For Want of a Nail - Misha Route (Updated 11/1/19)

[ProfAllister]

All this is correct.
The problem is that Hisao is your narrator, and since he is able to narrate all the stuff about Misha giving him CPR that means that he is conscious at the time. Sure, Misha could have mistaken him for being unconscious, but he seems to at least have his eyes open and be following events around him.
(He also stays concious during CPR until Shizune comes back with the nurse which actually had me laughing out loud when I read it the first time. I'm not sure giving the kiss of life to a conscious person would even work. They'd probably breathe against your breathing just by reflex.)

Again: It doesn't matter what Hisao's condition is - as long as he is conscious, he is breathing, and his heart is beating, thus there is no reason to perform CPR.
CPR is quite likely to stop whatever spontaneous pulse and breathing the patient still has going, replacing it with the artificial version - and breaking a few ribs in the process*

If Hisao had blacked out before Misha started CPR and been told about it after he woke up again, everything would have been fine.

*In first aid courses, currently the procedure we teach is to start CPR after ascertaining the patient is unconscious and not breathing. Checking for pulse is no longer recommended for lay helpers, because it can be difficult to correctly find a pulse if it is weak and you're not doing it regularly and also because if there is no respiration there's a high likelihood** of there not being any pulse either.
I'd still take the few seconds to ascertain the patient really has no pulse left before starting a measure that might mess up whatever pulse there might still be.

**not sure how high right now...

1: Aren't you in Germany? Do you sleep? At all?

2: We've got pretty much the epitome of unreliable narrator here. He's having a near-death out-of-body experience here. It's a bit of a cop-out, admitted, but we have no guarantee that what he's seeing is what's happening. Additionally, given our limited understanding of the very concept of consciousness, as well as anecdotal accounts of individuals "perceiving" while ostensibly unconscious, it's entirely an assumption that what he purports to be seeing is the product of a conscious mind. To put it more bluntly, if I had mentioned Hisao seeing Rin sprout elephant ears, I wouldn't put much stock into someone's objection of the biological improbability of that event.

3: Current guidelines recommend compression-only CPR for SCA. No "romantic" kiss of life (followed by equally romantic vomiting all over the place).

4: Keep in mind the distinction between what you should do (i.e., CPR recommendations), what is best to do (i.e., omniscient/hindsight), and what an actual human being might do in the heat of the moment (i.e., probably neither of the above).

5: Hisao isn't the standard "stranger collapsing in the middle of the street." He's a high-risk candidate for SCA with a diagnosed heart condition. His circumstances weigh pretty heavily in favor of "when in doubt, CPR."

6: Blacking out may have been the standard major heart trauma approach in the VN (cf: intro, Lilly's good end), but it was dramatically appropriate for the "I'm such a pathetic loser" vibe being conveyed. Missing out on the action so totally just wouldn't have been dramatically appropriate here.

[ArmedLiberal]

Defibrillation is indicated for ventricular fibrillation or ventricular tachycardia. The vast majority of patients will be unconscious, but some might not be.
If a paramedic diagnoses one of those conditions after looking at an Electrocardiagraphy of a conscious patient (or they know the patient's medical history) that is okay.

I really doubt your paramedic friend would have given CPR to a conscious patient, though. CPR is a last ditch measure to supply oxygen to body cells when a patient is not breathing and their heart has stopped beating, i.e. when they are functionally dead already and literally can't get any worse. CPR will do nothing for a patient like Hisao. It won't restart his heart or anything - it just buys time until you can get a defibrillator or a doctor with medication. (You can forget about any Baywatch episodes where someone wakes up, coughs a few times and walks away after getting CPR.)

As long as a patient is conscious, they are also breathing, so there is no need to take such extreme measures - in fact you can make things a lot worse.

Yes, I meant the defibrillation. I wouldn't want to inflict CPR on a conscious patient myself (I'm a certified medical assistant with an AAS in the same). The process usually ends up breaking ribs even in otherwise healthy patients.

[BlackWaltzTheThird]

(sees what Waltz meant)

...He's not really getting CPR, is he?

I don't mean to allude to any questionable erotic acts. The tone of the ending was something I brought up during editing and some discussion ensued. Of course, I may have been reading into it too much, which would be revealed by the general public's collective reactions.

[ArmedLiberal]

While this is true, I am disappoint that you assume I didn't do my homework.

