June 17, 2008

Some Doctors Treat Heart Attacks With ‘Cooling’

Two months after a clogged artery stopped his heart, Tom Fuller plucks his bass guitar just a tiny bit more slowly than he used to. His handwriting is a little sloppier.

After that, Fuller runs out of his list of things he can't do quite as well as he did before April 13, when he collapsed in his Sacramento driveway.

While no one can be certain, his cardiologist thinks it's "very possible" that Fuller's recovery was aided by the new cold wave gradually taking hold in emergency care.

A carefully applied, carefully maintained reduction in body temperature seems to work wonders in some people whose hearts have been shocked back into beating. It improves survival rates and lessens brain damage.

Doctors don't know exactly how cooling exerts its protective power, but evidence that it works is growing. The American Heart Association has been urging cooling for certain cardiac arrest patients since 2003.

Yet five years later, many hospitals still haven't cooled their first cardiac patient.

"It has been slow to be adopted in many places," said Dr. Lance Becker, director of the Center for Resuscitation Science at the University of Pennsylvania, and head of the heart association's research working group. "There's no question it is slower than we'd like."

In the Sacramento region, neither UC Davis nor any Kaiser hospital routinely cools all patients who fit the latest heart association suggestions. Sutter hospitals in downtown Sacramento have been cooling more patients in the past year, as individual doctors requested it.

Only Mercy San Juan and Mercy General have full-fledged protocols outlining who should be cooled, when, and how to coordinate the hours-long process with intensive care and other departments.

"We're probably the earliest in town, but I think we're a little late to the table," said Dr. Scott Baron, who is Fuller's cardiologist and chair of emergency cardiac services at Mercy San Juan Medical Center in Carmichael.

"So many people have cardiac arrests and have CPR and they come in and they never wake up," Baron said. "The people who get this hypothermia do way better."

90 degrees up to 18 hours

Mercy San Juan and Mercy General started their new cooling protocol in February, using chilled intravenous fluid and cold wraps to gradually bring body temperature down to roughly 90 degrees and keep it there 12 to 18 hours.

UC Davis, Kaiser Permanente and Sacramento's two Sutter hospitals are all working on protocols that would spell out when and how they should cool people, with hopes to have the rules in place later this year. One Kaiser hospital is training nurses on a machine that should make cooling more efficient.

For the most part, smaller Mercy and Sutter hospitals in communities from Davis to Woodland to Roseville aren't using deliberately induced hypothermia to treat heart patients.

Nationwide, Becker said, only about half of U.S. hospitals are following the heart association's cooling recommendations, and it could take another three to five years before 90 percent do.

He estimates that if therapeutic cooling were fully instituted nationwide, it could save or improve thousands of lives annually.

Becker is not surprised that cooling has joined a long list of research-driven innovations that take years to make their way into everyday medical practice.

Some doctors and hospitals prefer to wait for more data. Others move slowly because change is time-consuming.

On top of that, hypothermia has lagged because relatively few heart patients fall into the group that benefits from it. For example, people who walk into a hospital with chest pains but never lose consciousness don't need it. People who are resuscitated and quickly gain consciousness on their own also aren't candidates.

The procedure also demands coordination across broad groups: emergency rooms, intensive care wards, cardiac testing and monitoring areas, and sometimes even ambulances.

"It requires a change in the mind-set of everyone involved," said Dr. Peter Murphy, who directs the intensive care unit at Mercy San Juan. One or sometimes two nurses per patient are needed, he said.

Doctors can only guess at what happens to protect people when they're cooled down below the body's normal 98.6 degrees. Cooling may slow damage that continues even after a heart is restarted, or it may reduce the harm caused by oxygen returning to oxygen-starved areas. The roles played by brain chemistry, free radicals in the bloodstream, and metabolic rates all are being investigated.

NFL player got procedure

While many hospitals have moved slowly on cooling, word is spreading among the public. Television doctors use it. People remember that Buffalo Bills player Kevin Everett avoided paralysis after he was injured on the field last fall -- and then cooled down as part of his treatment.

In hospitals that don't offer cooling, relatives sometimes have stepped in to demand it.

"I have gotten phone calls at 2 a.m. from places around the country where an ER doctor says this family wants me to call you, and we've never cooled anyone here," Becker said. The doctors ask him to talk them through it. Once they see the results, he said, most doctors become cooling converts.

Fuller, who sells truck parts and plays guitar in a band called Roni and the Flight, is also a believer.

"I feel real fortunate," Fuller said, before getting together with friends he's made music with for decades.

Three of them gathered in a garage last week, to trade throaty songs about sweet-lovin' women and grateful men, along with their own stories of aching backs and surgeries.

Fuller said he has consistently surprised physical therapists and others on his rehabilitation team.

"Most people familiar with recovery from these things, they're kind of amazed that there aren't more lingering problems," he said.

Becker, whose research focuses on ways to save more lives during and after resuscitation, expects cooling criteria to keep being broadened.

"It's being studied for stroke, heart attack and many conditions in neurosurgery," he said. Researchers are also exploring whether being cooled could help with traumatic brain and nerve injury, as it may have for Everett.