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.