You'll recall the Nurse's dire warning about a blow to the chest, yes? He was referring to commotio cordis. Hisao has Long QT syndrome, placing him at elevated risk for commotio cordis. Commotio cordis is a type of sudden cardiac arrest. Treatment recommendations for sudden cardiac arrest include immediate application of an AED, and CPR until the AED is deployed (also relevant). I could go on, because (unsurprisingly) there's a wealth of resources regarding CPR and heart health.

The key takeaway, however, is that a layman can't easily determine if a (potential) cardiac arrest victim is unconscious, and any delay could be fatal. Performing CPR on a healthy conscious person is a terrible idea. Performing CPR on someone who's been diagnosed with a serious heart condition who just had a traumatic event and isn't responding is a significantly less terrible idea. In fact, the rule of thumb, based on that whole "seconds matter" concept, is that if you're in doubt as to whether you should apply CPR, you should err on the side of performing unnecessary CPR - CPR when it isn't needed can cause all kinds of nastiness, but withholding CPR when it is needed dramatically increases lethality of the event.

And yeah, I guess I could continue on that point in a lot more detail, too.

TL;DR - CPR on a healthy conscious person = bad; CPR on an unhealthy/questionable person who seems to be having heart problems and isn't responsive = good.

Also, getting medical recommendations from cripple porn fanfiction = WTF is wrong with you?

Interesting. One of the potential adverse effects of methylphenidate is prolonged QT interval. They actually had to do two EKGs on me to verify I wasn't going to die because my psychiatrist put me on Ritalin. I suspect they'd have to do the same thing if I ever went on escitalopram... it can prolong QT interval, too.

Yeah, pharmacology us a specialty of mine... I find it interesting, and I understand the underlying biochemistry.

[ArmedLiberal]

I'm no doctor, but I would expect that you don't just immediately fall unconscious when your heart stops beating (see heart attacks). You can easily argue that Hisao is on his way out of consciousness. In that case CPR is probably still premature but given that Misha is also not a doctor I don't expect her to know that. In a weird roundabout way it's actually kind of logical. Wrong, but understandably so.

Also, I see you left that last line intact, Prof. I shall observe what people make of it.

Ones heart doesn't just "stop" during a heart attack. Ischemia is the palpable sensation, but Vtach and Vfib don't happen until later, and yes... the loss of mean arterial pressure generally then results in loss of consciousness. That said, it takes time for Vtach to fully develop into a loss of MAP... specifically, the heart has to more or less drain itself sufficiently of available blood to pump. The main risk of Vtach is conversion to Vfib or to asystole directly, from what I recall.

At least, that's my limited understanding of the process. I'm up on CPR/BLS with AED for Healthcare providers, but I haven't been through ACLS/PALS yet (though I really do want to do them).

[Mirage_GSM]

1: Aren't you in Germany? Do you sleep? At all?

Weekend. DST.

3: Current guidelines recommend compression-only CPR for SCA. No "romantic" kiss of life (followed by equally romantic vomiting all over the place).

CPR stands for CardioPulmonary Resuscitation.
It is a combination of giving the patient the kiss of life to bring oxygen back into his lungs/blood and a heart massage to keeep the oxygenated blood circulating to keep the brain suplied with that oxygen.
A "compression-only" CPR will have a very limited efficiency, because after a few minutes you will be circulating blood that is almost without any oxygen.
And if the patient was still breathing before he will almost certainly stop breathing on his own if someone starts doing CPR...

5: Hisao isn't the standard "stranger collapsing in the middle of the street." He's a high-risk candidate for SCA with a diagnosed heart condition. His circumstances weigh pretty heavily in favor of "when in doubt, CPR."

I've been trying to drive home the fact that when conscious - no doubt - no CPR.

6:.... Missing out on the action so totally just wouldn't have been dramatically appropriate here.

Now THAT is something that is absolutely your perogative

[Mirage_GSM]

Also, getting medical recommendations from cripple porn fanfiction = WTF is wrong with you?

Oh, and people are getting medical recommendations from sites WAY worse than this one, and I only wish I was kidding...

[ProfAllister]

I know we're kind of going down the rabbit hole here, but the more recent comments you've been making are simply wrong (or outdated). I would be inclined to drop the subject, but discussion of CPR for the layperson is a bit of an always necessary public service announcement.

http://heart.arizona.edu/frequently-asked-questions is one of many sites that pretty much addresses all your objections.

To a layperson:

If they are unresponsive, assume cardiac arrest.
Gasping (a type of respiration) is NOT a reason to not do CPR.
"It is better to perform a few unnecessary chest compressions for someone with a beating heart, rather than withhold chest compressions and circulation from someone in cardiac arrest."
"The key message here is that you cannot do more damage. It is important to recognize that someone in cardiac arrest is dying or will soon be dead unless you intervene."

