How Effective is Cardiopulmonary Resuscitation (CPR)?

Having written about the Good Samaritan Law, let me now briefly write something on the Survival Rates for Cardiopulmonary Resuscitation (CPR).  

A lot has been written about CPR. But what are the percentages or chances of survival so far in documented history for a victim of AMI even if CPR is instituted within say 5 or 10 minutes since the brain cannot tolerate anoxia or lack of blood perfusion within 3 – 5 minutes or so. What would be the chances of survival even if cardiac fibrillations to restore cardiac rhythm to normality using an AED is given within a certain time limit.

The chances of survival for a victim of acute myocardial infarction (AMI) or sudden cardiac arrest (SCA) depend heavily on the timeliness and quality of interventions such as CPR and defibrillation. Here's a summary of current survival statistics based on documented research and guidelines:

Within 5 Minutes: 

High-quality cardiopulmonary resuscitation (CPR) initiated within the first 5 minutes of cardiac arrest can significantly improve the chances of survival. Studies indicate that survival rates are approximately 30-40% when CPR is started promptly, although this varies depending on factors such as the location (out-of-hospital vs. in-hospital arrest), cause of arrest, and the patient's underlying health conditions.

Within 10 Minutes: 

If CPR is delayed beyond 5 minutes but started within 10 minutes, the chances of survival drop to 10-15%. Beyond this time frame, survival rates are much lower due to irreversible brain damage caused by prolonged lack of oxygen and blood flow to the brain.

The brain can tolerate anoxia for about 3-5 minutes before permanent damage occurs. However, high-quality CPR helps circulate oxygenated blood to the brain and vital organs, buying critical time until advanced interventions (like defibrillation or advanced life support) can be provided.

Defibrillation and Survival (Using an AED):

Defibrillation with an automated external defibrillator (AED) is essential in restoring a normal heart rhythm during ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). The survival chances improve significantly if defibrillation is performed promptly

1.      Within 3 Minutes: If defibrillation occurs within 3 minutes of collapse, survival rates can be as high as 70-75%, particularly in out-of-hospital cardiac arrest cases caused by VF or VT.

2.      Within 5 Minutes: The survival rate drops to approximately 50-60% if defibrillation is delayed to within 5 minutes of cardiac arrest.

3.      Within 10 Minutes: Beyond 10 minutes, survival drops sharply, with rates below 10% unless exceptional circumstances (e.g., hypothermia) are involved.

Combined Effects of CPR and AED Use:

When CPR is initiated immediately and followed by defibrillation within 3-5 minutes, survival rates can reach 50-70% in cases of VF/VT-related cardiac arrest. Public access defibrillation programs and training in both CPR and AED use have been shown to significantly improve outcomes in community settings.

Key Factors Influencing Survival:

1.      Time to Intervention: Survival decreases by 7-10% per minute without CPR or defibrillation.

2.      Quality of CPR: Effective chest compressions (2 inches deep, 100-120 compressions per minute) and minimal interruptions are crucial.

3.      Underlying Cause: Survival is higher in cases of VF/VT compared to asystole or pulseless electrical activity (PEA).

4.      Bystander Involvement: In settings where bystanders initiate CPR and use an AED before emergency medical services (EMS) arrive, survival rates improve substantially.

Real-World Data:

In the United States survival rates to hospital discharge after out-of-hospital cardiac arrest with bystander CPR and AED use are about 10-12% on average but are higher in cases of VF/VT arrest.

In-hospital cardiac arrest, the survival rates are higher, at around 25-30%, due to immediate access to advanced life support.

Early intervention is key to improving outcomes. CPR initiated within the first few minutes provides critical oxygenation to the brain, and defibrillation within 3-5 minutes is often lifesaving in VF/VT cases. Expanding public access to AEDs and training more people in CPR can significantly increase survival rates from sudden cardiac arrest.

Normally in CPR, 30 chest compressions are followed by 2 rescue breath given with chin lift, head tilt

The American Heart Association (AHA) has updated its CPR guidelines to recommend Hands-Only CPR for bystanders in certain scenarios, particularly for adults who experience sudden cardiac arrest outside a hospital setting. This approach focuses on uninterrupted chest compressions at a rate of 100-120 compressions per minute, eliminating the need for rescue breaths unless the rescuer is trained and confident in giving them. The change is based on the following considerations:

Why Hands-Only CPR?

It is easy for lay rescuers. Performing chest compressions alone is simpler and less intimidating for untrained bystanders. Many people hesitate to provide mouth-to-mouth rescue breaths due to fear of disease transmission or lack of confidence in their technique.

Effectiveness in the First Few Minutes:

During the initial minutes of cardiac arrest, there is often enough oxygen in the blood to sustain vital organs, provided chest compressions circulate this oxygen. Hands-Only CPR ensures consistent blood flow to the brain and heart until advanced help arrives or an AED is available.

Fatigue and Practicality for Single Rescuers:

Rescue breathing interspersed with chest compressions (30 compressions to 2 breaths under the current guideline for trained individuals) can indeed be exhausting, especially for a lone rescuer. Hands-Only CPR reduces the physical burden and allows for sustained, effective compressions.

What About Rescue Breaths?

For trained individuals the AHA still encourages the traditional CPR technique with 30:2 compression-to-breath ratio for trained rescuers, especially in cases involving: 

1.      Infants and children.

2.      Drowning victims or those with respiratory arrest (e.g., opioid overdose or airway obstruction).

3.      Situations where oxygenation is critical, and the heart has not yet stopped.

For untrained bystanders, hands-only CPR is the preferred approach because studies show it is nearly as effective as conventional CPR in the early stages of cardiac arrest. It simplifies the process and encourages more people to act.

