I AM A SOLDIER FIRST, DOCTOR NEXT

For a soldier the most important thing is to never give up, never give in to circumstances, and to soldier on no matter what's in your way or how hard the situation is. Always believe that something good is going to happen. All these golden words of military life served me in later civil life.

Inspite of the fact that “Nothing in life is promised except death” all are scared of  the word ‘death’ and doctors hate it in their lexicon. Inspite of the fact that “Nothing in life is promised except death” doctors do not let others die without a fight to save him or her.

When heart and breathing stop it is known as death for a common man.  It is known as Cardiac arrest or Clinical death in scientific terms which occurs due to  cessation of blood circulation and breathing, the two necessary criteria to sustain life. It occurs when the heart stops beating and / or in irregular rhythm such as ventricular fibrillation. There are many causes of clinical death such as suffocation, asphyxia, drowning,injuries, poisoning, anaphylaxis etc..

Biological death ensues clinical death. It happens when brain cells/and other cells die due to lack of oxygen (hypoxia). Hence, attending to clinical death early and performing proper rescue techniques secure the best chance of preventing biological death.

Within 4 to 6 minutes of clinical death, some brain damage may set in. Within 6-10 minutes of clinical death, brain damage is likely. And after 10 minutes of clinical death, irreversible brain damage is certain, except in special circumstances such as severe hypothermia where biological death may be delayed.

The procedure to revive the heart and to restart the respiration is known as Cardio Pulmonary Resuscitation (CPR). This is a complex procedure and is normally abandoned after 15 to 20 minutes of Cardiac Arrest as after 10-15 minutes of clinical death brain damage is certain and even if heart and respiration restarted the patient will be a vegetative one(like a vegetable).

But from the true life story of a patient of this hospital who survived Cardiac arrest of 45 minutes duration without any brain damage due to timely and apt resuscitative measures points to Soldiers, when committed to a task, can't compromise. It's unrelenting devotion to the standards of duty and courage,  not letting the task go until it's been done. This is the second case in the world literature to be revived by an unconventional method of using biochemical defibrillation such as potassium chloride and calcium chloride the two most powerful last weapons left in my armoury to fight and bring the patient back to life.And  they did,  there by rescued the patient from the jaws of death when all other methods failed.  Patient is still alive hale and hearty after 16 years of the event.

The patient Mrs. Aleykutty (name changed), 37 yrs female was admitted to Indira Gandhi Co-operative hospital on 6th April 2000 by consultant surgeon for right leg varicose vein surgery. On 7th April 2000, having  administered general anaesthesia in stages surgery commenced.When the surgery was in progress in right groin suddenly the ECG monitor showed a flat line, indicating that the heart stopped beating, pulse (Carotid, femoral) not palpable, BP not recordable and  heart sounds not heard. All these mean Cardiac Arrest or Clinical Death.

Asystole is a cardiac arrest rhythm with no discernible electrical activity on the ECG monitor. It is a flatline ECG.The heart is not functioning. It is a life-threatening condition that requires immediate action.

                                               Flat line ECG,Heart stopped beating

                                                   Ventricular Fibrillation                     

Cardio Pulmonary Resuscitation,the method used to restart the heart beating again and to restart the breathing, initiated and continued, but the fibrillation , one type of dangerous arrhythmia(abnormal heart beat) stopped on occasion, but returned when external cardiac massage, pressure over the heart to restart it, resumed.

                                                             External cardiac massage

At this stage having tried all conventional methods and having abandoned by cardiologist  and neurologist declaring the patient as vegetative, during fibrillation Potassium Chloride 10 ml (15%) pushed intravenous. This produced Asystole ( monitor showed flat line). Immediately 10 ml of Calcium chloride (CaCl2 ) pushed intravenous and Ext. cardiac massage continued. Monitor showed sinus rhythm (that is after 45 minutes of asystole,complete stoppage of heart first noted).  BP recordable, radial pulse palpable. Pupils started reacting to light which were widely dilated. Patient started breathing spontaneously and moving all the four limbs.  Opening eyes and responding to Verbal commands.

When the patient recovered from cardiac arrest, Surgeon was allowed to complete the rest of the surgery which was temporarily suspended during the cardiac arrest and closed the surgical wounds. Then the patient was shifted  to Neuro-ICU and was put on ventilator, ionotropics, electrolytes and nutritional support along with intensive monitoring.

The CT scan of brain on 8th April 2000 showed no abnormality .On 12th April 2000 patient was extubated and was on tracheostomy for a couple of days. Tracheostomy was closed on 24th April 2000. On 3rd May 2000,  on discharge,  patient walked out of the hospital with minimal neurological disturbance.

Though myself and Dr.Antony M.J performed External cardiac Massage for nearly 45 minutes there was absolutely no complications of that procedure such as fracture ribs, pneumothorax, hemothorax, rupture of aorta, rupture of ventricles and pericardial tamponad etc..  One should not be impatient to give either intracardiac injection or internal cardiac massage.

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After 15 minutes of the cardiac arrest cardiologist left followed by neurologist,then others,but the Soldier was sticking to the ground.I am a soldier ?rst and doctor next and I felt as if  the nascent smell of gun powder started emitting from my body and Soldiers when committed to a task, cannt compromise. It's unrelenting devotion to the standards of duty and courage, not letting the task go until it's been done.And the patient survived the cardiac arrest,  history is made. At last Victory for a soldier.

[Dr. (Major) B. C. Nayak is an Anaesthetist who did his MBBS from MKCG Medical College, Berhampur, Odisha. He is an MD from the Armed Forces Medical College, Pune and an FCCP from the College of Chest Physicians New Delhi. He served in Indian Army for ten years (1975-1985) and had a stint of five years in the Royal Army of Muscat. Since 1993 he is working as the Chief Consultant Anaesthetist, Emergency and Critical Care Medicine at the Indira Gandhi Cooperative Hospital, Cochin]