A doctor considers how EMT delays affected Chris Christie’s 91 y.o. cardiac arrest victim

John asked me to weigh in on the Chris Christie bridge scandal, specifically with regard to the report that EMT response was slowed in the case of a 91 year old unconscious woman who later died of cardiac arrest at the hospital.

[UPDATE FROM JOHN: A new story says that the woman died at home, couldn't be resuscitated.  Her daughter, who voted for Christie, doesn't think the delay affected the outcome. And she's entitled to her non-medical opinion, but generally speaking I wouldn't recommend delaying an ambulance coming to resuscitate anyone whose heart has stopped, let alone someone that old.]

As you may know, after Gov. Christie’s office shut down traffic at the George Washington Bridge last fall, in order to punish the local mayor who didn’t support Christie’s re-election campaign, the resulting traffic jam affected local EMT service, including slowing the emergency response to the elderly woman.  This is a look at how medical response time affects your potential recovery in a case such as the 91 year old woman’s.

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It goes without saying that I don’t know the specifics of this woman’s case, so I won’t be diagnosing her. But I can speak generally about how delays in treatment affect potential recoveries in similar cases.

First, here’s how a local paper described what happened to the woman:

It also took EMS seven minutes to reach an unconscious 91-year-old woman who later died of cardiac arrest at a hospital. Although he did not say her death was directly caused by the delays, Favia noted that “paramedics were delayed due to heavy traffic on Fort Lee Road and had to meet the ambulance en-route to the hospital instead of on the scene.”

With regards to the second line of that quote, it may be that the ambulance is staffed with Emergency Medical Technicians (EMTs) who are limited in what they can do to assist a patient. Paramedics have more advanced training and can do more than EMTs can. For example, paramedics can start large, central IV lines, use advanced airway devices and perform other procedures that EMTs can’t. So a delay in the paramedics getting to the victim may have had an negative influence on the outcome.

Let’s start with a little medical background. The coronary arteries supply the heart with oxygenated blood. A heart attack occurs when plaque, on a wall of a coronary artery, activates platelets in the bloodstream. A clot forms obstructing all or virtually all flow of blood.

The heart, which is a muscle that works constantly, even during sleep, needs oxygen, just as other muscles do. With the coronary artery blocked, the heart muscle cells are deprived of oxygen. Over a short time the cells begin to die off. Most often, the longer the time till the heart gets its blood supply restored, the greater the damage. More heart cells die. Those cells can no longer help the heart pump blood. So the efficiency of the heart to get blood to itself and to other tissues (brain, kidney, liver and all other organs) decreases. As a result, those organs may become less- or non-functional. Also, the dead heart tissue cannot help conduct electrical impulses, necessary for the heart to beat regularly. So the heart may begin to beat erratically, causing another decrease in the tissue perfusion (perfusion: supplying tissue with oxygen and nutrients via the blood supply).

There are a few sayings in medicine that specifically mention this. One is “Time is myocardium (heart muscle tissue).” It means that the longer the area of the heart muscle goes without being reperfused, the worse the damage is. Ideally the faster the reperfusion occurs, the less damage. Reperfusion can be accomplished by removing the clot. This can be done by “clot buster” medications injected intravenously (anticoagulants), or the preferred method, putting a catheter into the affected coronary artery and placing a stent.

Often the phrase “door to balloon time” (sometimes written D2B) is used. Meaning the time the patient arrives at the ER till the time the patient gets a cardiac catheterization done to get the heart tissue reperfused. At first, when the benefits of time to reperfusion were first studied, a D2B of 120 minutes was thought to be good. Research showed that the faster the clot was removed allowing reperfusion, the better the outcome (less damage to heart and other organs.) Many hospitals are trying to bring D2B time down to less than 60 minutes. So ELAPSED TIME IS CRITICAL (Remember the phrase, “time is myocardium.”)

Of course, no one can say exactly what would have happened in this woman’s case. We don’t have all the details. For example, we don’t know if she had a previous heart attack, how long an area of her heart was without blood, or which coronary artery(ies) were involved. All of those, and several other factors, can bear on the outcome.

Actually, for the EMS to reach her in seven minutes (according to news reports) is a fairly rapid response time. The problem lies in how long it took them to get her to the hospital where the clot busting drugs could be given or cath could be done. The delay in getting her to the hospital would be just as important as how soon the EMTs got to her. Presumably, traffic congestion could have also delayer her transport to the hospital – it’s an important question for someone to look into.