[Mirage_GSM]

Wow... This makes me afraid to become unconscious for any reason anywhere near where this is taught... Glad I'm a continent away!

First, the patient being "unresponsive" is extremely vague. What is "unresponsive"? Is a patient unresponsive if they don't answer you but just follow you with their eyes as Hisao is doing in this story? Certainly. But they are also certainly neither unconscious nor do they require immediate CPR.

I can think of a dozen reasons why someone might be unconscious or unresponsive (without even trying very hard) that don't mean that there's anything wrong with the patient's heart, starting from intoxication (alcohol or drugs) over hypoglucemia, apoplexy or poisoning to head trauma or neurological issues - neither of which is an indication for CPR.

And of course doing CPR on someone with those conditions can be dangerous.
Let's not talk about a few broken ribs - those are small things in comparison - but by doing CPR first you're a) messing up the heart rhythm of the patient if they still have one (CPR will never be quite as effective as a naturally beating heart) you're b) quite likely messing up his breathing as well, and if you're doing "compression only" CPR (wich is really only CR) you're not even replacing the naturally occuring respiration with an artificial one and c) you're not giving them the kind of first aid they really need for their condition.

And no, my comments are neither wrong nor outdated. I'm in the Red Cross and I'm doing EMT trainings regularly including a CPR training at least once a year.

But maybe SC would be willing to say his opinion on the matter. He's probably the person with the most medical knowledge on these forums

[brythain]

Poor Hisao. As if his heart hasn't been messed around with enough, as it is.

[ProfAllister]

Wow... This makes me afraid to become unconscious for any reason anywhere near where this is taught... Glad I'm a continent away!

I wouldn't be so sure. In particular, note the pictographs in pp 85-88 and the section on risks in pp 91-92

First, the patient being "unresponsive" is extremely vague. What is "unresponsive"? Is a patient unresponsive if they don't answer you but just follow you with their eyes as Hisao is doing in this story? Certainly. But they are also certainly neither unconscious nor do they require immediate CPR.

On the one hand, it's odd that you criticise the term "unresponsive," as that's the term literally used just about everywhere. On the other, lots of medical professionals, especially in different fields, disagree on what "unresponsive" actually means. For the layperson, though, it's pretty simple: if they don't respond to shaking, shouting, possibly pinching (pain), they're "unresponsive". There's a recommendation to at least check that breathing's not normal, but this is a high-stress situation , so the recommendation is pretty much "if you aren't certain that it's normal breathing, better to do CPR."

As for the "following with eyes," that's an assumption on your part. Not a terrible assumption, but not something stated in the text. You're also assuming that Misha (or one of the others) would notice something as subtle as a minimal eye movement

I can think of a dozen reasons why someone might be unconscious or unresponsive (without even trying very hard) that don't mean that there's anything wrong with the patient's heart, starting from intoxication (alcohol or drugs) over hypoglucemia, apoplexy or poisoning to head trauma or neurological issues - neither of which is an indication for CPR.

This is true, but the general likelihood of those happening in a situation where a layperson bystander is the first responder are statistically few. And in Hisao's case, those alternatives are laughably unlikely in comparison.

And of course doing CPR on someone with those conditions can be dangerous.
Let's not talk about a few broken ribs - those are small things in comparison - but by doing CPR first you're a) messing up the heart rhythm of the patient if they still have one (CPR will never be quite as effective as a naturally beating heart) you're b) quite likely messing up his breathing as well, and if you're doing "compression only" CPR (wich is really only CR) you're not even replacing the naturally occuring respiration with an artificial one and c) you're not giving them the kind of first aid they really need for their condition.

All viable concerns for an EMT or other medical professional. For the average Joe, though, attempted CPR on an unresponsive individual who doesn't need it will most likely result in a responsive individual and maybe a couple bruises; attempted CPR on an unresponsive individual who does need it could save his life. Either way, ideally, CPR will only be performed for a couple minutes before an AED and/or medical professionals arrive - for non-cardiac arrest issues, those few minutes generally won't make much of a difference, but make a massive difference for cardiac arrest.

And no, my comments are neither wrong nor outdated. I'm in the Red Cross and I'm doing EMT trainings regularly including a CPR training at least once a year.

Never intended to lay aspersions on your qualifications/knowledge, but the fact remains that what you are saying is simply in disagreement with all the current recommendations for laypeople and CPR, including the CPR training I've personally received.

