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April 23, 2011

Va. medics use therapeutic hypothermia to save runner

By Sarah Bruyn Jones
The Roanoke Times

STERLING, Va. — Ed Deitch didn't have a pulse. Clinically, he was dead. The 64-year-old high school American history teacher had collapsed about 100 yards from the finish of Saturday's National College Blue Ridge Marathon. Deitch had come from Sterling to Roanoke to run the half-marathon portion of the race with his 32-year-old daughter. He was beating her.

She had given birth to her second child three months earlier. "I saw somebody go down ahead of me," said Bethany Cook, Deitch's daughter. "But with the rain, and I didn't have my glasses on, I didn't know it was him until I reached him."

After tending to him in the road, medics quickly got Deitch out of the rain and into an ambulance, where a defibrillator was used. His pulse returned, but he was not conscious. He didn't respond to any simple commands. It took less than five minutes to take him to the emergency department at Carilion Roanoke Memorial Hospital.

There a new protocol for treating heart attack patients was put in place. Deitch was put on ice. The aim of induced hypothermia, in which doctors lower a cardiac arrest patient's body temperature to about 92 degrees for 24 hours, is to save the brain.

As Deitch's body struggled to recover from the biological problems that follow sudden clinical death, his heartbeat was there but his brain was competing with all of his other organs for oxygen.

Scientific studies have shown that cooling the body allows a person to survive with less oxygen and preserves cognitive function. It is used only on cardiac arrest patients who do not wake up once their heartbeat is restored and who meet other criteria for the treatment.

It doesn't work every time. So when doctors started to warm Deitch early Monday, they didn't know if he would wake up. He regained consciousness about 9 a.m. and his first words were a sign to his family that he was himself. "I knew if he was mad, he was OK," said Margie Deitch, his wife. "When she [the nurse] told me he said, 'What the hell. What the hell,' I knew. I said, 'Oh, that's Ed. He's back.' "

Wednesday he was sitting up in his hospital bed, emotionally overwhelmed with gratitude for those who saved his life. "They literally brought me back from the dead," he said. "You could not ask for better care." Carilion Clinic implemented its new hypothermia protocol in July. It is being done only at the system's flagship hospital in Roanoke, where two cooling devices have been leased.

The device consists of large pads attached to a computer. The pads are wrapped around the patient and cool fluid circulates through them via tubes that are attached to the computer. The cooling equipment costs about $40,000, and the non-reusable pads are $1,000 a patient. Carilion is planning to add a third device this year and is looking at whether to continue leasing the equipment or purchase it.

Additionally, Carilion has been working with first responders throughout the region to train them in the new protocol. The sooner the cooling process begins, the better. EMS crews are now carrying ice packs that can be placed at the patient's neck, groin and armpits while en route to the hospital. The therapy has been slow to come to Roanoke and the region.

Studies have promoted the benefits of induced hypothermia for cardiac arrest for nearly a decade. The American Heart Association has included the therapy in its lifesaving guidelines for cardiac arrest for years. In 2005, international recommendations urged the treatment, and a study in a 2002 New England Journal of Medicine article showed, on a small scale, that induced hypothermia appeared to improve the outcomes of cardiac arrest patients.

Dr. John Burton, Carilion's chairman of emergency medicine, said the treatment has been slow to be embraced at most hospitals but that the majority of larger academic centers now use it regularly. Salem-based LewisGale Regional Medical Center plans to implement induced hypothermia in its protocol for treating cardiac arrest patients, spokeswoman Nancy May said.

"We're definitely planning on doing it. I just can't give a specific implementation date or time frame," she said. Carilion put some time into developing its internal protocol, which included deciding how a patient's body temperature would be lowered, Burton said.

Besides using the device Carilion selected, some hospitals use internal cooling catheters or cooling blankets, he said. "It's a game changer," Burton said. "We can't believe it. ... But when you start cooling you will have a dramatic change in survival rates."

Burton said patients with cardiac arrest typically have between a 2 percent and 10 percent chance of surviving. Research shows that with hypothermia, the survival rates jump to between 35 percent and 45 percent, he said. More recent reports have shown some places reporting even higher survival rates, Burton said.

"Prior to this, we've been saving people's organs but we haven't been saving their brains so they still died," Burton said. The treatment has been initiated on 42 patients. Of those, half were cooled for the full 24 hours. Deitch is the hospital's ninth survivor. "All nine who have survived were like him; they had their memory," said Nancy Altice, a cardiology nurse specialist who has worked closely with the new protocol.

That isn't to say there aren't small gaps in the patients' memories, but they are able to function on their own. Deitch passed several tests checking his language, motor skills and problem-solving abilities, Altice said. The last thing Deitch remembers is picking up his race packet and T-shirt the afternoon before the race.

He doesn't remember anything from the day of the race. Deitch, who has been a runner for three years and ran the same race a year ago, said he also has learned a lesson. Doctors said his cholesterol and blood pressure were elevated. So even though he had been training well for the race and eating a nutritious diet, he wasn't taking care of those two symptoms.

After he was brought to the emergency department and the cooling process had begun, he was rushed to the catheterization lab, where two stents were inserted to open up the blood flow to his heart. Once he's discharged, which could be today, he will have to go through cardiac rehabilitation and will be monitored to make sure both his heart and brain are functioning well.

"I'm going to be at the start of the marathon next year asking everyone, 'Have you all had your cholesterol test and blood pressure checked?' " he said.

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