If, when when EMS reacher her, she was unconscious, that could mean that she had suffered cardiac arrest due to the heart attack, or that her blood pressure was low (shock) because the heart was not pumping efficiently, or that her heart was pumping too erratically to get enough blood to her brain, or she could have fallen from the heart attack (MI = myocardial infarction) and knocked herself out.

Also, the story says she died from cardiac arrest. She may have arrested in transit to the hospital or after she got there.

In cardiac arrest there is no blood flow to any organ heart, brain, etc. So if there were no flow, she’d have had brain damage that would have started soon after the brain was deprived of oxygen. (Time is also neurons – the longer brain cells are without blood, the more of them will die.) Neither the brain nor heart can regenerate very well.

So:

1. Delay in getting treatment is critical. And that delay will have a negative impact on the outcome. There could have been a delay in getting to patient initially, a delay in making diagnosis, a delay in transporting her to hospital, a delay in starting treatment, or a combination of these. The bottom line is that the longer it takes, the worse the outcome (in general). Time is myocardium.

2. Depending on the area of the heart attack, the size of the area of heart involved, history of previous heart attacks, etc., it’s possible that nothing would have saved her life. But it’s also possible that prompt treatment would have saved her.

3. Heart attack and cardiac arrest are different. It sounds like she may have had a heart attack (MI) at home, and later had a cardiac arrest at the hospital. An MI could have lead to cardiac arrest. Cardiac arrest, even in a hospital, has poor survivability.

4. It’s more likely that, at 91 she may have had previous heart disease or even a previous heart attack. If that were true, her odds of surviving a heart attack at her age were probably less than those of a healthy 60 year old, but it’s impossible to say for sure. I’ve treated a 103 year old for an MI and she walked out of the hospital. I’ve treated a 14 year old who couldn’t be resuscitated and died.

The upshot is that rapid treatment can be crucial, and delay can lead to death.


Mark Thoma, MD, is a physician who did his residency in internal medicine. Mark has a long history of social activism, and was an early technogeek, and science junkie, after evolving through his nerd phase. Favorite quote: “The most exciting phrase to hear in science... is not 'Eureka!' (I found it!) but 'That's funny.'” - Isaac Asimov

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  • Joan

    Has anyone mentioned the fact that on 9/11 or thereabouts this bridge is one of those who are supposed to be high targets for a terrorist attack? I think the terrorist that attacked was Christie.

  • http://adgitadiaries.com/ karmanot

    They get the house and insurance—a win/win in the Christi mode.

  • http://adgitadiaries.com/ karmanot

    We breathlessly await further wisdom.

  • Jett

    Don’t kid yourself. Christie plays things “Sopranos” style. He knew exactly what was going on, and embraced it fully.

  • Jett

    Except for his handling of Sandy, I never liked Christie and certainly never thought of him as Presidential material. He’s nothing more than a spoiled, rotten bully.

  • 1nancy2

    Ha. Righto. Love the fetus, hate the child…deny all services to the kid born poor to a single mother. These f. er’s are sick, nasty, mean, shrill and stupid. Remember Sarah, the miserable dummy?

  • Corey

    Oh it’s ok, it wasn’t a fetus, conservatives could care less about actual humans.

  • AnthonyLook

    The daughter is not legally afforded the decision making determination of death or time thereof, additionally; the daughter does not make the decision if negligence leads to 2 or 3rd degree murder charges.

  • Bill_Perdue

    It’s murder. Not as bad as the millions murdered by the Clintons, Bushes and Obama, but murder nonetheless.

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  • smkngman3

    Just came across this…….
    “The terror charges facing two environmental protesters who unfurled a banner and dropped glitter at an oil and gas company’s office in Oklahoma are “outrageous” and “egregious”, according to the lawyer representing them.” GuardianUK

    A banner and glitter is terrorism, immobilizing a city for four days is…….

  • Ford Prefect

    WV has 1.8 million people, so roughly 16% of the state’s population have no water. I guess they can dream for clean water. SOP is for the tax payer to pick up the tab and let the crime go unpunished, so after figuring in all the waste, fraud and mismanagement that goes along with privatized clean-up efforts, they might get a little help in a number of years. I’m sure Austerity will figure into the lack of meaningful remediation, if the people are willing to accept that nonsense.

  • http://www.newmillgay.com/ The_Fixer

    I don’t find him handsome, I suppose others may. I know that my mother was a Reagan supporter partly because he was “handsome.” Needless to say, she kind of had her priorities a little mixed up.

