Learn Something Every Day

50-year-old woman recent heart surgery to replace a valve. Visiting nurse says the patient is bradycardic. The officer tells me the patient doesn’t look very good. I find the woman laying on the couch with a nonrebreather on. She says she doesn’t have any pain, but doesn’t feel well, and vomited a couple hours ago. Her skin is dry, but her complexion is grey. I get her in a hospital gown and on the monitor. She’s in a third degree block at 30. Still her BP is okay 112/60. And she is satting at 100% so I switch her down to a cannula.

Out in the ambulance, I put a 16 gauge in her right AC, toss her some Aspirin and give her 4 of Zofran for the nausea. And we head in to the hospital. Nonlights and sirens. She is stable, maintaining her rate at 30. Her BP remains constant.

I think about putting her on the pacer pads, but don’t want to alarm her. I explain what is going on, and how she is going a little too slow, but that she is stable now. I assure her if anything happens I have the ability to keep her heart going at a steady rate.

I have had many patients with third degree heart block, but they have all been largely stable and asymptomatic. It costs $80 to open up the pacer pads. If anything happens, I can just rip the package open and slap them on and start zapping away.

At the hospital the ED doctor takes a report from me and then asks if I applied the pacer pads. No, I say, she’s been pretty stable.

And the ED gets a good set of vitals too, except of course for the 30 pulse. The doctor explains to a med student that even though the patient is in 3rd Degree Block, she is stable. He has called the patient’s heart doctor who is in the building. If the student wants to go to lunch that will be okay.

The nurse asks me then if the patient has any allergies. I say Penicillin. The patient’s sister who is now in the room pipes in that she is allergic to amoxicillin. The nurse who has just left the room for a moment comes back in and I add that the patient is allergic to amoxicillin. That’s the same as penicillin, the nurse says. Really, I say, why you learn something to new everyday. See, the doctor says, even an experienced paramedic can learn new things. True, I say.

I leave to go write my run form, and while I am writing it, I think about writing “Had pacer pads out on standby,” but then I don’t because I don’t think I can really write that unless I actually put the pads on. No big deal, I think. I saved $80, plus since I do the ordering, I won’t have to put in a new order yet. We have been getting a little low on our combi/defib/pacer pads.

I finish writing the form and I come back and there is quite the crowd in the patient’s room. I go in to drop off my form and see her jerking. She is really jerking and I can see now she is being paced. She is trying to talk, but her whole body is jerking. I have paced people before, but never seen anyone twitching so violently. There is a tall man in scrubs in the room and he is talking on a cell phone. I need to get the cath lab open, I need those bodies off the table. This lady is dying down here.

Wow, I think.

The doctor turns to the lady and says, “Its going to be okay. You need a pacemaker. We’re going to take care of you,” then a moment later he is back on the phone shouting, “She’s going to die if we don’t get her on the table.”

It seems while I was out of the room, the patient suddenly went asystole. She is now being paced at almost full power, and even at that they are barely maintaining capture. I watch as they sedate and then intubate her, and then finally rush her upstairs.

That was sudden, I say to the ED doc after the room has cleared.

She just went asystole, he says. Good thing we were still in the room.

I didn’t put the pads on because I thought she was stable, I say.

I always put the pads on, he says. You never know.

I hear you, I say.

Hey, I’m always open to learning.

Just then the medical student appears.

Did I miss something? she asks.

***

Post script: At last report, the patient is doing very well. They put in a temporary pacer in the cath lab without problem.

12 Comments

  • Rogue Medic says:

    I wonder if they placed the pads in a way that minimized the amount of muscle, other than heart muscle, between the pads. Too often, I have seen the pads placed on the pectoral muscles, which is unnecessarily painful for the patient. It also requires much more current to stimulate the heart.

    I do not see how opening the pacer pads and placing them on the patient would have led to a better outcome. The pads would not have prevented the asystole, unless you had already been pacing her. Even that is not certain.

    We like to think that some simple rule would prevent bad outcomes, but a good assessment is the best thing we can provide our patients. She was stable according to everybody, except the doctor acting less in control than an Oklahoma trooper.

    The doctor turns to the lady and says, "Its going to be okay. You need a pacemaker. We're going to take care of you," then a moment later he is back on the phone shouting, "She's going to die if we don't get her on the table."

    Nice bedside manner.

    Did anyone else see the asystole? Or did Dr. Loose Cannon just get scared by a slow rhythm? It wouldn't be the first time.

    I hope the sedation includes something with retrograde amnesia after the She's going to die screaming. Maybe the doctor is just trying to use some secondary catecholamine infusion – scare the patient so much that she dumps adrenaline into her blood stream.

