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The case of 26-year-old Justin Smith, which is being called a medical miracle, is prompting some health professionals to rethink protocols for treating patients with severe hypothermia and cardiac arrest. On Feb. 21, 2015, a multidisciplinary team at Lehigh Valley Health Network, working against incredible odds, resuscitated Smith’s lifeless body after he had been found frozen in a field and declared dead by police and paramedics. Today Smith not only lives, but thrives: He plays golf with his father, cheers on the Phillies and is now attending college.
Smith’s recorded body temperature (68 degrees Fahrenheit or 20 degrees Celsius) is among the lowest on record in which the victim actually survived and is among the few in which someone with no pulse/heartbeat or respiration for such a prolonged period survived. It’s also believed to be among the few cases in which someone who had almost no brain functioning on being first examined made such a strong neurological recovery.1,2,3 Smith lost his toes and two fingers, had to relearn to walk and use his hands, and has some minor neurological issues.
When Smith (who had been missing overnight in subzero weather) was found, his body temperature was so low it could not be detected initially. He had no pulse or respiration. Several of Smith’s organs, including his kidney and lungs, also had started failing.
The “miracle” started unfolding when LVH–Hazleton emergency room physicians got the initial call from paramedics and police describing Smith as dead and recommending DNR. Instead, the paramedics were ordered to start CPR and bring Smith in by ambulance.
At Hazleton, “it was all hands on deck” as medical and nonmedical staff, including housekeeping, took turns performing manual CPR on Smith. Blood tests checked Smith’s potassium levels. When the results came back normal (4.7), resuscitation continued. (Normal potassium levels suggested that Smith’s cells had not yet died off in large amounts due to lack of oxygen; abnormal potassium levels would have indicated continued resuscitation would be futile.)
Cardiothoracic surgeon James Wu, MD, was consulted and determined Smith was a good candidate for extracorporeal membrane oxygenation (ECMO), a last-resort option to support selected patients with cardiac or respiratory failure. Smith was hastily transported to LVH–Cedar Crest by MedEvac helicopter minutes before another major storm blowing in would have grounded the flight. CPR continued on the helicopter flight.
At LVH–Cedar Crest, Smith was hooked up to the ECMO VA device with the initial goal of gradually warming up his body temperature and stabilizing him, Wu says. Tubes placed in Smith’s femoral artery drained blood out of his body, oxygenated it, removed CO2 and warmed it before recirculating it back into his body. The team administered IV as well as heparin to prevent clotting.
With some hypothermic patients who are rewarmed, most of the body’s organ functions can return, Wu says. ECMO had been used before at LVH to warm hypothermic patients, “but typically those patients had a pulse and some blood pressure.” Because Smith had neither, “we gave him a 50-50 chance.”
Once his body temperature reached about 30 degrees Celsius (86°F), “his heart started to fibrillate,” says Wu, who monitored Smith’s heart using an ECMO TE probe. So the team then shocked his heart. To everyone’s amazement, Smith started to have slow, normal heartbeats that eventually got faster as his body warmed.
Now team members faced another problem: They could no longer continue to adequately oxygenate Smith because pulmonary edema had set in. So the team switched him off VA ECMO (now that his heart had achieved a full normal rhythm) and switched him to VV ECMO, inserting the tube through the right neckline. He remained on ECMO for four days.
What happened at the neurological level
An initial neurological scan showed Smith had very little brain function. His pupils were inactive and his eyes were not moving. Later, after Smith’s heart was functioning normally again and he received oxygenation via ECMO, nurses and other caregivers noticed he would twitch or move when his name was called. Other tests and scans, including EEG and MRI imaging, showed that Smith’s brain was normal. All of these pointed to potential recovery, so the treatment team stayed the course.”
Over time Smith not only became more aware and responsive, but his personality returned as well. The neurology team at LVHN believes this miraculous neurological recovery was possible: due to hypothermia. With hypothermia, if you can get the body as cold as it can get without the tissues actually freezing, you can stop the machinery of oxygen needed in metabolic use and essentially go into a state of suspended animation. In Smith’s case, it’s hypothesized that brain cells didn’t die because they were in a state of suspended animation from the extreme cold.
Implications for treatment of hypothermia
Smith’s case opened a new door to resuscitation medicine with the possibility that other patients might benefit from ECMO technology. In 2015, Pennsylvania’s Department of Health updated its protocols for resuscitating hypothermia patients to specify they be transported to an ECMO-capable facility when possible.
Wu notes that ECMO is more widely utilized in major cardiothoracic surgery centers, however the procedure still carries high risks: Worldwide, the VV ECMO survival rate is about 65-70 percent; the VA ECMO survival rate for non-cardiac arrest patients is 40 percent and only 25 percent for cardiac arrest patients, Wu says. A patient should not be put on ECMO if there is no potential for end organ recovery or the possibility of bridge to device or transplant, he says.
“I think we have an opportunity to improve on those numbers,” Wu says. Smith and his caregivers succeeded against incredible odds. “As with any miracle, there was a lot of luck and hard work involved,” Wu says.