    Yeah, Walker’s a lot like Mitt. They both remind me of robots. Well-rehearsed and pretty much devoid of empathy and any emotion that doesn’t involve their personal success. I’ve seen Walker’s press conferences many times, and he’s almost mechanical in how he pans the audience with his eyes. But looking into them, it’s like there’s nothing behind them in terms of emotion. A perfect Randian mind, that’s all.

    Wisconsin gets its reputation as a “purple” state because of Milwaukee and Madison, along with a small sliver of Southwestern Wisconsin being reliably blue. The rest of the state is red with a capital R. I live in the Northeastern part of the state, and it’s depressingly Red around here. Although Green Bay is getting slightly bluer, the rural areas surrounding it are quite Red.

    It’s all very puzzling and depressing to me as it has a progressive past (Fightin’ Bob LaFollete).

  • Whitewitch

    I lived in West Virginia for a while, the economy is so tight that a disaster like this will impact them very badly. Many have no means of transportation…lots of them live off the water in their wells….

    Hopefully they will be taken care of….but when your biggest hope is to get Black Lung disease so your family is taken care of after you die then there is really not much to dream about.

  • Ford Prefect

    It would certainly help with their polling numbers.

  • Ford Prefect

    It helps to be a sociopath in these situations. Not having a soul helps one sleep better, it seems. That said, it’s all built in to elite culture now. Causing mass suffering is heralded as “making tough decisions” by the press and the campaign adverts. Being mean is now a “value” amongst our betters, which is probably why Obama can brag to his staffers that his drone “program” has made him “really good at killing people.”

    Meanwhile elsewhere in the real world, 300,000 people in West Virginia have no water to drink or bathe in because Deregulation. Personally, I’ll take a traffic jam over that any day.

  • ComradeRutherford

    This guy should be happy that his health was sacrificed so that one Republican could extract petty revenge on his political opponents.

  • Ford Prefect

    I can certainly understand not wanting to be in the middle of that pie fight, as well. It’s not like it would help with the grieving process.

  • Whitewitch

    Funny how the correlation between the ending of the Unemployment by not extending payments is not reported in the “news”. I guess the RW won’t play that because they will have too much fun touting it when the rate goes up if/when the UE extensions go through.

    I have posted the same questions Ford, how is it okay for Congress/House to go on vacation when thousands are loosing their UE on the 28th of December…and they are still playing with that and it is the 10th. How do the unemployed eat, pay rent and care for their children.

    Goddess I worry for us…really worry.

  • Ford Prefect

    I don’t know, “The next president of these United States”? A courageous leader, willing to take on special interests like commuters? I’m sure David Brooks, Frum or Nooners will think of something catchy.

  • Ford Prefect

    Indeed we should ask it. It’s at the core of our entire governing ethos and has been for decades now. In this sense, the hullaballoo over Christie’s behaviors is simultaneously understandable and a bit hypocritical. Dems want their people to be bullies and GOPers want theirs as well. I’m not confident one can be a non-bully and really get ahead in politics anymore.

    The Duopoly just lowered the U3 unemployment number from 7% to 6.7% by kicking 1.3 million people off of unemployment insurance. How many of them will needlessly die from that bit of fiscal bullying? And how is cutting food stamps (ie, taking food from hungry children to protect corporate subsidies) being celebrated as “making tough choices” not a wanton act of bullying? US foreign policy, anybody?

    Once the media buys into his “I’m the real victim here” schtick, they can go back to stomping the poors. We might as well label the next general election BullyPalooza 2016.

  • cole3244

    i hope you’re right.

  • Buford

    … and arrest them… but otherwise, yes.

  • smkngman3

    Whether this woman would have died anyway should not alter the fact that things could have been much worse. Had there been a fire or explosion or a train derailment…..
    If you call a Nun that chains herself to the gates of a nuclear facility, or an “occupy” protester a “terrorist” what would you call a politician that terrorizes a city for political payback?

  • http://www.americablog.com/ Naja pallida

    It could have just as easily have been a child, or much younger person who needed emergency medical care. The family most likely just wants to grieve for the loss of their loved one and not deal with the political spotlight – like most people would in such a situation.

  • cole3244

    the family says they don’t blame christie.

    i wonder how much suffering they did you would think they would be a little more concerned the delay might have had an effect, once a goper always a goper i guess.

  • Whitewitch

    Funny how that works…like yeah go bully them for us and get us what is “ours,” but here is my lunch money so you don’t bully me.

