JEFF HANSEN,The Birmingham News
BIRMINGHAM, Ala. (AP) — In the back of a screaming ambulance, Eldrid Primm fought to breathe. An oxygen mask over his mouth didn't help and, two miles from the UAB Emergency Department, the Honda assembly line worker blacked out.
"I don't remember anything until we got to the emergency room doors," Primm said. "Then there was chaos. They took me straight to the back, my shirt comes off, and they put all this stuff on me — electrodes, sticky stuff, IVs.
"I knew I was in trouble."
Primm was about to come as close to dying as a person can and still survive. Yet he emerged not only alive but with no damage to his brain — thanks to a UAB practice, initiated last year, of cooling cardiac arrest patients in an effort to preserve brain function.
Over the next two hours, more than 20 people would try to keep the 38-year-old alive. Dr. Marty Vander Noot, assistant professor of emergency medicine, was on duty that Saturday afternoon.
"We knew for sure he was sick," the doctor said. "He needed oxygen. He had trouble breathing."
Vander Noot learned the Lincoln man had awakened that morning suddenly short of breath. To help Primm, the health team had to find the cause of his crisis. But a sudden onset of breathing problems has a long list of potential causes, Vander Noot said.
Doctors treated Primm for acute onset of congestive heart failure, then a chest X-ray of lung fluid excluded congestive heart failure as a cause.
A second suspect was pneumonia, yet Primm had no fever and appeared sicker than a pneumonia patient. As the team struggled to find an answer, "we told him we were going to intubate him (place a breathing tube down his trachea), sedate him and give him excellent care," Vander Noot said.
But when they started to put an IV line into his jugular vein, Primm's heart stopped. "We lost his blood pressure," Vander Noot said. "It went to zero."
"Within seconds we were starting CPR," the doctor said. "A team of people would rotate in and out," standing on a stool to get above Primm's body. This was Primm's first code.
"I bet there were 20 people who worked on him," Vander Noot said, "and 90 minutes of chest compressions."
Vander Noot still wasn't sure what was wrong. But helped by previous training, he jumped to a diagnosis on incomplete information — a pulmonary embolism. This is an often-fatal blood clot in the lungs that has broken off from elsewhere in the body. Like a cork, it blocks the flow of blood through the lungs.
Vander Noot told Primm's family that he was going to give Primm "a very strong, possibly dangerous drug, to save his life." The drug was tPA, tissue plasminogen activator, which can dissolve blood clots.
"Ninety-nine out of a hundred doctors wouldn't have figured it out," Dr. Henry Wang, associate professor of emergency medicine, said later of the diagnosis. And most medical people would have given Primm no chance of survival after all that CPR, Wang said.
Even after starting the drug, the team had to continue chest compressions. As Primm's heart slowly regained its ability to pump, a CAT scan and a D-dimer blood test confirmed Vander Noot's diagnostic leap. A large clot still partly blocked the lungs.
"It was so large an hour after we gave the tPA that I wondered how large it had been before," Vander Noot said. And some tissue in the left lung had died from lack of oxygen. As Primm's circulation stabilized, two hours after arrival, he faced his second crisis - potential brain damage.
"Primm was lying on a stretcher, intubated, and he had no response to any stimuli," Vander Noot said. "What you worry about the most is you might restart someone's body, but the brain has no function."
The return of blood to an oxygen-starved brain can set off a cascade of biochemical reactions that kill brain tissue. One new treatment exists to try to stop that damage: cooling the body to about 90 degrees Fahrenheit and holding it there for 24 hours.
For reasons not fully understood, this "therapeutic hypothermia" can make a difference between good brain function and impairment of the mind. Injured cells that otherwise would have died somehow survive.
UAB Hospital last year was the first in Alabama to start this treatment and has given it to about 30 patients, about one a week, Wang said. Primm was a perfect candidate for the deep chill.
The team began to force his core temperature down, placing ice packs at his groin and armpits and feeding ice-cold saline into his veins. Still, nurse Pezini gave him little hope.
"My guess was that he'd be dead in three hours." After Primm was moved to intensive care, his sedation momentarily weakened at one point.
"When I woke up, I was freezing cold," Primm said. "Oh my God, I was so cold! I had uncontrolled shivering. I felt like ice."
Several days later, he woke again. He was warm, his throat hurt from the respirator tube, and a lot of lines were hooked to his body.
Down in the emergency department, "most of our staff was sure he had died," Vander Noot said. After a week or so, a hospital chaplain learned Primm was alive. He took a nurse who had helped give CPR up to visit, to show her the outcome of her work.
"When she saw me she started crying," Primm said. "'I can't believe you're here,' she said. 'I thought you were gone.'"
Primm moved to a neurological unit, and then spent the last part of his three-week hospital stay in rehabilitation.
"They drilled me the whole time I was in Spain Rehabilitation," he said. "I had speech therapy; they said they were exercising my mind. They put me to work, and there was no sympathy.
'It's time to get up,' they'd say. I appreciated that."
By the third day he didn't need his walker. "They got me on the bike, had me lifting weights."
As discharge day neared, Primm visited each of the units that cared for him and said goodbye to the patient care coordinator who affectionately calls hypothermia patients "frosties."
Primm said he didn't cry during his goodbye tour at UAB.
"I felt pure thankfulness," he said. "But I felt like the cards weren't enough. I felt cheap. I can't thank them enough."
Information from: The Birmingham News, http://www.al.com/birminghamnews