Dispatched for a “Cardiac Disorder”. One of about 500 a week that we go to 495 of which turn out to be not cardiac disorders. Some aren’t even in parts of the body near the heart. It’s just easier for the dispatchers to do it that way, so that’s what they do. On the way to the call we look at the comments on the screen. 38 male, pacemaker firing.
“Uh, isn’t that what it’s supposed to do?”
“Well, maybe it’s a demand pacemaker.”
“But how would you know if that was kicking in?”
“Well, maybe it’s an overdrive pacemaker for SVT.”
“Or maybe the dispatcher doesn’t know the difference between a pacemaker and a defibrillator.”
“Um, could be.”
We arrive in due course to see one of the BLS guys coming out for the heavy duty stair chair. Uh-uh. That’s never a good sign.
We walk into a well kept pretty messy apartment, which at least is on the first floor. We find our patient who is, uh, large. Very large. My guess is 400 pounds and I really should get a job guessing heights and weights at carnivals. I was about 10 pounds off, which isn’t bad.
“What’s happening this morning sir?”
“My defibrillator keeps firing.” To prove his point our patient let out a huge scream and levitated off the bed. Which to my amazement didn’t collapse into splinters.
“I see.”
“I was in for them to adjust it a couple of weeks ago and OWWWW – there’s something wrong with it.”
“I guess there is.”
The BLS guys had put the patient on O2, which wasn’t going to help but probably wasn’t going to hurt. Besides it looked like we were doing something while we got ready to do something. If you know what I mean and I think you do.
We also got a blood pressure, respiratory rate, and some history. The blood pressure was high, which was expected, the respiratory rate was a bit fast, but nothing worrisome. The history was as good as the patient could give, but wasn’t all that helpful. The list of meds contained no surprises. The medication surprises came later on, at the hospital.
While all that was going on I put the leads on and turned on the monitor, which showed us this,
“Hmmm.”
At which point things went, as Law Dog says, “Sideways”. But just a bit.
Those jumpy bits in the strip are where the defibrillator fired. While the doctors will tell the patient that the might feel a bit of discomfort if the AICD discharges, the truth is it hurts like hell. At least every patient that I’ve ever transported who has had his or her AICD discharge tells me. I think in this case, the AICD fired about 10 times in all.
I should mention that there were some shocks in this sequences that were not recorded on paper. While continuously recording “Arrhythmia Andy’s” performance would have been educational, it would have killed many trees and spotted owls. Nor was I always quite fast enough on the Print button to get all of the interesting rhythms. At one point it seemed that the monitor was defibrillating Atrial Fibrillation, but I didn’t think that’s what it was doing. In fact I was pretty sure that machine was shocking sinus tachycardia some of the time. Which certainly was not the way it was supposed to be.
Here is an example of what seemed to be sinus tachycardia, but clearly wasn’t. In this case it wasn’t being shocked, but you get the point.
“What do you think we should do?”, I asked my partner.
“Versed.” was the answer. I was pretty sure he meant for the patient.
Good plan, and since it was slightly outside of our protocols, or so I thought, we got on the radio and consulted medical control. Who OKed the Versed mainly because the doctor on the radio had no idea what our protocols are. I think my partner could have asked to cut the patient in half to count the rings and the doctor would have said yes.
While my partner was on the radio, I started the IV. If you’re in EMS you know what happened. I penetrated the skin, got a nice flash as the stylet pierced the vein, and then the defibrillator discharged and the patient levitated off the bed. Fortunately the IV stayed in and I was able to advance the catheter and then secure everything in place. Then we gave the Versed. Which I think mostly made us feel better, because it didn’t seem to help the patient all that much.
Now came the hardest part of the call. Which was getting the patient out of the house and into the ambulance. Fortunately the four of us were able to get him into the chair and down the mercifully short front porch steps without difficulty. Well, without MUCH difficulty, because a 390 pound patient always presents some obstacles.
In the ambulance, we got everything sort of settled in and started off to the hospital. We gave more Versed, but things seemed to be getting worse, not better.
That doesn’t look very much like sinus tachycardia, does it? My thinking was that we were dealing with Atrial Fibrillation. Interestingly, defibrillators are placed for Atrial Fibrillation, they are placed for people with Ventricular Tachycardia. Which, as I mentioned, wasn’t what was going on here.
And the patient kept getting worse. By now we, or at least I, had decided that maybe it wasn’t a defibrillator problem. After all, even at 38 a patient with as many problems as this guy has is a ripe candidate for developing all sorts of bad conditions. And so I got a brilliant idea. He still had plenty of blood pressure, his rate was taking off, he was feeling worse, his rhythm was irregularly irregular. It had to be Atrial Fibrillation, right? Now what do we do?
My partner looked at me and I suggested “Diltiazem.”
He agreed and I mixed up and drew the correct dose for a patient this size. Which was at the maximum for a patient of his substantial size.
Have you ever watched The Three Stooges? I have. A lot.