  • Whitewitch

    I totally support testing of candidates for sociopathic tendencies. For Scott Walker I think it is because he is somewhat “handsome” and people do vote on looks in lots of areas of life (job interviews etc.). But Scott also has a lot of baggage that might affect the voters of really liberal states (I would not say Wisconsin is very liberal). So they will just have another Mitt on their hands.

  • http://www.newmillgay.com/ The_Fixer

    Yes, we need to stop electing not only bullies, but other sociopaths as well.

    This would be hard to implement, but I think a test for sociopathy should be a requirement for any candidate for public office. That would eliminate most high-profile Republicans from consideration.

    One of my worries is that with Christie probably not running for president now is that he makes our own governor Scott Walker look reasonable as a presidential candidate. While not as overt a bully as Christie is, he still is a sociopath and has no business leading the country. He’s been warming up to get on the ballot, and that scares me. He’s one of those people who can fool a lot of the electorate. He’s done it twice in Wisconsin (of course a lot of people in this state are easy to fool).

  • http://www.americablog.com/ Naja pallida

    So the answer is to have NYPD storm Christie’s offices, beat everyone down and pepper spray them, and then we can call the problem resolved.

  • http://www.newmillgay.com/ The_Fixer

    Bingo! Why do you think that he hasn’t apologized and he’s thrown others under the bus? He’s afraid of the liability issues involved here.

  • Badgerite

    Truly. I think there was a lot more that went on here than has come out yet. See Rachel Maddow’s show for Thursday night. I think she nails it. This could have actually been a retaliatory strike against New Jersey State Senator Loretta Weinberg who sits on the committee that would confirm any of Christie’s appointment or reappointment of judges to the New Jersey Supreme Court. Fort Lee is in her district. The bridge closures started on August 13th. Christie gave a press conference on the 12th withdrawing the re-nomination of a Justice Hoen to the bench and calling the democrats on the committee “animals”. The whole controversy dates back to Christie’s refusal to re-nominate to the bench a first and only black justice to service on the New Jersey Supreme Court. All of Christie’s replacement nominations were turned down. And he refused to re-nominate to the bench Justice Hoen, whose husband worked in his administration, because he didn’t want her ‘subjected to the same kind of treatment’. His rather testy new conference announcing her refusal to re-nominate her and the conference in which he called the democrats “animals” was on the 12th. Bridge closure starts on the 13th. Hmmmmmmmm!

  • http://www.americablog.com/ Naja pallida

    So he’s either incompetent, ignorant, or incapable of executing the office he holds in a manner consistent with the public’s interest. No matter what thread they want to draw to excuse him comes around to him not being a very good leader or manager.

  • MyrddinWilt

    It would be difficult to win but it would gain discovery power certainly.There would be a lot of groups willing to fund such a challenge.

  • therling

    It’s funny to watch his supporters struggling to find a consistent narrative with which to defend him. If he did it, “he’s got balls.” But “he didn’t do it, it was the dog that farted.” Now he’s got balls “because he did a two hour press conference.” Oh, and Benghazi.

  • Buford

    Compare/contrast to the 700 Occupy protesters who were arrested for impeding traffic “for several hours” on the Brooklyn Bridge –

    http://www.cbsnews.com/news/700-arrested-at-brooklyn-bridge-protest/

  • Buford

    Funny. So this issue is important enough to Christie that it warrants a 2-hour public press conference to ‘set the record straight’, but not important enough for him to ask his Deputy Chief Of Staff why she did it prior to firing her.

    Puh-leeze.

  • http://AMERICAblog.com/ John Aravosis

    True for malpractice, but would be interesting in a pain and suffering case against the state of NJ or that staffer (if one case sue the state, not sure what the law says about that). I suspect a jury would be quite sympathetic.

  • http://AMERICAblog.com/ John Aravosis

    Who does this? A man who’s dying to president in 2016 and watching his lifelong aspirations go up in smoke/ That’s who.

  • http://AMERICAblog.com/ John Aravosis

    That’s the thing. Imagine if it was your mom who got a delayed response from 911 because Chris Christie was ticked at the local mayor. I’d be filing a billion dollar lawsuit right about now.

  • devlzadvocate

    To be expected. Ask questions of a Reptilian and you are crucifying him. Actually crucify a Progressive and you are just trying to “get to the truth”.

  • Badgerite

    When you are in pain or a especially a loved on is in pain, every second is an eternity.
    It would be nice if Christie actually took some personal responsibility for the blatant callousness and politically motivated pettiness of the people he surrounded himself with.

