Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Article Comments

When A Routine Case In The EP Lab Goes Awry

Easy case.

Seen it a hundred times.

Old guy (or gal).

Comes into ER.

Found “down.”

“Hey doc, looks like his hearts goin’ slow. I think he (or she) needs a pacer.”

“On any meds that might do this?”

“Nah.”

“How’s his (her) potassium?”

“4.3, normal.”

And like lots of times, you head in. Glad you can help. Call-team’s on their way, thanks to you. Called the device rep to make sure they can be there just in case, too. Cool as a cucumber. Nothin’ to it. Been here, done this.

You arrive to a guy (or gal) that looks pretty good. Maybe has one or two medical problems. Heart rate’s better thanks to the atropine and the fluids they gave him (her) on arrival. The intraosseus line in the tibia is impressive, too. (“At least he (she) wasn’t awake when that happened,” you think.)

So you review, examine, plan your approach. EKG on presentation? Ouch, heart rate agonal. Wide complex rhythm of right bundle branch rhythm. Look at the monitor: “lots more right bundle branch rhythm there, thank goodness, P waves, too.” you secretely notice.

Seems he (or she) is willing (how many times does he (or she) want to pass out at home?), understands what lies ahead, that the crew’s on their way. “We’ll be taking you over in just a few minutes. Any other questions?” There are none.

Perfect.

And after a while the crew arrives, assembles the poor guy (or gal) on the table and ships him (or her) over to the cath lab area. Chest is prepped, equipment assembled, antibiotics given, monitors connected…

… damn we’re good. Smooth operators.

So the local anesthetic is injected and the incisions made. Dissection to the pre-pectoralis fascia just above the breast muscle accomplished, even the wires passed easily into the vein using ultrasound guidance. Even having a nice chat with the guy (or gal).

Poetry in motion.

Sheaths placed in the vein over the guidewire, pacing leads placed through the sheath. Until, from the control room…

“We lost our EKG.”

You glance up. Nothing on the monitor. Brain shifts from 33 rpm to 78 rpm, then higher….

“Okay, boys and girls, let’s find the problem. Device rep? Turn on pacing from your PSA.” You fluoro. No heart motion. Curved stylette goes into the longer lead.

“I’ve got the airway,” the nurse shouts. “Should we start CPR?”

“Not yet, moving the lead to the ventricle…”

“Crap, he’s (or she’s) moving. Seizing. Sh%^#t! Hold him on the table! Need… him… under… flouro…. just… one… more… second…”

“There! Turn on pacing!”

You look up. Pacing has begun. EKG shows capture. Your sphincter relaxes. A bit. Until beneath the surgical drape, thrashing …

“It’s okay sir (or madam)! You just passed out. Don’t try to get up off the table. You’re in surgery, remember?”

Calm ensues.

Suddenly flat line on the monitor again….

“What the?…”

You step of the flouro pedal again. Lead looks good. Moving.

“He’s still with us,” the nurse shouts. “Still got a pulse ox reading. Must have knocked off the EKG lead…”

“Come on, guys! How many changes of underwear do I need to bring for these cases? Sheesh! … Sir (or Ma’am), you doing okay?”

“Uh, yeah, doc. What… happened?…”

“You passed out again on us. Just like you did at home. It’s all good now, we got that lead in place.”

And so, as dusk settles over the horizon on another thrilling ride in the EP lab, you stop to reflect on just how lucky you and the patient were that day. By the grace of God you had access to the vein already, the lead in the right atrium, and the presence of mind and experience to position the lead to the ventricle in the nick of time.

You know others before you weren’t so lucky. You know that others, despite their best efforts, had the patient die. You know how terrifying those seconds were. You wonder if they got sued.

No fault of their own. Just fate.

So you vow from that day forward that you’ll always place a temporary pacing wire from the leg before you start an emergency case like this on the weekend.

It’s all about having control.

And reducing your underwear cleaning bills…

*This blog post was originally published at Dr. Wes*


You may also like these posts

Read comments »


Comments are closed.

Return to article »

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

Read more »

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

Read more »

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

See all book reviews »