In one short, Moe comes up with one of his typical brilliant ideas. Larry and Curly start to do whatever it is they have to do in order to get the plan off the ground. The camera closes in on Moe and he says,
“It was my idea, but I don’t think much of it.”
Which is how I felt about the Diltiazem. I just had the feeling that it wouldn’t help and might hurt. Which I mentioned to my partner. Who said that he thought we should give it. I said that we should give the hospital a call and see what they thought. One thing about this partner is that when he gets an idea in his head, it takes a crow bar and an act of Congress to get it out. So, back and forth we went. And forth and back for that matter.
At which point the patient decided to entertain us by throwing another rarely seen, at least by me, rhythm our way.
So the monitor/defibrillator/pacer/toaster oven shocked the patient out of Atrial Tac (and yes it is almost at 300 beats per minute) into something else. Only it wasn’t entirely clear what something else was. Damn. Now the patient was feeling worse, getting really diaphoretic, and looking like crap. I gave up the idea of giving the Diltiazem just as we backed into the hospital.
Where we were greeted by an empty triage area. Well, empty except for the two ambulance crews and the triage nurse.
“Uh, where’s the trauma team.”
“Oh, do you think we need them?”
“Yeah, we thought that was made clear on the radio.”
“You called on the radio?”
I looked and around and we were in the correct hospital. At least to the extent it was the hospital to which the patient had said he wanted to go. I don’t know if it was correct in that it would give the patient the best care, but that’s the patient’s decision in this case.
So, we proceeded into the resuscitation room and the trauma team kind of wandered in. We gave the story, I printed out a 15 foot long Code Summary, and then stood back to watch. At first the doctors wanted to give Diltiazem. Then they thought maybe Amiodarone because it had to be Ventricular Fibrillation. Then, they looked again and it wasn’t Ventricular Fibrillation. So, they decided to give more Versed. And Fentanyl. If nothing else, the patient would be sleepy. “Resting comfortably” as they say.
Then they brought up his old chart. History of Ventricular Tachycardia. Did have a defibrillator. Had been in recently for an “adjustment”. Meds included Metoprolol. Is known to be none compliant with medications.
Ding! You are now free to control your heart rate.
Yes sir, the medications work a lot better when you actually, you know, take them.
So, they gave him some Metoprolol IV and his heart rate dropped down to a reasonable rate.
It turns out that there was a problem with his AICD and he was non compliant with his medications. The combination meant that his AICD was seeing what was his normal underlying Atrial Fibrillation, interpreting it as Ventricular Tachycardia and shocking it. He was admitted so that cardiology could correct whatever was wrong with his AICD in the morning.
My life would be so much easier if patients would read the text books. Oh, and take their medications. It’s almost like medications are designed to fix specific problems and that taking them might make the patient better.
It probably wouldn’t hurt if he lost a couple of hundred pounds too.
Good run and you had to use your brain. That is really good to keep your head on straight. I have been the EMS for almost 20 years…We all had the runs that made u use your brain. You did good.
Reading your blog it sounded to me that maybe you are heading towards burnout. Your discription of the pt was interesting. By mentioning the fact that our JOB includes dealing with obese pt, small pt, mean pt, nice pt, ugly pt and pretty pts. Your tone says that being obese is a problem. Do you know that 80% of USA is obese. Obese can mean 30-what ever over weight it all depends on your height and boy. We obese pt can be difficult but that is why u wanted
EMS to us your brain and help people or was it the money. I know you like riding around with the siren on to get attention. Not enough from mommy.
I’m just tired everybody attacking us fat pts. I’ve tried and tried but cannot lose the weight. So has millions of people some of us don’t have luck.
I just want u to know that we as EMT’S have to handle all pt’s. I hate to lift big people also, but at least you had four with you and the lift went fine.
Keep up going strong but, watch your upcoming burnout. You might talk to your supervisor about your problem. One more thing you don’t know your protocols????? At least we have a copy in our trucks if we get stuck.
God bless and be safe my friend.
Bill
NREMT-P
Bill, I’ve been doing this almost twice as long a you have. I also know that weight control is very difficult and more so if you’re in EMS. The schedules and work load are not conducive to healthy eating. I’ll tell you the same thing that my doctor tells me. Diet and exercise are the only two things known to help with weight loss. Eat right, work out. That doesn’t mean you have to spend time in a gym. I ride a bike and have more than one, including a stationary bike at home. Ride 30 minutes every day and you’ll see a difference. Eat less fat, carbohydrates, and sugar, and you’ll see a bigger difference.
Oh man… That one about went Rodeo on you… and I’d have been hauling butt to the Hospital!!!
Ok back to the story, loss of capture, can you overdrive, versed 2-5 mg up to 10-15, torsads mag sulfate, wide v tach why does your partner suggest Diltiazem. Lidocaine 1mg is nice, do not see v fib, if it was a afib alot of artifact lead placement and conduction issues yes a beta blocker…….Metoprolol……………i have placed a pt on left side and rt arm over there head and has relaced the wire to get a proper placemaker conduction without advasive proceedures as a ACP , but with new defib/pacemakers placed in the abdomine hard to do.
