Make hypothermia for cardiac arrest "cool": What's your excuse?

My EMS director emailed an article to me last year about therapeutic hypothermia. At least my thought processes have come a long way since I heard of this a half a decade ago with skepticism. However, I'm ashamed to admit I've done nothing more than push those emails around to my hospital administration. The comfortable rhythm of my institution usually requires that I be the squeaky wheel to get something changed or implemented, and this wheel has fallen down on her job.   

So what excuses do I have for essentially having ignored the 2002 Australian study that demonstrated efficacy for survival of out-of-hospital cardiac arrest? Well, I'll go over a few of them, and perhaps you might "own" some of these excuses too. Maybe we can therapeutically work through our "cooling phobia" together, just you and I, and actually implement something soon enough to save a life that wouldn't have otherwise been saved. More accurately, the thing we would be saving would be someone's brain, their personality, the essence of who they really are, and what they mean to their loved ones.  I'll approach this exercise with a bit of self-loathing and introspection in order to make the point that you might be guilty of the same complacency I've been harboring.

Excuse #1: It might be too difficult to do. Duh. It's a cooling blanket or ice packs placed about the torso and the head. You can even buy a helmet, for Pete's sake, with a special coolant contained within it.

Excuse #2: I don't know what the target temperature is, and I'm an awfully busy cardiologist and I don't have time to research it.  L-A-Z-Y Walton-Shirley! You are completely LAME! The target temp is 89-93˚F. (If you are potentially LAZY Canadian or European cardiologist who doesn't want to do the conversion, that's 32-36˚C.) All this information was published a while back and discussed right here on heartwire. Were we behind the door when that information came out? 

Excuse #3: I don't have time to keep up with the temperature for 12 to 24 hours. It's probably a lot of trouble, anyway. For Pete's sake, we'll have to use a rectal thermometer and just get beyond the yuck factor. Relax, a nurse will do it for us, doctor, and even record it somewhere that we can just look at it occasionally. Relax--I'll bet we could write protocol orders or even get templates from hospitals that are routinely using cooling so we won't have to put any extra effort in on this project (or make any extra phone calls for ourselves. You know how we hate phone calls)!

Excuse #4: I'll bet it's not cost-effective. Wrong again. The cost-effectiveness (CE) ratio is $47 168 per quality-adjusted life-year. To give all of us nonstatisticians some idea about what that really means, the CE ratio for dialysis is $55 000 and for public defibrillators is $44 000. So, get off the pompous "in-this-era-of-healthcare-reform-President-Obama-wouldn't-like-it" argument because it IS cost effective.

Excuse #5: I'll bet it rarely ever works and is probably not worth all the trouble. WRONG WRONG WRONG. Don't try to massage your complacency with that crap, Walton-Shirley. The number needed to treat for this therapy is a whopping 6. Just S-I-X!!! You have no moral excuse not to do this. In two separate studies, the discharge to home or rehab was 49% to 51% of patients studied compared with 29% to 39% who were "otherwise" not so lucky . . . meaning neurologically impaired to the point of no meaningful life. Walton-Shirley, you live in the conservative southern US where you are supposed to believe in that golden rule: "Do unto others as you would do unto yourself."

Don't you have a conscience? Wouldn't you want your own brain saved if it could be?

Excuses # infinity: Well, this therapeutic cooling thing seems awfully important. Maybe I should just get on the phone right now . . . but, it's 6:30 am and I haven't exercised yet and I remember Debbie (that's my cath lab director) reminding me that I have an outpatient cath "Monday am," which is today, and I have a couple of inpatients that I left in the hospital on Friday for my partner to round on . . . and three or four stress tests . . . plus I'm rounding for my other partner today . . . and I'll bet we have six or seven consults to do, plus all of the house ECGs to read, and don't forget the echos. There are always tons of echos . . . 

. . . and I might have to wash my hair this morning.  Oh well, I'll get to this cooling thing sometime.

See:
Simple cooling methods improve neurologic outcomes after cardiac arrest, new review confirms
 

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