Case Study 36

The Answer


  • Patient is in cardiac arrest.
  • There is no sign of injury, no mechanism for spine injury.

The Plan

  • Continue CPR.
  • Initiate access to AED, Advanced Life Support, and evacuation.
  • Move patient onto a pad. Use clothing to insulate him (no sleeping bag available).

Anticipated Problems

  • Continuing CPR during a litter carry will be very difficult.
  • If patient awakens, we will need to keep him warm (the weather is cool, the ground cold).
  • We may need to start rescue breathing with the chest compressions.


Comments from a person on the scene of the actual event:

“The CPR looked nothing like what I expected or had practiced. For the first minute the person giving chest compressions (a physician) did >100 compressions/minute and no breaths. The compressions were amazingly deep. I know we practiced how deep to push, but now I really know what it looks like. He paused very briefly (I think he checked for a pulse) then did >100 compressions and no breaths for another minute. He was focused on the patient and said nothing while he did compressions.”

“The patient made guttural noises with each compression (that was also unexpected). After the second or third set of compressions (I'm assuming because he found a pulse) the doctor shook the patient vigorously and yelled the patient's name. At that point the patient took a huge gasping breath, opened his eyes, and spoke.”

Comments from NOLS Wilderness Medicine: 

This is a great example of two hallmarks of an effective response to cardiac arrest: early recognition and early and effective compressions.

Early recognition includes scene size-up, in this case a witnessed collapse, and the check for responsiveness and ABCs that are part of the initial assessment. Assessing a pulse in the patient who may have a cardiac arrest is challenging, so we also look for "signs of circulation" (coughing, breathing, movement) in the patient. 

Early and effective compressions are a key to success. Start compressions as soon as cardiac arrest is recognized. “Push hard, push fast” – with minimal to no interruptions in the compressions, at least 2" deep, lower half of sternum, complete recoil, minimum rate of 100/min. It’s clear the doctor who was giving the compressions knew this – he was focused and relentless until the patient awoke. We can make an educated guess that the early and aggressive compressions kept the brain alive and allowed the heart to resume pumping. 

In the Circulation Airway Breathing (CAB) approach of urban CPR, the common cause of cardiac arrest is the heart, thus the emphasis on chest compressions. If the collapse is witnessed there is enough oxygen in the blood to preserve heart and brain function for a few minutes if it is circulated with effective chest compressions. It’s even OK to do compression-only CPR. But in wilderness it may be more likely for cardiac arrest to be secondary to hypoxia from airway obstruction (avalanche, drowning). These people, and those who have been in cardiac arrest for more than a few minutes, benefit from rescue breathing: combine compressions with rescue breathing (mouth-to-mouth or mouth-to-mask) in a 30:2 ratio.

Two other hallmarks of effective response to a cardiac arrest – early AED and early access to Advanced Life Support (ALS) - were not possible in this wilderness scenario, but the responders called 911 immediately and initiated the response that would bring the AED and ALS as soon as possible to the patient. Where is your nearest AED?     

CPR is not a pretty sight. Effective compressions are deep; the patient’s skin color is awful; guttural sounds and vomit are common. This should not deter the rescuer. 

The success rate from out-of-hospital cardiac arrest remains low. Statistics for wilderness CPR are dismal. For miracles like this to happen, the people on the scene, like this physician and the WFR-trained companions, need to recognize the cardiac arrest immediately and immediately start “pushing fast and hard.”

Is your CPR training current? Could you have reacted as quickly as these rescuers?

End of the Tale

The patient collapsed at 11:00 am. The companions were able to call 911 from the scene. After the patient awoke they completed the patient assessment (which had stopped in the initial assessment phase), moved the patient onto a pad, kept him warm, and checked vital signs. Paramedics arrived at 12:00 noon. The patient was evacuated by helicopter at 12:30. He had remained responsive since awakening. The patient had surgery on several blocked coronary arteries and has recovered well.