Resuscitation

[OneRoomSchoolHouse]

I learned something new yesterday. My cousin who works in a hospital said that when they apply the paddles to shock someones heart, there is a horrible cracking sound as the body is compressed. I HAD NO IDEA!! Seems that, especially with older people, their ribs end up cracking while trying to resuscitate. The movies always make it look so easy, one or two shocks and all is well. Just thought I'd share...

[MeanestMomInMidwest]

I think perhaps what she is referring to is when ribs are broken during CPR. That happens often and is unavoidable.

 

Nothing about medicine is as pretty as TV.

[Sputterduck]

Maybe Meanest is right. I've never heard a horrible cracking sound due to the paddles.

 

One thing that did surprise me in EMT school was that they told us how uncommon it is to actually be brought back to life with them. In the movies, people almost always come back with the paddles. No so irl.

[asta]

Yeah - most people don't realize that your ribs are cracked during CPR, either.

 

 

a

[Perry]

I learned something new yesterday. My cousin who works in a hospital said that when they apply the paddles to shock someones heart, there is a horrible cracking sound as the body is compressed. I HAD NO IDEA!! Seems that, especially with older people, their ribs end up cracking while trying to resuscitate. The movies always make it look so easy, one or two shocks and all is well. Just thought I'd share...

CPR cracks ribs, but the paddles don't. They deliver an electrical current through the chest. There is no cracking sound, although the patient jumps as the shock is delivered.

a video. Not for the squeamish. The defibrillator use starts at about 2:15.

[lionfamily1999]

I think perhaps what she is referring to is when ribs are broken during CPR. That happens often and is unavoidable.

 

Nothing about medicine is as pretty as TV.

:iagree:

 

It is a violent act, attempting to return someone to life.

[Mrs Mungo]

I think perhaps what she is referring to is when ribs are broken during CPR. That happens often and is unavoidable.

 

I agree. When I did lifeguard training I was taught that ribs are frequently broken during CPR. Also, when you pull someone out of the water and/or give them mouth-to-mouth they throw up. They don't show that on tv, either.

 

Nothing about medicine is as pretty as TV.

 

Is anything in life as pretty as TV?

[elise1mds]

Yeah, and my cousin who is in lifeguard training said you're not even allowed to do mouth-to-mouth the same way we used to. Now they're trained to use a tube to do the breathing instead of making skin contact because of the fear of disease transfer. Not to mention the lifeguards who get vomited on...

[Mrs Mungo]

Yeah, and my cousin who is in lifeguard training said you're not even allowed to do mouth-to-mouth the same way we used to. Now they're trained to use a tube to do the breathing instead of making skin contact because of the fear of disease transfer. Not to mention the lifeguards who get vomited on...

 

 

I first went through lifeguard training almost 20 years ago and even then we had a fold-out mask that included a tube with a valve that prevented people from vomiting in your mouth.

[farmgirlinwv]

I wish they'd share this w/ people when they're asking them about their code status. I really think people don't know what mom or dad are really going to go through w/ a full code. We've had to do too many codes on very elderly people who's ribs start breaking w/ the first compression, and there really is very little hope of helping them. Too many people are in the dark about what happens during a full code.

[Chrystal]

As a nurse who worked in a CVICU, I never heard a cracking sound when we used the paddles.

In fact most of the time I never heard much of a sound at all.

Also, the way you see it on TV where the bodies jump, that isn't how it happens either. It just doesn't. But it makes for good drama, huh?:001_smile:

 

As for how often it works, it depends on what the rhythym you are shocking. Once again, on TV they show the doctors shocking asystole, but that is not a shockable rhythym. If all electrical activity in the heart has stopped it doesn't just start again like a car battery. What you are doing is repolarizing the electrical activity so that it is in rhythym. The kind of heart rhythyms you can shock are all where the electrical activity is disorganized. If the person running the code really doesn't understand, or just wants to try anyway, they may call for a shock when one is really going to help.

 

And yes, most of the people I shocked survived.

[Chrystal]

CPR cracks ribs, but the paddles don't. They deliver an electrical current through the chest. There is no cracking sound, although the patient jumps as the shock is delivered.

a video. Not for the squeamish. The defibrillator use starts at about 2:15.

 

 

I went and looked at the video in your post and that isn't the same kind of paddles that we use in the hospital. Those are a totally different animal.