Fatigue in Single-Rescuer Scenarios:

Administering compressions and breaths continuously as a single rescuer can be exhausting, even within minutes. Hands-Only CPR removes the need for coordination between breaths and compressions, reducing physical strain. If possible, switching rescuers every 2 minutes (or when fatigued) is ideal to maintain effective compressions. However, if no help is available, consistent chest compressions are more critical than pausing for breaths.

Evidence Supporting Hands-Only CPR:

Research shows that bystanders who perform Hands-Only CPR achieve survival rates comparable to traditional CPR in adults with sudden cardiac arrest due to:

1.      Improved willingness of bystanders to act. 

2.      Better circulation of oxygenated blood when compressions are uninterrupted.

For children, however, survival outcomes improve significantly with traditional CPR (compressions + rescue breaths), as paediatric arrests are more likely to result from respiratory issues rather than primary cardiac events. The Hands-Only CPR approach is a practical and lifesaving guideline, especially for untrained or hesitant rescuers. It simplifies the process, making it easier for anyone to respond in emergencies. While rescue breaths are vital in specific cases (e.g., children, drowning), uninterrupted chest compressions are crucial for maintaining circulation and increasing survival chances. Training the public on Hands-Only CPR and AED use should be a priority in all communities to improve response rates and outcomes during cardiac emergencies.

My personal feeling on hands only CPR is that the compression of the chest itself would already draw in air in and out from the lungs (chest walls) albeit not as efficiently as the diaphragm moving up and down between the chest and the abdomen. This is much better than doing nothing.

My logic about applying only chest compressions to indirectly drawing air into and out of the lungs during CPR is valid and supported by physiological principles. Chest compressions, when performed effectively, generate changes in intrathoracic pressure that can result in passive air exchange, even without traditional rescue breaths. Here's why this happens and how it supports my point:

Mechanism of Passive Air Exchange During Chest Compressions and Chest Wall Recoil: 

During each compression, the chest is forced downward, increasing intrathoracic pressure and compressing the lungs. This pushes some air out of the lungs.

When the chest recoils, negative pressure is created, which can draw air back into the lungs. This process, while not as efficient as normal breathing driven by the diaphragm, still facilitates some air movement.

Ventilation via Thoracic Pump Effect:

The rhythmic compression of the chest acts as a pump, not only circulating blood but also moving small volumes of air. This is why compressions alone can maintain partial oxygenation, especially in the first few minutes after cardiac arrest when oxygen reserves in the blood are still present.

Residual Oxygen in the Blood:

In the initial moments of cardiac arrest, oxygen stored in the blood and lungs can be circulated to vital organs by chest compressions. This is often sufficient to sustain brain and heart tissue until advanced interventions (e.g., AED or rescue breathing) are applied.

Hands-Only CPR is much better than doing nothing. Studies show that most bystanders hesitate to act in emergencies because they are unsure how to give rescue breaths or are uncomfortable with mouth-to-mouth contact. Hands-Only CPR removes this barrier, focusing on the most critical element: maintaining blood flow to the brain and heart.

Efficiency of Hands-Only CPR vs. Conventional CPR in Early Stages of Cardiac Arrest:

In adults, sudden cardiac arrest is often caused by a primary cardiac event (e.g., arrhythmias), meaning the lungs and blood still contain oxygen at the onset. Hands-Only CPR ensures that this oxygen is circulated, supporting vital organ function.

Limitations Without Rescue Breaths:

Over time, as oxygen levels in the blood deplete, the absence of ventilation (rescue breaths) may reduce effectiveness. For this reason, traditional CPR (with breaths) is still recommended for trained individuals and in cases where oxygenation is critical (e.g., drowning, asphyxiation, or paediatric emergencies).

My view agrees with current guidelines and the science of CPR. Hands-Only CPR:

1.      It simplifies the process for untrained rescuers.

2.      It maintains blood flow to the brain and heart, preventing early brain damage and improving survival odds.

3.      It facilitates passive air exchange, which is "good enough" in many cardiac arrest scenarios during the critical first few minutes.

In an emergency, encouraging bystanders to focus on continuous, high-quality chest compressions is lifesaving. While it may not achieve perfect oxygenation, it buys crucial time until professional help or equipment (like an AED) arrives. The passive role of chest compressions in drawing air into the lungs is scientifically sound and reinforces the importance of Hands-Only CPR as a vital first response.

CPR Using Toilet Bowl Plunger: 

Since CPR can be very exhausting especially for a single rescuer, the use of a toilet bowl plunger if available to perform the CPR has been done and suggested. The toilet bowl plunger works on the principle of vacuum that sucks and pushes.  This may minimize broken ribs, further trauma on the casualty, but more important tremendously reduces fatigue for the rescuer by kneeling to give chest compression and leading even further down and forward to administer rescue breaths every 15 - 30 compressions. This will cause the first responder to collapse himself, with another causality added. 

The advantage with the toilet bowl plunger is that it does not exhaust the person so easily or quickly and can even be performed while standing without needing to bend or kneel. The toilet bowl plunger I believe would be much more gentle, more effective, what's more since it works on 'sucking actions' it may also be directed on the abdomen where the diaphragm is to pump it anteriorly and posteriorly to draw in air into the lungs.

Using a toilet bowl plunger as an improvised CPR device is both creative and thoughtful, especially in addressing the physical demands and potential rib trauma associated with traditional chest compressions. 

Let us briefly look at its application further from both a physiological and practical perspective:

The plunger's design creates a suction effect during decompression, which could help mimic the natural recoil of the chest. This recoil is crucial for allowing the heart to refill with blood between compressions, enhancing circulation.

Decompression could also improve passive air exchange, as the negative pressure created may aid in drawing air into the lungs.

CPR is physically demanding, especially for a single rescuer. A plunger allows the rescuer to use their arms in a more ergonomic position (standing or kneeling without leaning forward excessively), reducing strain on the back and shoulders.

