Boy who survived 90 minutes of CPR might change the way hospitals handle heart emergencies

Boy who survived 90 minutes of CPR might change the way hospitals handle heart emergencies

Using a walker, Owen Coulter, 5, travels down the hallway at Dell Children’s Medical Center of Central Texas on Feb. 7, determined to walk out of the hospital almost two months after he was brought there by ambulance.

Friends and family threw him a party with superheroes — both comic book and real life doctors and nurses attending. The Austin Fire Department saluted him and gave his family a ride around the block in a firetruck.

People wore shirts with “Owen’s Superhero Squad” written on them. Some of the staff shouted, “We love Owen,” or cheered; others cried as he got into the firetruck. Friends decorated their home for his arrival.

It was a party for a kid who just might change the way doctors at Dell Children’s and other hospitals treat kids who have a cardiac arrest in the emergency room. Owen’s case will be studied — he went from talking to his parents to undergoing 90 minutes of staff-performed CPR to be kept alive while doctors tried a procedure in the emergency room that is usually saved for the operating room or a sterile lab. Doctors are already talking about changing the way they staff the team that performs ECMO, during which an extracorporeal membrane oxygenation machine oxygenates blood while bypassing the heart and lungs. Could more kids like Owen survive lengthy CPR?

The miracle of Owen might not have happened had Dell Medical School and Dell Children’s not brought a new pediatric cardiovascular team led by Dr. Charles Fraser to Austin last spring and had members of that team not been there that morning, Dec. 13.

It started the weekend before. Owen, then 4, had a low-grade fever. It was a typical virus, his mother, Kristin Coulter, said, and then he was back to preschool on Monday and Tuesday.

On Tuesday, he had puffy eyes and just didn’t look good. On Wednesday, Dec. 12, they took him to the doctor’s office. All tests came back negative. It wasn’t strep. It wasn’t flu. He had all the symptoms of being sick, but the tests didn’t show anything, Kristin Coulter said.

Later that night, “He was complaining about his legs hurting,” she said. They continued to alternate between Tylenol and ibuprofen.

On Thursday morning, they took their two other kids to school. When they pulled back Owen’s blanket, “he still was not looking good,” Kristin Coulter said. “His feet and ankles looked purpleish.”

She and her husband, Darin, got in their truck and began driving from their home in Liberty Hill to Dell Children’s. They didn’t get far before they had to pull over. Owen vomited. It felt more serious. “We’re not going to make it to Dell,” Kristin Coulter remembers thinking. They went to a St. David’s Emergency Center.

There, doctors tried to get a line in him for intravenous fluids. They could not. He was clammy, but he didn’t have a fever. In fact, his temperature was below normal. They needed to transport him to a bigger hospital, and at first they wanted to take him to a hospital that was closer, but his parents demanded that he be transported to Dell Children’s. The previous year, they had spent Christmas at Dell Children’s with their daughter Madelyn, 8, who was diagnosed with Kawasaki disease, which causes swollen lymph nodes, a rash and swollen hands and feet. It also affects the heart. She was given immunoglobulin therapy and made a full recovery.

The transport team arrived, and Kristin Coulter went into the ambulance with Owen while Darin Coulter drove their truck to Dell Children’s.

During transport, Owen was cold and pale and lethargic, but he was awake and responding to his mom and making good eye contact, the transport team said. “You could tell immediately he was very, very ill,” said Justin Solomon, one of the pediatric transport team nurses.

But he wasn’t the sickest kid they have ever seen.

“He was talking to me,” Kristin Coulter said. “Man, I’m so cold” is what she remembers Owen saying to her. “The whole team was keeping me calm, too,” Kristin Coulter said. “It was scary ... to not know what’s going on with your child.” The emergency room at Dell Children’s was full of people when they arrived, Kristin Coulter said. Staff put a heating blanket on Owen to try to get his temperature up. Kristin Coulter remembers it being about 95 degrees instead of 98.6 at this point.

Within 10 minutes of being in the ER, Owen started telling people that he needed to go to the bathroom.

“He was talkative,” said Dr. Patrick Ryan, the doctor coordinating emergency room care that day. And that’s when Owen’s heart stopped beating. He “had a heart event in front of us,” Ryan said.

Kristin Coulter remembers a nurse pulling her into the hallway. She was screaming for Owen to stay with them.

Darin Coulter, who had arrived at the hospital, sat beside Owen and held his hand and talked to him. “I didn’t want him to be alone,” Darin Coulter said. He knew from experience as a firefighter with the Austin Fire Department and having performed CPR on people, “This isn’t good.”

The emergency room team began working on Owen. They organized a chain of five people to perform CPR for two-minute rounds and then rotate. When they got tired, more people were brought in.

They began pushing epinephrine through the central line they had been able to get in before his heart stopped beating.