You're correct that, for a trained medical professional, especially an EMT, there are much better protocols in place (to say nothing of training and equipment). But, again, for the average Joe, there are three possible outcomes: rough up someone who would be okay (relatively) without CPR; rough up a corpse (with noble intent); or save a life. There really shouldn't be much controversy that it's best to err in favor of the third outcome. Especially as the respective non-CPR results are: leave him be (to get proper medical care); ignore the corpse (no difference); let him die.

But maybe SC would be willing to say his opinion on the matter. He's probably the person with the most medical knowledge on these forums

Yeah, you'd think he'd be champing at the bit here. On the other hand, he could just be happy that the rescue breaths don't include tongue.

[HoneyBakedHam]

Oh, Allister...

[Mirage_GSM]

I'm now at the point where all I could do is reiterate my previous points - which is something I won't do for SC's sake if nothing else...

Just one thing:

This is true, but the general likelihood of those happening in a situation where a layperson bystander is the first responder are statistically few.

I don't have any official statistics to back this up, but in my personal experiance I've encountered quite a few unconscious - or at least unresponsive people over the years.
Most of them were due to intoxication - alcohol or drugs, a handful were due to hypoglucemia, one or two were due to apoplexy and the rest fainted from trauma or shock.
So far I have luckily never been in a situation where I had to apply CPR in a real-life situation.

So, from my personal experience the first of your three possible outcomes is the one that is overwhelmingly likely to happen.

I'll be happy to continue the discussion via PM if you want to.

[ArmedLiberal]

I'm now at the point where all I could do is reiterate my previous points - which is something I won't do for SC's sake if nothing else...

Just one thing:

This is true, but the general likelihood of those happening in a situation where a layperson bystander is the first responder are statistically few.

I don't have any official statistics to back this up, but in my personal experiance I've encountered quite a few unconscious - or at least unresponsive people over the years.
Most of them were due to intoxication - alcohol or drugs, a handful were due to hypoglucemia, one or two were due to apoplexy and the rest fainted from trauma or shock.
So far I have luckily never been in a situation where I had to apply CPR in a real-life situation.

So, from my personal experience the first of your three possible outcomes is the one that is overwhelmingly likely to happen.

I'll be happy to continue the discussion via PM if you want to.

One real quick note: you're far more likely to be near a lay person than a First Responder/EMT/Paramedic/Other. Just a sniff test tells me that you're far more likely to get initial care from a lay person while waiting for professional intervention. That's why compression-only exists… sadly, if you don't get an AED or professional help to the person in under two minutes, permanent damage is going to set in. That's why compression-only is stressed—unless you have someone better trained, it becomes exponentially less likely to survive.

With no intervention, it's less than 1% survival. With CPR alone, it rises to just above 1%. With professionals or an AED arriving within 10 minutes, I think the statistic is 10% (off the top of my head; I'm nearly due for a CPR/BLS/AED for Healthcare refresher). If an AED or professional help get to a person within 2 minutes, the survival rate is in excess of 66% (again, all of this is off the top of my head from my last BLS course).

We just had this discussion in my Human Physiology class on Wednesday. The professor is the Dean of Curriculum at the Medical College of Wisconsin's Green Bay campus. The point is that the statistics already suck if you go into cardiac arrest, and sometime between two and six minutes, the odds drop below 50% survival. The best thing a lay person can do is activate EMS (9-1-1 in the US, 1-1-9 in Japan, etc.) and keep the blood moving so it can dump its existing oxygen payload in the core organs.

[Edible_Funk]

Between this and United States of Misha, these are my favorite expansions of Misha's character. You really nail everything that the VN sets forth for her. I also always thought she was more on the bi spectrum, simply because she never really seems interested in girls in general, just Shizune. And in the VN I always got the impression, "comfort" aside, that she was at least somewhat interested in Hisao as well.

But I like this story, I especially like your characterization of Hisao. For the most part he's a pretty blank canvas that takes on aspects of whatever girl's path you end up on, but this story has given a lot of insight into how exactly that occurs, making Hisao a character of his own. A few other fics here have also handled that fairly well, but since this is basically a fork off of Shizune's path, for some reason this Hisao seems more 'right' than many others I guess. I could see this being in the VN.

I like it. I have to know if that's supposed to be the ending or if there's more though. Also, I could swear the first time I read this, that last line read "At least I'm not dying alone." Did I imagine that, or was there an edit? Anyhow, love the story, love me some Misha with depth, love to see more.