By using a larger surface area for compression, it could distribute force more evenly, potentially lowering the risk of rib fractures. If used on the abdomen, the suction and compression could theoretically stimulate the diaphragm indirectly, helping to move air into and out of the lungs. However, this approach might divert focus from maintaining proper cardiac compressions over the sternum, which are critical for circulating blood.

Practical Considerations:

While the plunger could theoretically aid in compressions, its ability to generate adequate depth (at least 5 cm) and rate (100–120 compressions per minute) consistently would need to be evaluated. Standard chest compressions are highly effective when done correctly because they directly target the heart's position between the sternum and spine.

Injury Risk:

If improperly positioned, the plunger could cause abdominal trauma or interfere with the proper alignment of chest compressions. CPR guidelines emphasize compressing the lower half of the sternum, avoiding other areas.

Hygiene and Accessibility:

In an emergency, a plunger might not be readily available or clean, which could discourage its use.

Lack of Research:

While this idea is innovative, there is no current clinical evidence supporting the use of a plunger for CPR. Devices like active compression-decompression (ACD) CPR tools (e.g., the "Cardio Pump") are designed based on similar principles but have undergone rigorous testing to ensure safety and efficacy.

Existing Alternatives and Future Exploration:

Innovations like ACD-CPR devices, which use suction to enhance chest recoil and improve circulation. These devices are FDA-approved and have shown promise in improving outcomes in some cardiac arrest cases. If a plunger-based tool were to be developed, it would require similar testing to ensure it meets the necessary depth, rate, and safety standards.

The reasoning of using a toilet bowl plunger is ingenious and shows a deep understanding of the challenges faced by rescuers. While a plunger could serve as an emergency improvisation, traditional manual CPR or using an AED remains the gold standard, as both are backed by extensive research and guidelines.

Nevertheless, this idea could inspire further innovations in CPR tools, particularly for scenarios where rescuer fatigue is a concern. It’s this kind of creative thinking we (like myself), normally use in medical research that often leads to breakthroughs in medical technology!

Other Medical Emergencies: 

Finally, I think too much emphasis has been placed on cardiac arrest and CPR. In fact, we deal with so many medical emergencies too, from massive bleeding, choking, head, neck, chest, abdominal, hip and spinal injuries, electrocution, near drowning... all the way down to burns, poisoning, psychiatric emergency, suicidal behaviour, acute manic / psychotic episodes and the various types of shock.

 Shock for example is a life-threatening condition that requires immediate treatment. There are several types of shock, each with a different cause and treatment. Here are just some examples: 

1.      Hypovolemic shock, caused by a loss of blood or fluids, this type of shock is treated by replacing fluids intravenously. In severe cases, a blood transfusion may be needed. 

2.      Cardiogenic shock, caused by a heart problem, this type of shock is treated with intravenous fluids and medications to constrict blood vessels. Surgery may also be needed. 

3.      Distributive shock, caused by a pathological redistribution of blood volume, this type of shock is treated with a combination of fluids and vasoconstrictors. Septic shock, a type of distributive shock caused by blood poisoning, is treated with antibiotics. 

4.      Obstructive shock, caused by a blockage in circulation, this type of shock is treated by removing the obstruction. This may involve surgery or clot-dissolving medication. 

5.      Anaphylactic shock, caused by a severe allergic reaction, this type of shock is treated with epinephrine, antihistamines, corticosteroids, and oxygen. 

6.      Neurogenic shock, caused by damage to the central nervous system, this type of shock is treated with intravenous fluids and medications, including corticosteroids. 

Shock management also involves identifying and treating the underlying cause, restoring blood volume by using  fluid expanders (intravenous fluids) that increase the amount of fluid in the circulatory system. They are used in a variety of clinical situations, including plasma volume expanders (PVE) to treat cardiogenic shock, a life-threatening condition where the heart can't pump enough blood. PVEs restore vascular volume and stabilize blood flow. These fluid expanders include crystalloids, normal saline, Ringer’s solution, glucose-dextrose, etc. 

There are lots more medical emergencies we need to manage, not just acute myocardial infarctions and CPR. But we shall not go into them. I might as well write a textbook on emergency medicine for doctors instead of writing them here!  

 

 

 

 

How Much Vitamins Do We Need?

 

As a follow-up on the  previous article posted here on Saturday, December 14, 2024, on:

A Poser: Can Excessive Intake of Vitamin C Cause Kidney Damage?

https://scientificlogic.blogspot.com/2024/12/a-poser-can-excessive-intake-of-vitamin.html

Let me now write  a little bit more about vitamin C.

A lot of people believe if vitamins, including vitamin C is good for health, then more is even better? For instance, a deficiency of vitamin C causes survey but what if they take excess of it?  Wouldn’t that be better? We shall address this question shortly.  

Before we go into that, let’s find out how much vitamin C do we need daily? 

There was  a  famous classical Sheffield experiment done in 1944 on 20 volunteers who were given a diet containing less than 1 milligram vitamin C daily. Three received a vitamin C [ascorbic acid] supplement of 70 milligram daily, 7 received 10 milligrams, and 10 had no supplement. No signs of deficiency were observed in those receiving supplements over a period of 14 months. All 10 of the volunteers receiving no supplement developed clinical scurvy. The first changes were enlargement and keratosis of the hair follicles, beginning after 17 weeks of deprivation. Later the follicles became haemorrhagic and formed the characteristic scorbutic spots. Gum changes began to appear after 26 weeks. One subject developed effusion into both knee joints and ecchymoses of the leg. Two developed cardiac complications. A dose of 10 milligram of vitamin C [ascorbic acid] daily removed all the clinical signs and after 7 to 9 weeks of treatment the skin appeared normal.

