ST. PAUL, Minn. - When Tim Franko suffered a heart attack at work on Aug. 19, a bystander began to administer CPR within a minute. Paramedics tried to revive him for 16 minutes before transporting him to nearby Regions Hospital in St. Paul, where doctors would continue the effort for more than two hours.
Eventually, doctors in the cardiac catheterization laboratory saved his life by removing a blood clot. By then, he had received CPR for two hours and 45 minutes.
Franko's case is thought to be the world's longest example of extended CPR that successfully revived a patient with no heartbeat. But it's not the only recent case in Minnesota of a really long resuscitation.
Such cases of prolonged CPR are happening more often, in part thanks to advances in CPR technology - and to changing attitudes among physicians. Some say a patient now has a greater chance of surviving a prolonged cardiac arrest.
Franko, 56, of New Richmond, Wis., is still recuperating from his heart attack two months ago. But his recovery, by any measure, is stunning. Aside from some anemia and weakness, and sore muscles from the thousands of chest compressions that saved his life, Franko appears fine. Still, he came perilously close to death.
After clearing brush in 90-degree heat, he tried to cool off in front of a shop fan at the end of his shift and collapsed in his boss's arms. "My stomach was bothering me," said Franko, a maintenance mechanic. "My chest wasn't bothering me, but my stomach was a little bit upset."
Since then he's heard all about his extraordinary rescue -- from the bystanders who within a minute were giving him CPR, to the paramedics who, a few minutes later, strapped a portable CPR machine on him so he could be moved to an ambulance, to the emergency medical team at Regions Hospital in St. Paul who kept trying to save him long after others might have called it quits.
"Well, I'm real happy that they didn't give up because I'm here to talk about it," he said.
A self-described "tough, old guy," Franko's response to his ordeal is characteristically understated. But the emotion of that day is still raw for his wife Ellen.
"I didn't think he was going to come back," she said. "In the ER I kept telling him, 'you gotta fight. You're strong. You gotta fight.'"
Ellen Franko wasn't the only person who thought Tim Franko wasn't going to make it.
"It's an amazing survival story," said Johannes Brechtken, the interventional cardiologist who was on duty at Regions Hospital that day.
Brechtken removed the blood clot nicknamed "the widow maker" that was blocking a major artery in Franko's heart.
It was a remarkable feat considering that, just a few years ago, Franko wouldn't have made it to the hospital for treatment. Paramedics couldn't restore his heartbeat in the field, and with basic CPR it is not safe to transport patients to a hospital because emergency personnel cannot use seat belts if they are applying chest compressions with their hands.
In Franko's case, paramedics were able to rely on the LUCAS 2 Chest Compression System, an automated CPR unit. The device kept Franko's blood circulating, delivering much needed oxygen to his organs. That gave emergency workers the time they needed to transport him to the hospital. Once he arrived at the hospital, the device kept pumping while doctors tried to revive Franko and cleared his blocked artery.
"The device worked so well that he was able to even interact and blink his eyes initially, keeping a blood pressure going," Brechtken said. That's because the device compresses and lifts the chest. That increases a patient's blood pressure and helps their tissues work better. So while Franko's rescuers were working on him, he was able to answer some of their questions while blinking. That was an important early sign that his brain was still working.
The LUCAS device became available in the Twin Cities metro area about four years ago, and since then it has been adopted widely by Twin Cities EMS systems.
Automated CPR is transforming the work of emergency responders -- so much that the old CPR rules don't mean much anymore, said Dr. R.J. Frascone, medical director of emergency medical services at Regions Hospital.
"All you have to do is turn on the machine," Franscone said. "It used to be [if] a patient gets 15 minutes of CPR or 30 minutes of CPR, no shot, you might as well call it. With this device that's clearly not the case. We have patients with very extended periods of CPR."
Basic CPR still saves lives, and studies show that in many cases it can be as effective as automated CPR. But in a prolonged resuscitation, Frascone said, the Lucas device is taking rescue medicine beyond what anyone that was possible, "When do we stop? We don't know when to stop anymore because this machine does such a wonderful job," he said.
