Christopher, a paramedic on Blogspot offers us (hopefully!) a highly unusual scenario. It’s a great illustration of what could be following protocol over focusing on the patient. In the first, you treat whatever aberration you can find (because you can!), in the other, you treat what’s really there. Here’s his start:
EMS was dispatched for a 62 year old male with an altered mental status. Upon their arrival they found the patient to be non-communicative, responsive to verbal stimuli, in moderate respiratory distress, with pale, diaphoretic skin, and weakly palpable radial pulses. The patient was placed on the monitor during their initial assessment:
The FULL BLOG is HERE and because it has such great EKGs that I won’t duplicate, I suggest reviewing
it completely before you read on. Read it as if you were the ER Doctor on duty. Take your time, I’ll wait!
(Walks to refrigerator, gets Dead Guy Ale.)
Granted, this presentation may not have been complete, but in that respect I have to make a point. All we have to go on is what is presented to us. If we’re offered a scenario for our review it would make sense to present it as thoroughly as if
it were being presented to a doctor to get orders (or a lawyer for that matter!).
Having said that let me share my initial impressions, based on the information offered.
First, I’m not clear on WHY the cardioversion? Is it because his heart is galloping and showing a slow but steady drop in BP? Is it because the heart is going SO fast (for the patient) that it is suspected that it will give out or be further compromised (based on his history)? None of that is evident in this narrative. What was the clear, clinical reason.
Here’s what was said:
Given the presence of a WCT with hemodynamic instability the patient was prepped for synchronized cardioversion. Combo-pads were placed anterio-laterally, the Sync button was pressed, and sync markers were noted with each QRS complex.
The patient was then synchronized cardioverted at 100J biphasic:
He said a BP could not be obtained. There was no report of changes in the patient. Could this have been a stable tachycardia? If not, please, give me some hard evidence to go on. All I read was that “WCT with hemodynamic
instability” was the rationale for doing what turned into essentially a fatally-synchronized cardioversion.
I don’t get it.
What was happening with the patient? How could the medic (my read is that Christopher is presenting some other medic’s case) tell the patient’s circulation was getting bad enough to warrant such extreme intervention?
Any sort of cardioversion at any dosage of Joules on a conscious patient is an extreme measure because you’re likely going to stop the heart. It’s done “in hopes” that the heart will pick up and reorganize itself properly and resume its normal rhythm. That does not always happen in tachycardia. Even if the shock has no ill effect on the rhythm (the tachycardia stays the same), you run the risk of further compromising the patient by adding the stressor of the cardioversion.
Basically, if you commit to doing a synchronized cardioversion you have to accept you may be turning someone live into someone dead. And remember, that can be true with casual observers as well!
I really don’t see the evidence in the narrative for such drastic intervention. Even properly applied sychronized cardioversion has the high possibility of failure, and in this case, failure means V-fib and we’re not the ones who decide if it will convert itself or if another defib will restore a functional rhythm.
Of course, I’m coming from a place where I had to pull teeth to get orders back in the Stone Age!
Regardless, this case/presentation calls for the very clear documentation of a need for intervention. At the very least, this deserves a medical review, and perhaps Christopher is on that team. Hopefully, he’ll ask the same questions as me!
But the thing I didn’t see emphasized was that this case screams for exploratory surgery of that infernal MACHINE, a major review of that model and how it is applied and how people are trained to use it! What I SAW was sychronized cardioversion NEVER should have been tagged to Lead II. How did that happen? Who programs the machine to link itself to one Lead over another for synchronized cardioversion? (I plead ignorance.)
But that doesn’t matter because, as Christopher said, “sync markers were noted with each QRS complex.”
Whoa there! If the medic could see the markers for synchronized cardioversion on the screen/printout, why on God’s Earth couldn’t he/she figure out something was wrong?
Give me a break, THREE markers on each complex? How much more of a yellow flag could there be?
I’m not all that sure that our machines have progressed so far that we can transfer all our Blind Faith to them. Do you still trust your GPS to NOT lead you on to the Railroad tracks? How about a little bit of checks, balances and discernment here!
These are our tools, NOT our Directors.
As an emergency doc, I think they made the right call to cardiovert. I’d rather have them do that than muck around with drugs and such, given that the patient appeared shocky.
As for missing the “triplle-sync,” I’m just glad I get to learn from their experience. They seem to have handled the complication very well.
I concur. I’ve never even heard of triple-sync, let alone seen it. In my system, we rarely cardiovert, we generally use drugs as the first line of treatment. Given that, with the description given in the blog post, I’d cardiovert.
Cardioversion is not without risk. Since it stops malignant cardiac activity to give the heart to time to reorganize, by definition there is the risk that once stopped, it won’t start.
They remained calm when that happened and did the right thing. We don’t know the final outcome, but the patient was inarguably better when he got to the hospital than when the medics found him.
I’m surprised you’d question the use of cardioversion in this case. The patient had an extensive cardiac history per the article, poor perfusion demonstrated both by altered mental status and the fact that they only got the pulse rate from the carotid pulse, and was in respiratory distress. How long should a provider let a patient remain untreated to determine if the condition is “stable” or not? Why let an obviously bad situation (based on pt presentation) get worse?
As for the sync error, the printout should certainly be a “red flag”; but that also appears to be a post-call summary. Without seeing what the monitor’s screen display and/or real-time printout, we cant’t tell if the medic missed something or the machine didn’t give adequate visual confirmation of synchronization. Thank you to you and Chris for pointing out that possible failure during sync cardioversion.
I’m not so much criticizing the cardioversion as I’m asking for much better reporting to paint a picture that makes it clear to US that cardioversion is warranted. More than likely, on-scene the medics in question took the time to justify its use with more than what was reported to us. YES, there was evidence of poor perfusion and altered consciousness but before I make the call to cardiovert (with, as was shown, negative consequences), then I want to KNOW the patient is deteriorating. According to the narrative, that was not clear. No changes were reported. Once again, “Couldn’t get a BP” doesn’t fly with me; give me something! Our stock-in-trade is observing and communicating changes. In this case there was no mention of any, therefore causing me to question.
I also do not see the failure of the monitor/defibrillator as a minor issue. If this is a repeatable glitch as part of a design flaw, it needs to be addressed by the manufacturer AND WE NEED TO KNOW ABOUT IT!
My hope is this doesn’t stop here. This is one great lesson!
Oh, I certainly agree that the improper sync is not a “minor” issue; it’s a critical issue that has already nearly caused one death.
I was only suggesting that it isn’t clear from the print-out whether it was a flaw that was noticeable during the procedure; if it’s not noticeable (i.e. those triangles don’t appear like that on the monitor display screen), then it’s an even WORSE flaw because there’s no way to know if it’s happening until you shock them into VF.
We’re having a discussion of this over at EMTlife.com twith a representative of Physio-Control. (http://www.emtlife.com/showthread.php?p=417440&posted=1#post417440) that y’all may be interested in.
Let me make it clear the discussionis NOT about Physio-Control’s products in particular. This is a conversation in general about design in monitor/defibrillators in synchronized cardioversion.