You can also see in the video that while he "has no pulse" he is moving and alive. His heart activity is just disorganized. Probably in V-fib. Ventricular Fibrillation where the electrical activity in his heart is just random and not producing a pulse and moving oxygen around.

He twitches, but doesn't jump like on TV. They also give a stronger shock because they are designed to be use by lay people and therefore there is a margin built in for error in placing the pads and such.

 

Cool Video.

[OneRoomSchoolHouse]

Hmmm..so the ribs crack with CPR compressions and not the paddles...good to know! Also very interesting about the rythms.

 

As for the vomiting from a drowning victim...ewww...do they tell this to the teenagers when they all think it is so cool to become life guards? I do get that saving a life is much more important than being vomited on...or in.

[Perry]

I went and looked at the video in your post and that isn't the same kind of paddles that we use in the hospital. Those are a totally different animal.

You can also see in the video that while he "has no pulse" he is moving and alive. His heart activity is just disorganized. Probably in V-fib. Ventricular Fibrillation where the electrical activity in his heart is just random and not producing a pulse and moving oxygen around.

He twitches, but doesn't jump like on TV. They also give a stronger shock because they are designed to be use by lay people and therefore there is a margin built in for error in placing the pads and such.

 

Cool Video.

It's an Automatic External Defibrillator, and it does essentially the same thing as the paddles on a crash cart. The settings vary depending on the machine, but generally deliver 100 - 200 joules. That isn't really comparable to hospital defibrillators though because AEDs are biphasic and hospital ones are monophasic. Less energy is needed with a biphasic defibrillator than a monophasic.

 

I don't watch tv so I really don't know how it's misrepresented. But I have defibrillated people and I would call it jumping, though maybe jerking would be a better description.

[gardening momma]

Also, when you pull someone out of the water and/or give them mouth-to-mouth they throw up. They don't show that on tv, either.

 

As for the vomiting from a drowning victim...ewww...do they tell this to the teenagers when they all think it is so cool to become life guards? I do get that saving a life is much more important than being vomited on...or in.

I knew that the person throws up, and I'm sure I saw that on TV. Just let your kids watch more TV! :tongue_smilie:

[MeanestMomInMidwest]

Lots of accurate info here. Just wanted to pop back in say that most "paddles" went away with Marcus Welby MD. The shock is delivered via "pads" now that are applied to the patient and remain on throughout the code, in case a shockable rhythm is identified.

 

And, to answer a previous poster: as an ICU nurse I am very kindly frank with family members about what happens during a code. The time when most families are called upon to make such decisions is not the time they should be making the decisions (emotionally, mentally, etc.).

 

Everyone who is thinking about this, and thinking what your family would have to go through were they in the situation of making decisions for you, should pursue documenting your choices now, while you are able to make them known. Look into your state's procedures for Living Wills. Living Wills are not always followed in the hospital, but at least you will be giving your loved ones a guideline of what you would have wanted, and not making them guess at a time when they are emotionally overwrought.

< end PSA >

[NoPlaceLikeHome]

CPR cracks ribs, but the paddles don't. They deliver an electrical current through the chest. There is no cracking sound, although the patient jumps as the shock is delivered.

a video. Not for the squeamish. The defibrillator use starts at about 2:15.

 

:iagree: I had to use the paddles numerous times in my career in nursing as well as teach other basic and advanced cardiopulmonary resuscitation. Oh and they do work some of the time. In the field they would work less since they are not used as quickly as they are in a critical care setting. Time is of essence with CPR and defibrillation (electric shocks).

Edited January 14, 2010 by priscilla

[kalanamak]

I think perhaps what she is referring to is when ribs are broken during CPR. That happens often and is unavoidable.

 

 

This is why I am DNR. If I collapse at the computer, I want you ladies to sing Abide With Me and sit on your hands.

[Spy Car]

I, on the other hand, would prefer a few cracked ribs over death :D

 

Bill

[MeanestMomInMidwest]

I, on the other hand, would prefer a few cracked ribs over death :D

 

Bill

 

Sometimes the life that remains after a "successful" code is not what one would expect. 'Course most of my experience is with the frail elderly and/or those patients with numerous comorbidities.

 

Thankfully, I have been able to be in on some youngish success stories, and those are the ones I try to dwell on.