Increasingly, the technology is being used to save lives.
The LUCAS device kept Steven Froemel, of Alexandria, Minn., alive for more than an hour after he went into cardiac arrest on Aug. 11. Froemel recently visited the cardiac team that saved his life at the University of Minnesota Medical Center. His cardiologist, Dr. Uma Valeti, showed Froemel the LUCAS device that kept him alive while Valeti repaired a vessel that was detaching from his heart.
"Your heart was in arrest for about I would say 70 minutes or 80 minutes without a heartbeat and we couldn't shock you out of it," Valeti said. Froemel, a soft-spoken 62-year-old, can hardly believe he survived.
"Oh, I think that they could have just called it," he said. "I think about that. How could you not?" Dr. Valeti remembers having some doubts about whether he was doing the right thing in trying to save Froemel. He said there was a lot of tension in the cardiac catheterization laboratory that day.
"We frankly had a very senior faculty [member] that felt the patient was dead and that it would be futile to continue the work," Valeti said. "And I can't put my finger on one reason why the team continued to pursue it, but I think it was the collective sense that we had to keep going."
Valeti succeeded, and his patient is doing fine. But Valeti said there was a risk that he would fix Froemel's heart and later discover that his patient's brain was irreparably damaged, to the extent that Froemel would have to be cared for in a nursing home.
There are some ways that doctors can get a sense of how a patient's brain is coping with extended CPR. But there are no perfect tests during emergency situations, and research on the subject is thin, based only on a handful of cases.
"The whole business of resuscitation, I wish people who were doing it would report it!" said Mayo Clinic physician Roger White.
White, medical director of the Rochester Police Department's defibrillation program, recalls presiding over a 96-minute resuscitation more than two years ago in the small town of Goodhue, Minn., that used only manual CPR. Nearly two dozen volunteer responders took turns administering the CPR to a man who collapsed on a sidewalk on a cold January night.
At the time it was the world's longest successful case of standard CPR, and may still be. White said he's heard anectdotally about similar cases, but if the details aren't published, doctors can't learn much from them.
"I suspect there are long resuscitations going on and we don't know about it," White said. "Even if the outcomes aren't good, for heavens' sake, tell us. You know, maybe there are other ways we can do this."
Accounts of the efforts to save Froemel and Franko will be published in a state case series report that so far includes about 20 extended resuscitations that have occurred in Minnesota during the past two years. The cases are all resuscitations that lasted longer than an hour. They have occurred at the University of Minnesota Medical Center, Regions Hospital, Abbott Northwestern Hospital and the Hennepin County Medical Center.
Dr. Demetris Yannopoulos, medical director of the Minnesota Resuscitation Consortium, is writing the report on all of the cases. He said he is still gathering the data for the report, but it appears that more than half of the patients in the case studies survived with their brain functions preserved.
To anyone who would question whether such extraordinary life-saving efforts are worth it for only 10 or 11 people, Yannopoulos has a quick answer.
"I would say if it's my father and if it's your dearest friend, probably yes," he said.
Yannopoulos said the has visited every cardiac catheterization lab in the Twin Cities to encourage doctors to be more aggressive in trying to save cardiac arrests patients who may have a treatable problem such as a blood clot or a damaged vessel. He said it is now standard practice in the Twin Cities to get such patients into the catheterization lab within two hours of their going into arrest.
But not all physicians are comfortable with the uncertainty of the cases. There is still a lot of debate over how to best use new CPR technology, particularly when it isn't clear which patients will benefit from it and which may end up suffering more.
Ultimately other new technologies may help resolve that debate. Regions Hospital is planning an experiment that would apply a strip of electrodes to the foreheads of patients undergoing prolonged CPR.
Hospital officials hope the device will give them an accurate measure the patients' brain wave activity and ultimately help doctors decide if a patient has a good chance of recovering and going home.
By Lorna Benson, Minnesota Public Radio
MPR News and KARE 11 News reporter Trisha Volpe contributed to this report.
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