It wasn’t easy,” he said. “I got out of breath right away and had to sit down and catch my breath. It took me a little bit to be able to work my stamina back up to where it was, but I feel like I’m better than ever now.”
Howard credits his wife, the paramedics and the UAMS ECMO team with saving his life that night in February, which, ironically, ran into the early hours of Valentine’s Day.
“If it weren’t for them, I would be dead,” he said. “It all lined up just right.”
Members of the UAMS ECMO team agree that the circumstances conspired perfectly that night to save Howard’s life. But because of the limitations of ECPR, it cannot help everyone.
For one thing, ECMO equipment is expensive and requires special training to operate, which means it is generally available only in major metropolitan hospitals such as UAMS.
For ECPR to work, chest compressions must begin within five minutes of a cardiac arrest and continue until the patient is placed on ECMO at the hospital. Mechanical chest compression devices make the process much easier, but many small or rural ambulance services don’t have them.
According to the American Heart Association, 90% of cardiac-arrest patients do not survive.
Even with early and continuous chest compressions, ECPR patients often cannot survive beyond 60 minutes. Patients placed on ECMO after 30 minutes of chest compressions have a 60-80% survival rate, while the rate drops to 50% after 30 to 45 minutes of continuous compressions and then to 25% after 45 to 60 minutes.
“Despite the remarkable advances and improvements in outcome that have been accomplished in the field of complex cardiovascular diseases, one particular area that has been difficult to improve upon has been that of cardiac arrest,” said Michael Luna, M.D., a professor in the UAMS Division of Cardiovascular Medicine who oversaw Howard’s care and was instrumental in saving his life.
“Cardiac arrest, when not intervened upon, will lead to death,” Luna said. “Although there are measures that can be applied to these patients in an effort to abort certain death, they are successful in only a minority of patients. ECMO cannulation during conventional CPR allows the body to be circulated with oxygenated blood until we can figure out what lead to that patient’s cardiac arrest. If that inciting insult can be diagnosed and treated, then it gives the patient a shot at recovery.”
Luna added, “We have been hard at work, building our program to become a high-level center capable of providing care to the sickest of the sickest, and with that collective mindset, I am confident we can help more and more patients just like Dillon.”
Randy Rice, RN, clinical services manager for UAMS’ advanced heart failure program, said he is closely watching some ECPR pilot programs in other states, such as Minnesota and California, which are testing ways to save people who experience cardiac arrest outside the vicinity of a major hospital.
Howard said that the more he has learned about cardiac arrest, “I actually feel very lucky. I’m blessed, to say the least.”