 

And Bill, I'm pretty sure I wouldn't crack your ribs, big strong guy that you are. :001_smile:

 

ETA: Here's my second PSA - everyone should take a CPR class. If more out of hospital, witnessed cardiac arrests were responded to promptly with bystander CPR, many more would live to make it to (and out of) the hospital. New evidence points to the fact that chest compressions are KEY. If you're squeemish about putting your mouth on someone else's mouth, proper, effective chest compressions will help, even without rescue breaths. Contact American Heart Association or your local Red Cross to find a CPR class.

Edited January 14, 2010 by MeanestMomInMidwest

[Impish]

I, on the other hand, would prefer a few cracked ribs over death :D

 

Bill

When taking 1st Aid the first time, there was a young woman who was hugely concerned about breaking ribs. She went on about being sued, etc. I finally snapped, "Look, the person is DEAD. How much worse can it be? Snap a few ribs, be alive vs DEAD. Hmmmm. Tough choice!"

 

I have considered that perhaps I'm not a people person :D

[G5052]

Everyone who is thinking about this, and thinking what your family would have to go through were they in the situation of making decisions for you, should pursue documenting your choices now, while you are able to make them known. Look into your state's procedures for Living Wills. Living Wills are not always followed in the hospital, but at least you will be giving your loved ones a guideline of what you would have wanted, and not making them guess at a time when they are emotionally overwrought.

< end PSA >

 

And make sure that your doctor(s) and multiple relatives have copies of the documents. When my Dad began really going downhill last spring, my mother said he had never made his wishes known and refused to set any limits on treatment and refused hospice. She has dementia. Thankfully my aunt worked with the doctor, tracked me down, and I faxed the documents and took over after the doctor declared my mother mentally incompetant to make decisions regarding my dad's medical care (I was the alternate). Per his instructions we put him in hospice and did not invene when his heart and lungs began to fail. I hate to think what he would have suffered if it had not been documented, and if I had not been able to step in as I did.

[lionfamily1999]

Impish~

 

Here there are "good Samaritan" laws to protect people from being sued for just that.

[KidsHappen]

This is why I am DNR. If I collapse at the computer, I want you ladies to sing Abide With Me and sit on your hands.

 

I have also specifically told my family that I prefer DNR. Most of my family would respect my wishes but I honestly do not think that my hubby would be able to do so. He has already brought me back once and sat a bedside death watch another time. I simply do not think he has it in him to let go. It troubles me because sometime I really do wonder how many times a person can die and come back and be alright (as in all there, the same, etc.).

[kalanamak]

I, on the other hand, would prefer a few cracked ribs over death :D

 

Bill

 

By the time someone has asystole, the chances of walking out of the hospital are slim. Especially at my age.

[Truscifi]

As someone who has tried to resuscitate someone pulled out of the water, I have to say the vomit was the last thing I was thinking about. It was a friend though, it might have been different had I been a lifeguard with a stranger. I haven't been there so I don't know.

[Spy Car]

By the time someone has asystole, the chances of walking out of the hospital are slim. Especially at my age.

 

Please tell me you are not 50-ish :D

 

Bill

[Sputterduck]

Please tell me you are not 50-ish :D

 

Bill

 

50ish! Considering I think we have sons that are the same age, I was thinking you were about half that!

[Perry]

most "paddles" went away with Marcus Welby MD.

:eek: Marcus Welby! I'm old, but not THAT old. Last time I took ACLS was 1995 and we used paddles.

 

OMG, that was 15 years ago. Seems like yesterday. :lol:

 

Everyone who is thinking about this, and thinking what your family would have to go through were they in the situation of making decisions for you, should pursue documenting your choices now, while you are able to make them known. Look into your state's procedures for Living Wills. Living Wills are not always followed in the hospital, but at least you will be giving your loved ones a guideline of what you would have wanted, and not making them guess at a time when they are emotionally overwrought.

< end PSA >

:iagree:

Excellent point.