The experiment showed beyond any doubt that 10 milligrams. of vitamin C [ascorbic acid] daily will not only prevent scurvy but will also cure the disease. This, of course, does not mean that 10 milligram is an optimum requirement or a recommended daily allowance. In order to cover individual variations and include a safety margin, nutritionists  recommend a daily intake of 30 milligram. and thus, are in agreement with the recommendation of the League of Nations Health Organization Technical Committee on Nutrition made in 1938 [this Bulletin, 1938, v. 13, 979].

The Sheffield experiment is a classic example illustrating that only small amounts of vitamin  C are necessary, not just to meet basic physiological needs, but also cure scurvy. However, this doesn't imply that 10 mg is the optimal dose for overall health. 

Diagnostic Methods for Vitamin C Levels:

But how do nutritionists measure the status of vitamin C in the  body?  Is it too high, or is it too low people ask? 

Due to water solubility of vitamin C,  nutritionists use the saturation test to assess the status of vitamin C (ascorbic acid) in the body. If the body is already saturated with vitamin C, it will be shown in the urine rapidly. If there is a deficiency, then there is little urinary output and there will be a delay time in any output as they body will try to retain and absorb the ascorbic acid as long as possible. Unlike drugs that are toxic to the body, the body will try to get rid of them as fast as possible with the  shortest retention time. 

The diagnostic method nutritionists use to assess the status of vitamin C in the body and also for them to diagnose vitamin C deficiency disease, is  the Tillmann-Harris-Ray method.

 It consists essentially of the daily administration of 300 milligram of ascorbic acid intravenously, until at least half of this amount reappears in the urine. If the body was saturated, the ejection of this quantity takes place within 1–4 days afterwards. If hypovitaminosis dominates, then the ejection is delayed. So far, by examining blood directly only extreme values can be evaluated: above 1 milligram per cent indicates saturation, while below 0.4 milligram per cent indicates hypovitaminosis. Concentrations ranging between cannot be evaluated properly, because 0.5 milligram per cent may already signify saturation, while in contradistinction 0.9 milligram per cent may, in certain circumstances, indicate hypovitaminosis. 

The Tillmann-Harris-Ray saturation test is an interesting and somewhat historical method for assessing vitamin C status. While it highlights the body's capacity to retain or excrete vitamin C based on its needs, more modern methods, such as high-performance liquid chromatography (HPLC), are now used by nutritionists and nutrition biochemists to measure plasma concentration of ascorbic acid levels.

There may be a possibility of error in using such a  test owing to the variation in absorption and utilization of vitamin C from the gastro-intestinal tract because of varying degrees of acidity (anacidity), inflammation, the introduction of laxatives and other less understood factors.  The same error holds for tests which involve studies of the blood level of vitamin C instead of in the urine after the oral administration of this vitamin C. 

Since nutritionists are able to measure how much vitamin C is retained in the body, let us now find out what happens if we take excess of it.  This brings us on the philosophy of "more is better"

The idea that "if some is good, more is better" is a common misconception in nutrition. Vitamins, like any other nutrient, have an optimal range—neither too little nor too much is beneficial. The emphasis on a diet rich in fruits and vegetables agrees with current nutritional guidelines, as whole foods provide not only vitamins but also fibre, phytonutrients, and other compounds that work synergistically.

In the 1960s and early 1970s a few cases were reported of a conditioning effect of high-dose vitamin C intake with consequent rebound scurvy upon cessation of supplementation in man. Although these reports do not stand up to scrutiny they are often cited as evidence for such an effect. The same is true for the only published report on two infants with scurvy allegedly induced in utero by moderate vitamin C supplementation of the mothers. Experimental studies in guinea pig and man trying to reproduce a rebound effect have failed. Kinetic studies in man indicate that after high-dose vitamin C intake a large proportion of the vitamin is degraded in the intestine to CO2 by microbiological breakdown. Another large proportion is excreted unchanged in urine. The claim of rebound scurvy due to a conditioning effect of high vitamin C doses is still to be definitively shown.

Risks of “the more the better”  Vitamin C are: 

1. Risk of Oxalate Stones: While the human body metabolizes most vitamin C, excessive amounts can lead to the production of oxalate, a compound that may contribute to kidney stone formation in susceptible individuals. However, this risk is likely individual-dependent and may not apply to everyone.

2. Tolerable Upper Intake Level (UL): The recommended upper limit of 2,000 mg per day exists to prevent gastrointestinal disturbances like diarrhoea. As mentioned, water-soluble vitamins are excreted if consumed in excess, but this doesn't completely negate the risk of long-term high-dose supplementation.

3. Conditioning Effects: The "rebound scurvy" hypothesis has been debated, but the evidence is inconclusive. However, the body's adaptive mechanisms—such as increased urinary excretion of vitamin C when intake is high—are important to consider when advocating for mega-doses.

Nevertheless, vitamin C might be beneficial in specific contexts, such as improving creatinine clearance after kidney transplant surgery. This is an example of targeted therapeutic use rather than generalized supplementation. Vitamin C's antioxidant properties might play a role in reducing oxidative stress, which can benefit renal health in controlled situations.

The recommended daily amount for vitamin C varies from country to  country, generally it is 75 milligrams (mg) a day for women and 90 mg a day for men. During pregnancy, 120 mg a day are recommended. The upper limit for all adults is 2,000 mg a day. Although too much dietary vitamin C is unlikely to be harmful, large doses of vitamin C supplements might cause diarrhoea, nausea, vomiting, heartburn. stomach (abdominal) cramps, and possibly headache. But I think a daily diet rich in fruits and vegetable are more than adequate for the requirements of vitamin C for most people without the necessity of given vitamin C supplementation 

However, a slightly higher intake of vitamin C may help decrease the levels of creatinine in our body. For example, a 2021 review found that vitamin C helped increase creatinine clearance in people who underwent kidney transplant surgery.