    There was a bit of a related discussion of the use of precordial thump for similar presentations at Paramedicine 101

  • PC says:

    I realize that placing the pads wouldn't have changed the outcome. I was thinking more in terms of what if we had been called a half hour later and the patient had asystoled while I was taking him out of the back. Then it would have been nice to have the pacer pads all set to go. But like I said, all my 3rd degree block in the past had been quite stable — I had never seen one crash, and looking back at this patient versus the ones I've had in the past, I think she was much more suceptible. The others were usually old people feeling tired for a couple weeks coming from doctor's offices. The one today was nauseous and grey and a much more sudden onset.

    The ED Doc was great and I have high respect for him — the other doctor — from upstairs — was the one with the bed side manner. I just hope the lady wasn't listening to his rants. They did finally switch the pacer pads from the defib position to front to back — I think that

  • Rogue Medic says:

    It has been my impression that defib/pacer pads are often placed poorly. With pacing the result is not capture speeding up the heart rate, but pain.

    With her nausea, I don't think I would use ondansetron. I don't think it would directly cause problems. There is a mention of transient QT prolongation, but what doesn't? 🙂

    Some lists broken down by bad, moderate, and minor QT problems can be found here.

    My approach to arrhythmias is to assume that all symptoms are secondary to the arrhythmia until I have a good reason to believe otherwise.

    Nausea/vomiting in a 50 year old woman with a cardiac history. I do not see this as different from the typical male presentation of crushing/pressure to the substernal area.

    It is very difficult to say what I would do, never having seen the patient and being biased by knowing/suspecting that the patient was asystolic for a while.

    I still am not trusting that the doctor from upstairs recognized asystole or treated it effectively. This is not a criticism of all specialists, at all. Most I have dealt with have been great. This one sounds very different.

  • brendan says:

    While normally I'm all for no lights on stable patients, this would be one lady I'd want out of my truck. Not somebody I'd want to be sitting in traffic with.

  • VA PhireMedic says:

    At least you're lucky enough to have Zofran. We have Phengren and technically we can't use it except in Morphine related N/V, and even then even the paramedic has to call for orders.

    In any case, I most likely would have placed the pacer pads on, but thats my opinion. I personally don't worry too much about the cost of things when I'm making a decision, irresponsible maybe, but I really don't see that as my job. My job is to ensure that the patient receives the best possible care–not that your not placing the pads is bad either, its simply a matter of preference. I think the best thing for this patient was the idea of rapid transport and the ability to intervene if necessary (establishing an IV as you did and having the pacer pads at least nearby).

    All in all, this was actually a REALLY good call both for you and the hospital. It really could not have turned out any better and is a perfect example of the well run EMS/hospital systems. Good job.

  • VA PhireMedic says:

    Also, I never really considered that Amoxicillin and Penicillin were the same thing…oh well. I learn something every day too!

  • medicblog999 says:

    The way I see this is just two valid ways of treating the same patient. I don't see the placing (or not) of the pads as the main issue. The reassuring thing to see is that the thought process was there, it was considered and a decision based on clinical rationale was made by you. Hindsight is a great thing to have and on reflection you may change the way you would handle the same patient in the future.
    What I cringe to see is a paramedic who doesn't even pick it up as a complete heart block and treat appropriately. Unfortunately, we are not allowed to use the pacing facility of out lifepak 12s, but I'm sure that will be changing soon.

  • yusufyusuf says:

    Hi..!
    Nice blog…
    Have a nice day…

    06.06 ©

  • TOTWTYTR says:

    I don't think that the nurse meant that PCN and Ampicillin are the exact same drug, but that they have similar allergy profiles. Because they aren't the same drug, although both are antibiotics.

    As to the case, you were lucky. I don't care how "stable" someone with a bradycardia of 30 looks, they get the pacer pads applied. Consider it a lesson learned at no cost. Think like a medic, not a purchasing agent.

    We all make mistakes, the important thing is to learn from them.

    Medicblog999, what third world country EMS system do you work in? Can't use pacing? That's like 1980s medicine.

  • Mystery Medic says:

    Well I see Rogue Medic just coined a new EMS term, "acting less in control than an Oklahoma trooper", should start seeing that on future posts.

    medicblog999, How do you treat symptomatic 3rd blocks without electricity? Other then Atropine which is worthless for 3rd degree the only thing I could think of is IV EPI for some vasoconstriction.

  • So. IL Medic says:

    Mystery Medic – Treatments prehospital sypmtomatic 3rd degree bradycardia follow the acls protocol – TCP then consider atropine (as mentioned is usually useless in 3rd degree) then epi or good old dopamine. Old school medics might remember that isoproterenol was used once upon a time.

    A big problem with atropine in this case is if the block is MI related. If so, atropine will make the problem worse.

  • Mystery Medic says:

    Exactly, I would have the pacer pads on asap so what 999 use in their protocols if they can't use juice? What is their first drug of choice? I forgot about isoproterenol but I don't think anyone is still using that in the US prehospital.

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