Street Lessons #2 Troubleshooting the Monitor

In paramedic school, you are taught to apply your cardiac monitor to patients having chest pain as well as a variety of other aliments.  Simple enough.  If your teacher hasn’t told you, then your preceptor should be grilling it into you to always bring your monitor in to each call, as well as your house bag.  Some might say you should also be bringing in your suction –anything you might need.  You never know what you are walking into.  But in this post we are going to just talk about the cardiac monitor, and we are going to assume you have it with you.  (At least in cases A-D). Here’s where the problems begin.

Problem A 

Both batteries are dead.  You checked them this morning and you swear they both had four bars.  Now the monitor is either completely dead or the batteries are both down to one and flashing that they need to be changed, and then they go dead.  What happened?  Well, you thought you turned the monitor off after you checked it at the start of your shift, but you didn’t, and all this time the machine has been sucking the batteries down.  I can tell you I have on several occasions been driving to a cardiac arrest and just before I arrived, heard a sudden beeping from the back and the voice saying “Change monitor batteries.”  What do you do?  If you are still in the truck when the battery is beeping, you change the batteries out.  Simple enough.  But let’s say they are both dead and you don’t notice until you are in the house.  You take the spare battery out of the back.  How do you know you have a spare battery?  Because this has happened to you before, so you always keep a spare battery in the back now.  Always.

Problem B

The batteries are good, but when you attach the electrodes, nothing reads on the screen.  You recheck the leads and connection to the monitor, which you unplug and then replug several times, all with no change.  Still nothing.  You take the electrodes off and apply some new ones from the same open bag, and still nothing.  You blame the monitor.  Is it the monitor?  No, some of you may have guessed from your experience or from what I have written that reveals the clue.  The problem is the electrodes are from an open bag and they are dried out.  You were smart enough to switch electrodes, but you took the new ones out of the same open bag.  Try to always get your electrodes from a fresh pack, or at least keep a spare fresh pack in case you have this problem.  I know some medics like to preattach their electrodes, which is okay if you are very busy, but know this — from the moment you take them out of the bag, they start to dry out, and the drier they are, the worse the ECG quality will be until you get nothing at all.

Problem C

You need to do a 12-Lead.  Whoops, you have the regular cable, but the 12-lead attachment cable is missing.  It fell out and no one noticed or you forgot to check carefully this morning.  Either way, all you have is the four leads and your patient is having crushing pain and is cool, clammy and diaphoretic.  What do you do?  A modified 9-Lead.  This is how we did 12-leads before we had Life-Pack 12s.  Take the left leg lead — the red lead, and move it to the V1 position.  Run Lead III in diagnostic mode.  Repeat with V2, V3, V4, V5 and V6.  Label each lead as follows:  McL (modified chest Lead)1, McL2, McL3, etc…  While not exact replicas, they do passably well.  You do this and see hyperacute T waves in McL3 and McL4 and McL5.  Call in a STEMI Alert.

Problem D

This time you have your 12-Lead cables, but that is all you have.  You don’t have the four lead cables and without those, you can’t attach the 12-Lead cables.  Your patient is alert, but very clammy and you can’t feel a pulse.  What do you do?  Take out the defib pads, and apply them to the chest.  Hit paddles on the monitor and while you won’t be able to get a 12-lead, at least you know the rythmn and if it happens to be VT, you are all set.  If if is an SVT, and you want to give adenosine, go ahead, just be certain to hit print.  If it is a sinus, well at least you know that.

Problem E

Okay, so this time you are dispatched to a chest pain call and when you go to grab your monitor, there is no monitor.  D’oh!  What happened?  Who knows, but we could assume what happened to you is what happened to me as chronicled in the post D’oh!  I was lucky enough that my call was not a chest pain, but a BLS call.  Had it been a chest pain, I would have had no choice but to fall back on my BLS skills and call for a paramedic intercept.  Even if I was revealing my lapse and subjecting myself to punishment, you can’t let the patient be harmed.  Go ahead and call for a medic, and hope that your company and or medical control is lenient with you.

 

 

8 Comments

  • Jon says:

    I like the info in problem C, however I don’t understand what you mean about run lead III in diagnostic mode. Could you further explain that one to me?

    Thank you!

  • Matt says:

    For your dried out electrodes, the gel is simply electrolyte gel. You can moisten them with pretty much anything wet and they will work passably well again. Saline works great. I saw a frivolous paper a while ago which evaluated moistening dried electrodes with various liquids including tap water and ketchup, and they all worked okay.

    I also wanted to know about diagnostic mode. I’ve heard of this, but I don’t know how to access it except to run a 12-lead.

    • medicscribe says:

      Hi Matt and John-

      Thanks for the comments. Interesting idea about remoistening the electrodes. I’ll have to try that.

      Here’s the deal on the diagnostic frequency. There is monitor frequency and there is diagnostic frequency. The monitor frequency — what you see on the screen — provides the clearest view of the rythm, but is is not sophisticated enough for analysing the ST segment. When you print a 12-lead, it prints at diagnostic frequency. If you are doing a modified 9-lead, you may see an ST elevation on the screen, but if your monitor is configured to print in diagnostic, the ST elevation may not appear on the printed copy. Often the ST segment will return to baseline. If the diagnostic quality print maintains the ST elevation, then it is considered true ST elevation. If your monitor is configured to print in the monitor frequency, you will often see the false ST elavtation persist. All 12-leads are printed in the diagnostic frequency, but not all single lead strips are. If you are forced to do a 9 – lead, make certain your printer is configured to the diagnostic frequency. I often use this method for a quick look ECG where I take the left leg lead and move it to the V4 position and look for ST elevation. Sometimes I also use this for a quick look at the right side, by putting the red lead in V4R position. Always view in Lead III on the monitor.

      Hope this explains it. Check your monitor settings. I believe you can go into the print menu and change it on any particular call. To permanently change it, you need to use the passcode to unlock the default settings. Your supervisor may be able to help you with this.
      If your monitors are not passcode protected, the factory passcode is 0000. Download a Physico Control Life Pack manual for more help on this.

  • Peter, press and hold the Print button for 10 seconds on a LP12 or LP15.

    “DIAG” will flash on the screen. The bandwidth filter on your display will stay on, but the bandwidth filter on the printer is turned off, and what prints will be diagnostic quality.

  • BH says:

    Dried out electrodes, or electrodes that might be dry, should be thrown out, not moistened. They’re the #1 cause of poor readings according to our Physio maintenance rep. She doesn’t recommend storing them anywhere but a zip-lock bag.

  • Matt says:

    Thanks to Kelly and Peter!

    BH–I wasn’t recommending that you store your electrodes in the open air with the plan to wet them on a call. I was just offering another option to try if you find yourself on a call without any fresh ones. It happens to us all at some point.

  • Brandon O says:

    Zoll will print with diagnostic filters if you hold down Record as well.

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