  • therling

    Actual Facebook post:

    “It’s
    amazing that the media wants to crucify him. I believe that his aide
    did this without his knowledge. Look, who has a nearly two hour press
    conference, answers every question to the journalist’s satisfaction, and
    takes action on those who did this? We are still waiting for answers on
    Benghazi, the IRS, and NSA! A little one-sided journalism. IMHO”

  • devlzadvocate

    It seems some people want a bully type representing them to get them what they want, they just don’t want to be on the receiving end of a bully’s treatment. No surprise.

  • Buford

    .. even if they WERE looking to blame the traffic… which they are not.

  • Buford

    I think the even larger consideration is that they blocked up traffic on the world’s busiest bridge during the week of 9/11… when normal people usually take steps to ensure that traffic moves quickly and smoothly in the interest of public safety.

    It’s rational to suggest that those in traffic were sitting ducks.

  • devlzadvocate

    Pursuit of legal action following such events for patients of an advanced age is pretty much futile.

  • Whitewitch

    We need to stop electing bullies period. Why are so many running for office bullies – let’s ask that question.

  • devlzadvocate

    Yeah, what the hell was that this morning? And the false comparisons to the Obama Administration? Christie’s admin decisions had a direct and immediate negative impact in citizens in the local area, not some vague, perceived “maybe” affect. I got pissed off and changed the channel. Mika’s blood sugar must be off or she is crazy. Where did she meet Christie? WW?

  • Buford

    Actually, it’s pretty clear that the woman died at her home. The EMT’s tried to revive her twice… once at the house, and again in the ambulance… and both attempts were unsuccessful, hence she was pronounced dead at the hospital.

    ““We believe she died in her home, but they couldn’t pronounce her until she got to the hospital,” said Ms. Oleri’s husband, Frank Oleri. “The traffic didn’t make any difference.”

    More importantly, however, is that her family says the traffic delay was not a consideration in her death and does not intend to pursue the matter… and that’s all we really need to know.

    http://www.nytimes.com/2014/01/10/nyregion/woman-says-lane-closings-were-not-to-blame-for-her-mothers-death.html?

  • peteywheats

    The 91 year old may or may not have lived, but the larger picture is the fact that thousands of people are simply being treated like trash and being fucked over for no legitimate reason, only for the power trip of some fat jerk? At least with “bengazi”, “the IRS scandal” and “obamacare” there are legitimate reasons behind the things that happened. This is just pure assholeism.

  • MyrddinWilt

    We can’t know with certainty if the delay was significant. But the delay certainly could have been significant.

    From a legal point of view, the problem is not whether Christie can be proved to have ordered the lane closures but whether a crime was committed. Nobody anticipated a need to pass a law that would cover this particular set of circumstances.

    I expect that NJ will be passing a law to make impeding emergency vehicles a felony. There might even be a federal effort. Chris Christie will find it rather difficult to launch his presidential campaign if he is pleading the fifth while the Senate is holding hearings on a law of that type.

    If a crime was committed then it will be easy to get one of the minions Christie has thrown under the bus yesterday to turn him in for a lighter sentence. This is not something that the office staff would think up by themselves. The order to take revenge could only have come from the big fat bully himself.

    Delaying the EMT crew could allow an indictment for manslaughter, but getting a jury to convict would be a stretch. The facts would support reckless endangerment though. A creative approach would be to charge Christie with 50,000 cases of kidnapping. 18 U.S. CODE § 1201 seems to apply. It is certainly interstate, the bridge is between two states:

    ‘Whoever unlawfully seizes, confines, inveigles, decoys, kidnaps, abducts, or carries away and holds for ransom or reward or otherwise any person’

    The people were certainly confined in their cars and the payback element would fall under ‘otherwise’.

    50,000 times 20 years is a million years in jail.

  • HereinDC

    ….If you saw Rachel’s show last night…..probably/most likely was not the mayor Christie wanted to punish.

  • dula

    What about the economic damages done while NJ’s workforce and consumers were stuck in traffic instead of working and shopping? In the sort of predatory capitalism championed by Republicans, if we don’t keep consuming relentlessly, we die.

  • lynchie

    Christie at one news conference said ” the traffic tie ups are no big deal”. Also interesting he fired his staff for lying not for the retaliation against the Fort Lee Mayor. But MSNBC and Fox are om the rehabilitation mode. Mika seemed like she would blow Chris. “My friend”. They all love a bully, because they can act out their own toughness through him.

  • http://heimaey.us/ heimaey

    What about the stress levels he put on drivers unnecessarily? That has an effect too.

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