[KidsHappen]

They used paddles on my mother when she died of a heart attack in 2008. This was EMT personnel using equipment from an ambulance at her home. From my understanding they looked pretty much just like what you see on tv. SHe had already been without a pulse for at least 15 minutes and IMO they shouldn't have even tried to resescitate at that point. They cut her clothing off in her in her front yard, surrounded by strangers and they shocked her and she did jump or jerk. It was brutal and all it managed to do was traumatize my dd. It is her most vivid memory of the entire thing. :(

[Sputterduck]

They used paddles on my mother when she died of a heart attack in 2008. This was EMT personnel using equipment from an ambulance at her home. From my understanding they looked pretty much just like what you see on tv. SHe had already been without a pulse for at least 15 minutes and IMO they shouldn't have even tried to resescitate at that point. They cut her clothing off in her in her front yard, surrounded by strangers and they shocked her and she did jump or jerk. It was brutal and all it managed to do was traumatize my dd. It is her most vivid memory of the entire thing. :(

 

Often they will try to resuscitate someone who's been dead for a bit. The idea is that it helps the family see that everything that could be done was done.

 

If it is an infant, it doesn't matter if it's cold and been dead all night in it's crib. We were told to go through everything as if it had just died, out of compassion for the parents' long road of recovery that they are about to go on.

[KristenS]

I like that.

 

When my dad had his final heart attack, he was a few days home from the hospital after open heart surgery. Try figuring out, as a teen, how to do chest compressions on a man who's just had open heart surgery.

 

I think he was gone before we even started, and surely long before the ambulance arrived (we were pretty far out in the country), but it haunted me for years, that there wasn't more we could do.

[kalanamak]

Please tell me you are not 50-ish :D

 

Bill

 

Well, I hope you are sitting down....

 

 

Honestly, about once a month I catch myself muttering "you know you are middle aged when your peers start to die".

[kalanamak]

It was brutal and all it managed to do was traumatize my dd. It is her most vivid memory of the entire thing. :(

 

It is hard to get everything right. Sometimes part of the family is angry you didn't do enough, the part that there was too much.

 

When my dad was in his 90's and my mother still quite a spry 88, I told her if she had to call the ambulance, put the chain on the door and shove her hand out with the DNR and call loudly "he's 97. NO SUFFERING" and not let them in until they grunted in agreement.

 

She told me the two of them had a deal for the last 20 years of their lives: if one found the other in extremis or still warm, the living half would quietly go about their business until the body was stiff and THEN call for help. They'd have done it, too. Tough. Two tough old birds.

[Spinning]

I just went through BLS training a few weeks ago. Here is an interesting tidbit concerning AEDs: When deciding on a good demographic area to test them (risk factors that might cause sudden cardiac arrest), someone decided that Las Vegas Casinos would be a good test market for AEDs. As it currently stands, all casinos have AEDs in them. Our instructor said the BEST place to have heart attack, if you can chose, is a casino. J Evidently, casinos have high success rates with CA/MI. (Living in Las Vegas really does have its privileges.)

Our instructor also assured us that being a non-healthcare-provider ‘standbyer,’ we would be protected by the Good Samaritan law if breaking a rib during CPR. But you are a healthcare provider and break ribs, well, get an attorney. Or liability insurance. Crazy world we live in! People who work in healthcare truly are heroes.

[KidsHappen]

It is hard to get everything right. Sometimes part of the family is angry you didn't do enough, the part that there was too much.

 

Yes, this is hard because my hubby and I are not on the same page about this and the fact that we are not in agreement makes it even harder.

 

When my dad was in his 90's and my mother still quite a spry 88, I told her if she had to call the ambulance, put the chain on the door and shove her hand out with the DNR and call loudly "he's 97. NO SUFFERING" and not let them in until they grunted in agreement.

 

She told me the two of them had a deal for the last 20 years of their lives: if one found the other in extremis or still warm, the living half would quietly go about their business until the body was stiff and THEN call for help. They'd have done it, too. Tough. Two tough old birds.

 

I know I may be weird, but this really warms my heart. :001_smile:

[KidsHappen]

I just went through BLS training a few weeks ago. Here is an interesting tidbit concerning AEDs: When deciding on a good demographic area to test them (risk factors that might cause sudden cardiac arrest), someone decided that Las Vegas Casinos would be a good test market for AEDs. As it currently stands, all casinos have AEDs in them. Our instructor said the BEST place to have heart attack, if you can chose, is a casino. J Evidently, casinos have high success rates with CA/MI. (Living in Las Vegas really does have its privileges.)

 

I recently watched a documentary or something that said the same thing.

[KidsHappen]

Well, I hope you are sitting down....