The risk of toxicity from an overdose of vitamin C might be low as with the B-groups of vitamins, namely,  thiamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), biotin (B7), folate or ‘folic acid’ and cyanocobalamin (B12). These groups of vitamins are water-based and can easily be excreted in the urine when they are taken in excess.  

What we explain  could serve as a foundation for an educational article or presentation. It balances historical and modern perspectives while emphasizing practical dietary advice. We  might consider elaborating on specific subtopics, such as the role of vitamin C in collagen synthesis, immune support, and its debated effects on colds and cancer. 

Integration with Clinical Findings: 

Incorporating recent studies, such as the 2021 review on the intake of vitamin C and creatinine clearance, could further strengthen our argument.

As already explained, toxicity with vitamin C and other water-soluble B-group vitamins may be low, but this is not the case with fat-soluble like  vitamins A (retinol), vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol), E (alpha-tocopherol), and vitamin K (naphthoquinones). Fat soluble vitamins cannot be excreted in water-based urine. They are stored in the body's fatty tissue and in the liver. 

Fat-Soluble Vitamins and Toxicity

Fat-soluble vitamins (A, D, E, and K) highlight the contrast between water-soluble and fat-soluble vitamins. Unlike water-soluble vitamins, excess fat-soluble vitamins can accumulate in tissues and lead to toxicity. Acute and chronic hypervitaminosis A are well-documented, and the historical anecdote about polar bear liver is both fascinating and illustrative.

Excessive vitamin A intake can cause toxicity (hypervitaminosis A).  Acute systemic vitamin A toxicity typically arises when an individual consumes over 100,000 RAE ( RAE stands for retinol activity equivalents),  within a short period, often from supplements or high-dose medications. The toxicity symptoms include nausea, vomiting, headache, dizziness, irritability, blurred vision, and muscular incoordination. Acute toxicity is rare and is more likely to occur after consuming synthetic forms of vitamin A, such as the retinoid medication isotretinoin. Mucocutaneous effects include cheilitis and dryness of lips and oral, ophthalmic, and nasal mucosa. The suggested mechanism involves decreased sebum production, reduced epidermal thickness, and altered barrier function. Additional cutaneous effects include dry skin, pruritus, peeling of the palms and soles, and fissuring of the fingertips. Higher doses of vitamin A may lead to telogen effluvium. Severe cases may manifest with bone pain and increased intracranial pressure.

Chronic vitamin A toxicity is associated with prolonged ingestion of excessive vitamin A, typically exceeding 8000 RAE per day. This condition can develop after consuming substantial quantities of animal-based foods rich in preformed vitamin A, such as liver, or through the prolonged use of high-dose vitamin A supplements. The toxicity symptoms include dry, cracked skin, hair loss, brittle nails, fatigue, loss of appetite, bone and joint pain, and hepatomegaly. Chronic retinoid toxicity affects various organ systems. Bone-related effects include bone spurs, calcinosis, and bone resorption, leading to hypercalcemia, osteoporosis, and hip fractures. Central nervous system effects include headache, nausea, and vomiting.

The Eskimos have long been wary of eating the polar bear for this reason, but it's something the early Artic explorers found out the hard way. Ingesting the liver can cause vitamin A poisoning known as acute hypervitaminosis A. This results in vomiting, hair loss, bone damage and even death. Polar bear liver toxicity due to hypervitaminosis A was first reported by Europeans in 1597 when the Dutch explorer Gerrit de Veer wrote in his diary that while taking refuge during the winter in Nova Zemlya (an archipelago in the Arctic Sea in northern Russia) that he and his men became seriously ill after eating polar bear liver.

Fat-Soluble Vitamins and Toxicity

Poisoning due to excessive fat-soluble vitamins (A, D, E, and K)  highlights the contrast between water-soluble and fat-soluble vitamins. Unlike water-soluble vitamins, excess fat-soluble vitamins can accumulate in tissues and lead to toxicity. Examples of acute and chronic hypervitaminosis A are well-documented, and the historical anecdote about polar bear liver is both fascinating and illustrative.

 

 

You Are Welcome Ir. CK Cheong

 Dear Ir. CK Cheong,

Thank you for your kind words and encouraging comments in the comment column under: 

"A Poser: Can Excessive Intake of Vitamin C Cause Kidney Damage?" 

Please do not be misinformed that  those foods I mentioned there are the cause of kidney damage. This is not entirely true. I was only talking if they are taken regularly in excess especially when the kidneys are already compromised from other causes such as existing diabetes, high blood pressure, renal stones, autoimmune diseases  such as  lupus, IgA nephropathy, smoking, excessive alcohol, certain drugs like non-steroidal anti-inflammatory drugs (NSAIDs), cyclosporine, etc. 

Normally a healthy pair of kidneys can handle most of the foods we consume, provided we consume them in moderation. If you are concerned, you may measure the status and the health of your kidneys using some simple blood tests such as  measuring the amount of creatinine.

 A glomerular filtration rate (GFR) blood test is possibly the best measurement that tells how well your kidneys remove waste from your blood. A normal eGFR is greater than 90, but values as low as 60 are considered normal if there is no other evidence of kidney disease. However, GFR can drop as you age 

Of course you are very welcome to share my articles in this blog with whosoever you wish. The articles in this blog ranging from astronomy, analytical chemistry, biology, evolution, genetics, mathematics, drugs and medicine, food, nutrition, and health...  all the  way down to the mysteries of life and death, including poetry and slide shows on various lectures I gave...and even on spiritual life beyond death...hundreds of them on various subjects are especially written in simple non-technical language for the general readers 

If you like to ask a question or want me to write an article that may interest you - provided it is within my university training and my expertise please let me know. I shall try, provided I know the subject well 

We are all in this journey of forever learning 

Take care!

jb lim 

The Good Samaritan Law in A Medical Emergency

 

I saw on television last night and read it in the newspaper this morning that Malaysia plans to enact the Good Samaritan Law to encourage more people to become lifesavers in an emergency here:

https://www.malaymail.com/news/malaysia/2024/12/14/good-samaritan-law-will-encourage-more-people-to-become-lifesavers-in-an-emergency-says-health-minister/159852

Today I like to discuss a little bit  on the Good Samaritan law that will legally protect members of the public from being sued should they render aid to a casualty in a medical emergency even if the rescuer does it wrongly or caused more damage when they are not medically qualified or trained. 