But, don’t belittle your BLS crews when crap hits the fan its nice for the extra hands,20 yrs in this gig and on this educational site, the insults to the pt and coworkers not cool……….and some of your thoughts well it speaks for its self.
I think you mean Lidocaine 100 mg, but it makes no difference. Our protocol calls for Amiodarone, but it wasn’t V-Tach nor was it Torsades. It was AF, pure and simple. Nor was it a pacing problem, it was a defibrillator problem. Not a lead problem either. I don’t see where I insulted the BLS crew, so maybe you can clarify. The BLS guys were actually pretty helpful in this case. One of them is a paramedic student and he got a lesson in practical case management that you can’t get in school. They don’t teach 2/3 of what we end up seeing in paramedic school.
Wow sounds like a great call. Just curious on one thing. I might have missee it. Did anyone get a twelve or fifteen lead? Getting out of lead 2 will help alot in those situations and can get your diagnosis way quicker. V1 is the way to go. I took Bob Page’s class and it will make anyone a believer. Stay safe out there.
No 12 lead. In fact, they didn’t do one at the hospital for a while either. Especially since the initial problem was a device failure (failure in the maladjusted sense). There are times when a 12 lead is not the thing to do and this is one of them.
Ok, sry lido 1.0 mg/kg then 0.5mg/kg q 10 mins to 3.0 mg per kg, looks like limb leads with alot of artifact did you try dianostic mode, replacement of electrods, due to pts sz as well was probable a issue……..sweating ect. In the last strip i see 1 paced beat , there is a loss of capture a pacing problem, probably try to override it, if it knocks it out give you time to pace him till a temp pacer can be placed untill a new ICD is placed. I do see uncontrolled a fib and rapid shocks going off looks like the defib is trying to correct the loss of pace/uncontrolled a fib. Can you overide the pacer in your state…and how old was the pacer i know medtronic had a recall this year.
The BLS guys had put the patient on O2, which wasn’t going to help ………he was probably in slight distress will low 02 sats and compasating so the BLS Paramedics where helping a bit it just sounded that way.
A 12 and 15 lead in the field is a awesome tool as we TNK here,over ride, pace and cardiovert here.
Best of luck and be safe
Just because the monitor says there was a paced beat doesn’t mean it was a paced beat. It wasn’t, it was artifact from the defibrillation that the monitor read as a paced beat. This was an AICD failure, not a pacer failure.
wow that was an odd one …
as a note of clarification, there has not been an AICD manufactured in eons. it is unlikely that any AICDs remain implanted in patients. the device is referred to as an ICD.
the term AICD is a relic from the past and should not be used. AICD refers to a trademarked name of a product much like kleenex is a trademarked name for tissues or charmin is a trademarked named for toilet paper.
the device should be referred to as an ICD. this name properly describes the device as what it is: Implantable Cardiac Defibrillator.
Everyone I know, and that includes a lot of doctors still calls it an AICD. I think it might be a distinction without a difference. But, thanks for mentioning it.
Holy Christ…. At least he was alive when you arrived at the ED. And an interesting variety of things going on with the strips indeed. Especially when the AICD shocked him from the A-fib he was in into the VT. That would certainly be attention getting at the very least
Good news. I’m starting PT this coming Tuesday. The brace was unlocked Monday, and the surgeon put me on “auto pilot” – in other words, I have lifting restrictions (no more than 5-10 lbs max with the right for the foreseeable future) but can do just about everything else. He cleared me for light duty (I’m back in Boston for the first part of the tour this Saturday, robo-brace and all) and basically told me, “don’t screw this up. I’ll see you in a month…”
All things considered, it was encouraging.
I’m convinced, and on follow up Cardiology seemed to agree, that this was SVT with abberency not VT. Which is why we gave Dilt the consideration we did. Had we known, and I don’t think I mentioned this in the post, that he was habitually non compliant with his meds, which included Labetolol, we probably would have beta blocked him.
More importantly, I’m glad that you’re getting better Take it easy and don’t rush to get back on a truck. We old guys heal slowly.
You don’t seem like a nice guy at all!
Sorry to hear it. Then again, coming from some random guy on the Internet, it doesn’t mean much.
Do you carry those donut magnets that temporarily disable the AICD/ICDs? Did you consider using it here, and just managing the AF/VF yourself? How quickly did the ED disable the AICD after arriving?
Very interesting call. Gotta love the old “non-compliant with medications” people.
One question. Do you guys carry a magnet to disable the defibrillator component of the AICD? Out here, we carry a magnet shaped like a donut and about the size of a hockey puck. Our protocol states it should be taped over the AICD, where it’s supposed to disable the defibrillator component while turning the device into a continual-pacing mode.
No magnets. The ED did use theirs, but turned the device right back on because it made things worse. What worked was the combination of Versed, Fentanyl, and beta blockade.