 

 

Honestly, about once a month I catch myself muttering "you know you are middle aged when your peers start to die".

 

I am kind of Schizophrenic in this regard as I started having children young and then kept it up for a long period of time. My oldest step-son is 30 and my youngest child is 10. Only my hubby's bio parents are left from previous generations and we are already losing age mates and yet I still have kids at home and grandbabies being born. My mother missed her first great grandbaby by months and I have a very real fear that I will not even live to see all my grandchildren be born. My great grandma lived 'til 93, my grandma to 87, my mother only 60 and I am not sure I will make it that long.

[lionfamily1999]

Our instructor also assured us that being a non-healthcare-provider ‘standbyer,’ we would be protected by the Good Samaritan law if breaking a rib during CPR. But you are a healthcare provider and break ribs, well, get an attorney. Or liability insurance. Crazy world we live in! People who work in healthcare truly are heroes.

Does that include EMTs? Just curious, I learned about the Samaritan laws while doing my EMT training...

[Perry]

But you are a healthcare provider and break ribs, well, get an attorney. Or liability insurance. Crazy world we live in! People who work in healthcare truly are heroes.

Broken ribs are a routine complication of CPR. I can't imagine that anyone could ever successfully sue for that.

[lionfamily1999]

Broken ribs are a routine complication of CPR. I can't imagine that anyone could ever successfully sue for that.

I do remember being warned that you could be sued for anything, if you were a "professional." That is different than them having success, but I guess you'd want a lawyer anyway...... Although now that I think about it, it sure seems like a racket all its own.

[Spinning]

Lion: I'm not sure. It seemed from my class that EMTs would not be covered under GS Law. Our instructor was a paramedic in NYC and now here in LV, and brought up the GS law several times and made it sound like I was the only one in the class with whom it could really apply--the others worked in a healthcare setting; I do not. You would probably know more about it than I!

Perry: You would think not, but...well, I've seen people sued for crazier things! The instructor made it clear that cracked ribs were very common. Whether or not it would get thrown out in court would be one thing—AFTER some poor healthcare provider has went through the anguish and expense of the court system/hiring an attorney/dealing with libiability insurance for ‘saving’ someone’s life. I have a good friend right now that is going through completely nonsensical litigation for something he had NO part in. I guess this topic could jump over into tort reform. Again, I don’t work in a healthcare setting; my job is administrative in nature, so there is a good chance I don't know what I'm talking about, lol! :D

 

Our instructor also mentioned that healthcare providers ALWAYS needed to ASK the victim first before they started anything--OR just wait until they pass out if they were not agreeable. :001_huh:

[Perry]

Perry: You would think not, but...well, I've seen people sued for crazier things! The instructor made it clear that cracked ribs were very common. Whether or not it would get thrown out in court would be one thing—AFTER some poor healthcare provider has went through the anguish and expense of the court system/hiring an attorney/dealing with libiability insurance for ‘saving’ someone’s life. I have a good friend right now that is going through completely nonsensical litigation for something he had NO part in. I guess this topic could jump over into tort reform. Again, I don’t work in a healthcare setting; my job is administrative in nature, so there is a good chance I don't know what I'm talking about, lol! :D

That's true, people sue for all kinds of ridiculous things. I wouldn't be surprised if someone would try, but they would never win (theoretically, anyway), because there isn't any negligence.

 

Now, if you started CPR on someone who had simply fainted and broke their ribs, you might have a problem.;)

[asta]

I'm on the fence on the DNR issue. If I face up to it, I have to face up to SUDEP (sudden unexplained death by epilepsy). Yes, that is denial.

 

It is very hard from the patient's point of view, IMO. On the one hand, I don't want to be brought back from brain death. On the other, my primary presenting symptom prior to a full-on seizure is autonomic dysfunction (irregular heartbeat, messed up breathing, loss of toilet control, etc.).

 

So I guess it boils down to something along the lines of "if someone sees me go down, feel free to resuscitate. If they find me, and haven't seen me in quite awhile, it was my time to go."

 

 

a

 

 

(I actually know someone who experienced SUDEP and was brought back by CPR. She was a bit nutty to begin with, but she is quite "off" now. That is anecdotal, but I've always kind of wondered if it played a part - kind of like what KidsHappen said - not coming back "all there".)