Since the Good Samaritan law protects the ordinary man-in-the -street who helps the injured, but does it protect doctors, paramedics, emergency medical technicians (EMT), first responders, first-aiders who are trained and qualified, but they do more harm than good? Follow me all the way down as I shall address these difficult questions. 

Malaysia currently has no Good Samaritan law yet but will soon be passing a law for this. However, there are a number of countries that have the Good Samaritan law. I shall try to answer all these very interesting questions here. 

The Good Samaritan Law proposal in Malaysia, which has been gaining attention recently, is a significant step toward promoting altruism and civic responsibility. This law, if enacted, would aim to protect individuals who voluntarily offer assistance in emergencies from legal liability. The goal is to encourage people to act in good faith without fear of legal repercussions should unintended consequences arise during their attempt to help.

Currently, there are concerns in Malaysia about the legal risks for individuals providing aid in emergencies, which often discourages people from stepping forward.

The Malaysian government plans to table this proposal in Parliament for further discussion, reflecting Malaysia's effort to align with global legal practices and foster a more compassionate society. This initiative also underscores the importance of community responsibility and mutual aid in emergencies.

The law is intended to address this issue, creating a framework similar to laws in other countries that protect "Good Samaritans." For instance, in many jurisdictions, these laws shield helpers from civil lawsuits or criminal charges, provided their actions are reasonable and not grossly negligent.

Even Singapore does not yet have a specific Good Samaritan law that provides blanket legal protection to bystanders rendering medical aid. However, the Singapore Civil Law Act (Section 7) has provisions to encourage assistance during emergencies. It protects healthcare professionals and Good Samaritans acting in good faith, provided their actions are not grossly negligent. Additionally, under Singapore's Penal Code (Section 89), individuals are generally not held liable if they act in good faith for the benefit of another person, such as in a medical emergency.

Despite these general protections, there is no codified "Good Samaritan Law" except those in the U.S., Canada, or Australia.

However, many countries have implemented Good Samaritan laws in one form or another to encourage bystanders to assist in emergencies without fear of legal repercussions. Here are some of these countries:

In the United States Good Samaritan laws exist in all 50 states. Each state has variations, but they generally protect individuals who provide emergency aid in good faith and without gross negligence. The Aviation Medical Assistance Act (1998) extends similar protections for in-flight emergencies.

In Canada, most provinces have Good Samaritan laws, such as the Good Samaritan Act (2001) in Ontario, protecting anyone who voluntarily provides aid.

In the United Kingdom though they have no formal Good Samaritan law, common law principles shield rescuers acting in good faith from legal action, provided they are not negligent.

In  Australia, all Australian states and territories have Good Samaritan laws that protect volunteers providing first aid or assistance, such as the Civil Liability Act (2002) in New South Wales.

India has the Good Samaritan Guidelines (2016) that protect bystanders helping road accident victims. It ensures they won’t be harassed by police or hospitals.

France and Germany  are very exceptional. French law explicitly requires individuals to render assistance during an emergency, whether trained or not, under Article 223-6 of the French Penal Code. Failing to do so can result in criminal charges. France’s approach to making it mandatory by law for bystanders to render aid in emergencies is unique and worth exploring. Under Article 223-6 of the French Penal Code, individuals who fail to assist someone in danger can face. Fines: Up to €75,000 and imprisonment up to 5 years.

This law applies to anyone witnessing an emergency, not just medical professionals, unless assisting poses a risk to the rescuer's safety.

Germany’s Criminal Code (Section 323c) also makes it mandatory for bystanders to assist in emergencies. Failure to act can lead to fines or imprisonment.

China passed a Good Samaritan Law (2017) that protects people from being sued or held liable for rendering emergency aid.

Japan’s Good Samaritan laws provide limited protection to rescuers but hold them liable if their actions are negligent or exceed their training.

Other Countries like New Zealand, South Africa, Sweden, and Italy also have versions of Good Samaritan laws or common-law protections for emergency aid.

My Opinion on Mandatory Aid Laws.

Mandatory aid laws like France's are both admirable and complex. Here are the key considerations:

Pros of Mandatory Aid Laws, encourages a culture of responsibility. Such laws reinforce the moral and ethical duty to help others, fostering a more compassionate society. In emergencies, timely intervention by bystanders can save lives (e.g., CPR or stopping severe bleeding).

Deters Inaction:

These laws address the "bystander effect," where individuals fail to help because they assume someone else will step in.

By making inaction punishable, these laws ensure more people take responsibility in emergencies.

Boosts Public Awareness:

Mandating aid encourages governments to invest in public education on basic first aid, making more people confident and capable of responding to emergencies.

Challenges of Mandatory Aid Laws:

Risk to the Rescuer:

In some situations, rendering aid may endanger the rescuer (e.g., a dangerous accident site, exposure to infectious diseases). The law must account for these scenarios.

Lack of Training:

Forcing untrained bystanders to assist may result in well-meaning but harmful actions (e.g., incorrect CPR techniques or improper handling of spinal injuries).