Jimmy Young, one of the nurses on the transport team, stayed and was among the people performing CPR on Owen. “It actually seems chaotic, but there’s an organization to it,” Young said. “We work together.”

An hour passed, and everyone including Darin Coulter knew that CPR typically wouldn’t be continued that long.

“I don’t think anyone wanted to stop,” Young said. Every time they called for the team to stop CPR and check Owen’s heart rate, everyone hoped there would be one.

At least twice, they got a heartbeat back temporarily, Ryan said.

There were enough good signs to keep going, Young said.

They continued CPR, Ryan said, because Owen was an otherwise healthy child who lost his heart rate in front of them. They believed the CPR had been getting enough blood flow to the brain, and they had gotten his pulse back twice. “It’s so important to get good-quality CPR,” Ryan said. This case demonstrates that, he said.

In another part of the hospital, a team was on standby with an ECMO machine. They were there in case another patient having a scheduled procedure needed it. That patient did not.

ECMO oxygenates the blood through the machine without the blood needing to go to the heart and lungs. It allows the heart and lungs time to possibly recover from whatever is making them not function. In Owen’s case, doctors think a virus attacked his heart.

ECMO is not something that is typically used in an emergency room. It’s usually reserved for the operating room or a catheterization lab, with an ECMO team scheduled to be there.

Using the machine in the emergency room “was not previously thought possible,” said Dr. Carlos Mery, the heart surgeon who performed the ER surgery to place cannulas in Owen’s veins and arteries that connected to the ECMO machine.

“The fact that we are all here, there’s no reason why we wouldn’t try, even though it’s been a long time on CPR,” Mery said. Statistics, however, show about a 50 percent survival rate using ECMO, Mery said, and that’s ECMO performed under more typical circumstances.

For Owen, though, “it was a slim chance because ... we wouldn’t know what his neurological status was until afterward,” Mery said.

A “slim chance,” “potentially feasible,” is the way Mery explains it. “No one gave up,” he said. “That’s the reason why he is alive.”

His parents explain it this way: “God put the people there at the right time,” Kristin Coulter said.

It took another 30 minutes to get Owen on ECMO, for a total of an hour and a half of CPR and the uncertainty of what Owen’s brain function would be or if his heart would recover from whatever caused it to stop beating.

Even once he was on ECMO, “there was no guarantee he was going to make it through the night,” Kristin Coulter said.

He needed two more surgeries that night to get the cannulas in the right place and repair an artery.

When Owen was moved to the pediatric intensive care unit room at 1:30 a.m., it all felt familiar to the Coulters. It was the exact same room they had been in the year before with Madelyn.

After this whole day, Kristin Coulter said, “we were in shock.” They had been going on adrenaline.

Doctors repeatedly told them that they didn’t know what the outcome would be. They checked for brain activity and “he was still in there,” Darin Coulter said, but what would be the lasting side effects, and would he recover?

“He may not know who you are; he may not be able to eat or walk,” Kristin Coulter remembers being told. “They were not giving us any hope.”

The Coulters knew that Owen liked to be around people. They organized people to come and sit with him continually. They moved in across the street at the Ronald McDonald House, but one of them was always with Owen. Her parents flew in to take care of Madelyn and Owen’s twin brother, Hudson, at home.

On Dec. 17, doctors tried taking Owen off ECMO. “They were preparing us for the worst,” Kristin Coulter said. “No one thought he would be in the situation he is today.”

He was holding steady, but still on dialysis from kidney damage and on a ventilator. On Christmas Eve, they got the news that he was breathing over the ventilator. As doctors weaned him off the medical coma-inducing medication, they waited to see if he would know them.

He asked for Mom. “He can talk!” Kristin Coulter said. “It’s the best Christmas gift ever!”

The road ahead wasn’t easy. He had to be weaned off narcotics. He still had dialysis and some brain recovery to do. He wasn’t walking, but by Jan. 9, Owen was stable enough to move into the rehabilitation unit to begin recovery, including swallowing, speech, physical therapy and occupational therapy. His brain is working on rerouting the signals to his hamstrings, which are needed to walk.

“He’s never once complained,” Kristin Coulter said. “He’s been in good spirits. He’s been happy.”

They worried whether Owen would need to wait a year for kindergarten while his twin brother went ahead, but nope — he’ll be able to start in the fall.

While he was at Dell Children’s, the staff who transported him and worked on him in the ER continued to visit him. “How could you not? It’s Owie,” said Amy Dore, one of the transport nurses.

She credits the whole dynamic of the family for Owen’s success. “It’s impressive to do a full recovery,” Dore said.

“We felt so much love,” Kristin Coulter said. “Not only did they care for Owen, they cared for us and our family.”

Owen will continue outpatient therapies. “We don’t know where all the deficits are,” Kristin Coulter said.

“We prayed for 100 percent recovery,” Darin Coulter said. And it came true.

“He’s a miracle,” Kristin Coulter said.