[MeanestMomInMidwest]

I just wanted to pop back in to say that as a healthcare professional, I totally support the patient and patient's family's right to ask that "everything" be done. I also support their right to be accurately informed of what "everything" is. After informing the patient/family, and hearing their wish is that "everything" be done, I will be the patient's biggest advocate to get that everything.

 

And, if I find you down outside the hospital, I'm going to try to help you - not worrying about lawsuits, just doing what I'm trained to do.

[Catherine]

She had been hospitalized with a blood clot in her lungs, and collapsed 36 hours later. She had an hour long resuscitation effort, though I learned later that she was not pulseless for that entire time.

 

She woke up 36 hours after that and although she spent 21 days in intensive care, and another 5 weeks in the hospital, and another 3 months in rehab, she is mentally intact and living her life as she was before.

 

Miraculous! She was in the 5% that leave the hospital intact after a PEA arrest. I think the clot (she had what's called a "saddle embolus"_ was dislodged by good CPR. And we are VERY grateful for that.

[Catherine]

I want to be resuscitated, for sure, as long as I still have kids to raise. After that, say farewell.

[Terabith]

A lady in our church, maybe 50, not sure but she has two kids in high school, had a bad headache about a year ago. She just wasn't feeling well one Friday morning, so she asked her husband to drive her to the ER. On her way there, her heart stops. He's trying to drive, on the phone with 911. Pulls up and they take her out of the car and start CPR, etc. They work on her for 25 minutes with no response. They stop efforts and pronounce her dead. They tell her husband she is dead. As everyone is walking out of the room, a nurse sees a hand move or something, and her heart has started beating again and she has a blood pressure. In really bad shape, but alive, so they start work again. Transfer her to Cardiac ICU, but tell her husband the odds of her being anything but a vegetable are slim to none after such a long code and time without oxygen. Three days later, she wakes up and motions for paper and a pen and writes, "What happened?"

 

They took her off the ventilator a day or so later and she was walking around the room, eating, talking, even reading. She had no short term memory for about a week, but after that, she's fine. Absolutely NO results, neurologically or cardiac, from the episode. She's had some vocal nodules from the vent, but a hoarse voice is the only reminder of the episode. They've done a bunch of tests but have no idea what happened or why her heart stopped.

 

Every health care provider at the hospital said what happened to Helen was flat out impossible. Both a cardiologist and a neurologist who cared for her have become Christians, because they said that a miracle was the only possible explanation for the event and recovery.

[ChristusG]

CPR cracks ribs, but the paddles don't. They deliver an electrical current through the chest. There is no cracking sound, although the patient jumps as the shock is delivered.

a video. Not for the squeamish. The defibrillator use starts at about 2:15.

 

Wow, that video was amazing! Three shocks and then he woke up and could talk and knew where he was and who he was. Those lifeguards did great.....very calm.

[MeanestMomInMidwest]

A lady in our church, maybe 50, not sure but she has two kids in high school, had a bad headache about a year ago. She just wasn't feeling well one Friday morning, so she asked her husband to drive her to the ER. On her way there, her heart stops. He's trying to drive, on the phone with 911. Pulls up and they take her out of the car and start CPR, etc. They work on her for 25 minutes with no response. They stop efforts and pronounce her dead. They tell her husband she is dead. As everyone is walking out of the room, a nurse sees a hand move or something, and her heart has started beating again and she has a blood pressure. In really bad shape, but alive, so they start work again. Transfer her to Cardiac ICU, but tell her husband the odds of her being anything but a vegetable are slim to none after such a long code and time without oxygen. Three days later, she wakes up and motions for paper and a pen and writes, "What happened?"

 

They took her off the ventilator a day or so later and she was walking around the room, eating, talking, even reading. She had no short term memory for about a week, but after that, she's fine. Absolutely NO results, neurologically or cardiac, from the episode. She's had some vocal nodules from the vent, but a hoarse voice is the only reminder of the episode. They've done a bunch of tests but have no idea what happened or why her heart stopped.

 

Every health care provider at the hospital said what happened to Helen was flat out impossible. Both a cardiologist and a neurologist who cared for her have become Christians, because they said that a miracle was the only possible explanation for the event and recovery.

 

That is an amazing story and I'm glad for your friend & her family.

 

For every story like this, there is one where, by every medical person's judgment, the patient should have lived, but didn't. They are "miracles" the other way, I guess.