Potential for Misuse:

In countries with strict litigation cultures, mandatory aid laws might expose rescuers to accusations of negligence if the outcome is unfavourable, even if they acted in good faith.

I believe encouraging voluntary aid through Good Samaritan protections is generally more effective than mandating aid. While mandatory laws like those in France promote altruism, they should also:

Provide clear exceptions for situations where aiding would endanger the rescuer.

Include robust public education programs to ensure citizens have the necessary skills to assist effectively.

A hybrid approach might work best, where citizens are encouraged (and sometimes obligated) to act, but also protected by Good Samaritan principles when doing so.

Some discussions around the proposal highlight potential challenges, such as defining the scope of "reasonable assistance" and ensuring the law isn't abused. Legal scholars have also debated how the law would balance the need to protect Good Samaritans while safeguarding victims' rights​

However, I think most people will act instinctively in good faith to help an injured person in a road accident or rescue someone from drowning or in a fire, with or without the Good Samaritan law unless it poses a danger to himself or others acting in good faith. I don't think they will think of the legal aspect in an emergency

I believe in many cases, people instinctively step in to help during emergencies, driven by human empathy rather than a concern for legal consequences. Whether it's pulling someone from a car wreck, attempting CPR, or rescuing someone from a fire or drowning, these actions are often reflexive and motivated by the desire to save a life or alleviate suffering.

However, fear of potential legal repercussions can weigh heavily on people's minds in certain scenarios, particularly in countries where no Good Samaritan protections exist. This is especially true for situations where the helper is unsure about the consequences of their actions, such as inadvertently causing harm while attempting CPR or moving an injured person. The uncertainty about being sued or facing criminal charges might discourage some individuals from acting, even when they feel compelled to help.

The enactment of Good Samaritan laws aims to reduce this hesitation, providing peace of mind that acting in good faith will not lead to punishment. These laws serve not only as a safety net but also as a societal encouragement for bystanders to step forward and assist without fear. However, most individuals don’t deliberate on legal matters in the heat of the moment; their primary instinct is to save a life, especially if they believe they can make a difference without significant risk to themselves or others.

In cases of imminent danger—like a fire, drowning, or other life-threatening emergencies—people often weigh the risks to themselves before acting. Good Samaritan laws do not compel people to put themselves in harm's way, but they do promote a culture of mutual aid and responsibility by protecting those who act in good faith. France’s mandatory duty to assist reflects this ideal, though it raises questions about personal freedom and the line between moral and legal obligations.

In Malaysia’s context, while the instinct to help exists widely, implementing a Good Samaritan law can further reassure the public, fostering a stronger sense of community and ensuring legal clarity for those willing to help. It bridges the gap between moral duty and legal safety.

Let me explain how the law is going to apply for various groups.

1.      Members of the Public (Untrained Rescuers):

Protection scope for these individuals is generally the primary focus of Good Samaritan laws. If a bystander with no formal medical training tries to help but unintentionally causes harm (e.g., performing CPR improperly or exacerbating an injury), they are protected as long as:

They acted in good faith.

They did not act with gross negligence or reckless behaviour.

They did not demand compensation for their help.

2.      Medically Trained Individuals (Doctors, EMTs, Paramedics, Nurses, First Responders, and Trained First-Aiders)

Protection for Volunteering Off-Duty: If these individuals voluntarily offer help outside their professional setting (e.g., witnessing an accident while off-duty), they are usually protected under Good Samaritan laws, provided they:

Act within the scope of their training and competence.

Render assistance in good faith without reckless or wilful misconduct.

Liability for Errors: The law generally assumes that trained professionals are held to a higher standard of care than untrained individuals. If a trained rescuer performs a procedure incorrectly or goes beyond their expertise (e.g., attempting surgery at the scene), they could be at risk of liability if the act is deemed negligent.

Does the Law Protect Them if They Do More Harm?

The key issue here is negligence vs. reasonable effort in an emergency:

Reasonable Effort: If a trained professional acted in good faith and provided care that would be considered reasonable given the circumstances, they are often protected. For example, a doctor performing CPR may accidentally break ribs; this would likely fall under protected actions because broken ribs are a common side effect of proper chest compressions.

Gross Negligence or Wilful Misconduct:

If a trained individual acts recklessly, beyond their expertise, or in a way that shows disregard for the standard of care expected of them, they may lose protection. For example, a paramedic performing an unnecessary invasive procedure at a scene without proper tools or justification.

A first responder failing to follow basic protocols they were trained to observe.

Key Differences Between Untrained and Trained Rescuers:

Standard of Care: Trained individuals are generally held to a higher standard than untrained bystanders. Courts may evaluate whether their actions was in line with the expectations of their training.

Professional Duty: In some jurisdictions, doctors or EMTs may have a legal obligation to assist in emergencies (even off-duty), unlike laypersons who can choose not to intervene. This duty adds another layer of complexity to liability questions.

What Else Influences the Protection?

Jurisdiction:

Good Samaritan laws vary by country and state. Some provide explicit protection for trained individuals; others are less clear about this.

In certain jurisdictions, off-duty professionals may be treated differently from lay rescuers or those acting within the scope of their job.

Compensation:

Good Samaritan laws typically apply only when the help is voluntary and unpaid. If the rescuer is on duty or compensated for their aid, they may be judged under different legal standards.

Consent:

If a conscious individual refuses aid, and a rescuer still intervenes against their wishes, this could complicate liability. During my training in emergency medicine, I was told there are people who wish to die, and they tattooed on their chest this message:

"Do Not Resuscitae (DNR)" 

A DNR order means they do not want any CPR in the event their hearts or breathing stop. We have to comply 

However, in emergencies where the casualty is unconscious or unable to consent, implied consent is assumed.

