New Frontiers In Cardiology

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A reader passed this along to me and said that I might find it interesting. He got that right, if by interesting he mean horrifying.

The title gives my medically inclined readers a good hint of what happened.

SUPRAVENTRICULAR TACHYCARDIA CARDIOVERTED BY AN AUTOMATED EXTERNAL DEBRILLATOR IN A 9-YEAR-OLDMALE WITH A HISTORY OF WOLFF-PARKINSON-WHITE SYNDROME

The article is from Pre Hospital Emergency Care and I am quoting only limited parts of it to stay within the Fair Use guidelines.

A 9-year-old male presented to his schools nursing office with the chief complaint of abdominal pain while
partaking in recess activities. The on-site school nurse (a registered nurse, RN) trained in basic life support
(BLS) observed that the patient’s pulse seemed fast. He was also noted to be alert, oriented, and fully conversantwith the school nurse. The nurse was not aware of
any past medical problems.

According to a verbal policy implemented by the local school district, school nurses are required to use
AEDs on patients suspected of manifesting irregular heart rates or rhythms. Specifically, AED pads are
placed on the patient and the AED is powered on with the goal of potentially identifying a serious etiology.

The good news is that the patient survived this “treatment”. The article goes on to say that this was done before EMS arrived on scene and was without IV, airway support on standby, and of course without analgesia or sedation. Not to mention no Oxygen. A verbal policy is no policy because of this turned into a shit show, you can be sure that the school district would throw the nurse under the bus.

The patient encounter was immediately referred to the quality assurance office of our EMS agency. Upon further evaluation and consultation, the initial rhythm
interpreted by the AED was a narrow-complex tachycardia with a rate of 240 beats per minute, suggestive of supraventricular tachycardia (SVT). Most importantly,
after recognizing SVT, the AED delivered a cardioversion rather than a defibrillation.

Interesting that an AED can be reprogrammed to delver a synchronous cardioversion. I’ve never heard of that, but the report is pretty clear on it. One of my rules is that just because we can do something doesn’t mean that we should do it.

NOTE: The discussion part of the article notes that the device was a Powerheart AED, by Cardiac Science and it does indeed have an algorhithm for synchronized cardio version. I will also note for the record that my former service had a very unsatisfactory experience with Cardiac Science. That’s just for completeness sake and was about ten years ago, so they might have improved their quality control.

A multidisciplinary team, including members from our EMS agency, the school nurse, school district officials, emergency department personnel, and the patient’s cardiologist, reviewed the case. It was determined the nurse was following school district policy when she inappropriately utilized the AED. This ill informed policy was based on the anecdotal experience of a school district official with an AED. Following discussions with the school district, the policy on AED utilization was edited to exclude conscious patients from having AEDs attached.

Personally, I’d feel better if that read a a former school district official. Who unless he has MD and a lot of other credentials after his name has no business setting medical policy for the district. Nor should nurses be cardioverting patients willy nilly without a clear idea of what they are treating and without having the proper equipment and medications in case it all goes huckle buckle bean stock. That goes for paramedics and doctors too.

The article concludes with this sage advice.

This report emphasizes the importance of AED safety and proper application. AEDs
should only be applied to patients thought to be in cardiac arrest, which is consistent with national
guidelines.

AEDs should not be used as cardiac monitors in non-cardiac arrest patients unless the individual
caring for the patient has been trained to interpret the cardiac rhythm displayed on the AED monitor
screen. Lastly, our quality review process exemplifies the importance of system-level intervention (changing school district policy)for prevention of adverse
events.

My former service had a different brand of AED and the paramedics were trained and authorized to use them as single lead monitors (harking back to the early days of paramedicine)  and to over ride the AED functions to use them as manual defibrillators. That was for unusual circumstances only and wasn’t routinely done. Which was probably for the best.

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.