Recommendations for Trained Rescuers

To reduce the risk of liability while still helping:

1.      Stay within the scope of your training.

2.      Clearly communicate your actions to bystanders and the casualty (if conscious).

3.      Provide aid that is reasonable under the circumstances.

4.      Avoid invasive procedures unless necessary to save a life.

Trained individuals are generally protected by Good Samaritan laws, but their higher standard of care means they are more vulnerable to legal scrutiny if their actions deviate from accepted medical practices. Ensuring that their assistance aligns with their training and is delivered in good faith is key to retaining legal protection.

I was told during my advanced training in medical emergency and trauma care at the University Hospital of the National University of Malaysia (HUKM) and also during my training at the Kuala Lumpur Hospital, as well as in Selayang Hospital when I joined St. John Ambulance Malaysia as a Regional Staff Officer for Training  that doctors need to be careful in rendering  any medical treatment even in an  medical emergency in a passenger aircraft  flying over the air space of another country because their medical qualifications may not be recognized above that country, and even if it is recognized, was not registered for any medical treatment or practice in the air space of a foreign country.

This is a fascinating legal and ethical question that underscores the complexity of practicing medicine in emergencies, especially in international airspace or foreign jurisdictions. The situation touches on jurisdictional law, licensing requirements, and Good Samaritan principles. Here are  the relevant considerations

1.      Jurisdictional Challenges in International Airspace

Territorial Law: When an emergency occurs on a passenger aircraft flying over a foreign country, the legal framework governing the situation can be ambiguous. Generally:

The Law of the Country of Aircraft Registration: Most international conventions, including the Tokyo Convention (1963), state that the aircraft is governed by the laws of the country in which it is registered, even if it is flying over another nation's airspace.

Foreign Jurisdiction: However, if the aircraft lands in a foreign country for an emergency (e.g., a medical evacuation), the doctor’s actions may be subject to that country’s laws. In such cases, the doctor might face issues related to licensing or malpractice claims.

2.      Licensing and Recognition of Qualifications

Medical Licensing Laws: Most countries require medical practitioners to be licensed and registered within their borders to practice medicine legally. Even if a doctor’s qualifications are recognized globally, they are not automatically authorized to practice in every country unless registered.

For example, a doctor licensed in Malaysia, or the UK may not be registered to practice in the U.S. or Germany, leading to potential liability if they render care without legal standing.

Good Samaritan Protection:

Some jurisdictions and airlines extend Good Samaritan protection to doctors providing emergency assistance during a flight, as long as the care is given in good faith and within their scope of training.

However, this protection may not universally apply in all countries.

3.      Ethical Duty vs. Legal Risk

Doctors often face a dilemma in such scenarios:

Ethical Duty to Assist. The Hippocratic Oath and professional ethical standards obligate doctors to assist in emergencies whenever possible, regardless of location.

Refusing to help in a life-threatening situation could lead to moral, ethical, or even reputational consequences.

Legal Risk: Doctors may worry about malpractice lawsuits, particularly in countries with a litigious culture, even if their actions are well-intentioned.

Some countries’ laws might hold them to a higher standard of care due to their professional training, increasing the risk of liability compared to an untrained rescuer.

 4.      Protections for Doctors Assisting on Flights

Airlines' Policies:

Many airlines encourage doctors to assist in emergencies and have procedures in place to mitigate their liability. Some airlines explicitly extend indemnity coverage or Good Samaritan protection to doctors who step in to help.

Medical Kits and Ground Support:

Airlines are required to carry medical kits and often provide real-time medical consultation with ground-based professionals to support doctors onboard.

If a doctor works under the guidance of airline protocols or ground medical advice, their liability may be reduced.

5.      Practical Considerations for Doctors

Identify Yourself Clearly:

If asked to assist, the doctor should inform the crew of their qualifications, experience, and any limitations (e.g., a cardiologist may not be familiar with paediatric emergencies).

Document Actions:

Keep a clear record of the assistance provided, including steps taken and the reasoning behind them.

Ensure actions are limited to what is necessary and within the scope of their training.

Act in Good Faith:

The focus should always be on doing what is reasonable to save a life or prevent further harm, given the circumstances.

6.      International Conventions and Legal Precedents

Tokyo Convention (1963): Provides a legal framework for actions taken on international flights, generally applying the laws of the aircraft’s country of registration.

Good Samaritan Laws and Airline Practices: Some countries and airlines extend legal protections to doctors rendering emergency aid during flights. For example:

The U.S. Aviation Medical Assistance Act (1998) protects individuals providing emergency medical assistance on flights to or from the U.S.

Other jurisdictions may not have similar explicit protections.

My opinion is, while the concern about licensing and legal recognition in foreign jurisdictions is valid, I believe the ethical obligation to assist in life-threatening emergencies outweighs the potential legal risks in most cases. Key considerations include:

Good Faith and Reasonableness: 

If a doctor acts within their training and in good faith, most legal systems and airlines will offer some protection against liability.

Moral Responsibility: 

As a physician, providing aid could mean the difference between life and death. Even if legal concerns exist, rendering assistance balances well with the fundamental values of the medical profession.

Practical Safeguards: 

Doctors should communicate their limitations, follow established protocols, and document actions carefully to mitigate risks.

Ultimately, each doctor must weigh their ethical duty against the potential legal implications, but in most cases, stepping in to help during an emergency is the right decision both ethically and practically.

See another separate essay I wrote published on Wednesday, March 6, 2024

Doctors Facing Medical Emergencies: What They Can and Cannot Do?

 https://scientificlogic.blogspot.com/2024/03/doctors-facing-medical-emergencies-what.html

I shall write how effective is CPR and other medical emergencies for my next article, followed by a few other articles on health, nutrition, medicine, drugs, ..

Acute myocardial infraction (heart attack) is not the only medical emergency we need to manage. There are  dozens of other emergencies too