What was Your Worst Triage ER Experience?

[NYCEMS9115]

I remember this call and it went so smooth but the Hospital ER fu#ked it all up. You've ever been at triage; you've transfer the patient onto their bed and then they just pull off your ECG wires? Well here's a story of WHY you shouldn't do that until you've hear the EMS report.

Several years ago I was working on the Ambulance ; on the Lower East Side of NYC. We responded to an elderly male, complaining of not feeling well; it came over as a cardiac condition. Upon arrival it was a 20+ story apartment building complex . We took our equipment with the stretcher. When we reached the floor and approached the apartment door; the door was unlocked and he wasn't there to greet us. We called for him. He called for us from the bathroom; he was sitting on the toilet seat. He was fully clothed and stated needed to sit; he was very light headed but he never fell or passed out. He was very diaphoretic, his clothes were soaked. We immediately carried him from the bathroom to the stretcher which was by the doorway. He was given high flow O2; his vitals were no BP; no radial pulse, resp 28. A/Ox3; no pain just very light headed; he felt like passing out. No other complaints. His PMH, meds, & allergies; I can't recall. The symptom of light-headedness was all day; it was nighttime. His ECG was 3rd Degree AV Block at a rate of 30. The rest of his assessment was unremarkable. An IV 18g was started and fluids were given at KVO. After a brief discussion with my partner & the patient regarding pacing him : we decided to pace him; he went along with what we've decided. At his home we paced him at 60bpm and got capture at 70MA (no sedatives; no pain). We had a BP of 70/p, HR 60, RR 24. We moved him out of his apartment; locked his door and moved to the elevator. He stated he felt better; less light headed; no pain. I looked on the monitor and he was losing capture. So I increased the MA; gained capture at 100MA (no sedatives; no pain). We entered the elevator and proceeded to go down. He stated he felt almost normal: we can see the pulsation from his chest around the pad; no pain. We arrived to the lobby and captured was losing again. The MA was increased to 160MA, where there was complete captured. His BP 100/P, HR 60; no complaints, stated his symptom was gone. We moved him into the ambulance and gave a notification to the ER of choice, it happened to be the closest anyway. It was a 3 min ride. He was fine; no pain. I observed his rhythm losing capture again and I regained capture at 190MA (no pain at all). We arrived to the ER bay and his vitals were 116/68, 60, 24; skin was normal, asymptomatic, still very A/Ox3; answered questions appropriately . We pushed him to the ER. Even though we had made a note; we had to wait. I kept observing his rhythm and it was a Ventricular Paced Rhythm at 60bpm and at 190MA (we've capped out on the MA). We finally were directed to a slot; nurses were stripping him & doctors were listening (maybe the nurse should have too); I gave the report and the patient was following commands appropriately. When we moved him over to their stretcher; a nurse yanked off the wires of the ECG . What do think happened next? Yup, he was talking to the MD and stopped mid sentence. We didn't know what rhythm he was in because the RN removed the leads. It probably wasn't very good; he became unconcious and the staff was in a state of panic mode. I quickly stepped in, grabbed the leads from the RN, and placed him back my leads; turned on the Pacer, set the HR at 60bpm, and set the MA to 190MA (all in under 30 seconds ). He regained responsiveness and again stabilized. The MD said to the RN, "Don't do that again ." He ordered us to stay and the patient remained on our monitor until the Cardiac Fellow came to place a Tranvenuous Pacemaker; it took him an hour to come. My partner had to go back to our hospital to change batteries. The FDNY EMS Lt checked in on us; he ws a tad upset. Moral of the story; do you really want to pull on that wire?

Now what was your horror story?

[HellsBells]

Yeah had the same thing happen to me, it was a unit aid, not a nurse who pulled the wires, but they were able to reestablish the pacer without any drastic deterioration.

My partner was a little pissed though. I believe his exact words were " congragulations, you just killed our patient."

[HellsBells]

Yeah had the same thing happen to me, it was a unit aid, not a nurse who pulled the wires, but they were able to reestablish the pacer without any drastic deterioration.

My partner was a little pissed though. I believe his exact words were " congragulations, you just killed our patient."

[DwayneEMTP]

I've never paced anyone, so perhaps I don't understand the concept as well as I thought I did..

But what does, "losing capture" look like on the monitor? Can you explain how you can have partial capture?

Thanks

Dwayne

[fiznat]

Why didn't the ED just put the patient on their external pacer? Seems silly they made you hang around for an hour.

Duane, I assume by losing capture he meant that he wasn't getting electrical and mechanical response for every pacer spike. It is possible that you can have both initially, and then gradually (or quickly!) loose it. It would look the same as it does when you are trying to get initial capture, with an intermittent pacer response on the screen. Usually I set the current about 10 or 15 milliamps higher than the capture threshold to help this from happening.

[DwayneEMTP]

Why didn't the ED just put the patient on their external pacer? Seems silly they made you hang around for an hour.

Duane, I assume by losing capture he meant that he wasn't getting electrical and mechanical response for every pacer spike. It is possible that you can have both initially, and then gradually (or quickly!) loose it. It would look the same as it does when you are trying to get initial capture, with an intermittent pacer response on the screen. Usually I set the current about 10 or 15 milliamps higher than the capture threshold to help this from happening.

Thanks for that! It makes me a little crazy that I've never paced, it's the one intervention that refuses to leave my toolbox.

Thanks again for the explanation.

Dwayne

[NYCEMS9115]

Thanks fiznat... For whatever reson; I'm not getting email alerts on replies on walls. LOC (Loss of Capture) is when you have pacemaker spikes with inconsistent capture: spike then QRS, spike then QRS, spike, spike then QRS, spike, spike, spike then QRS. Just an example.

The ER had the Zoll: I had the LP12 and the Zoll's MilliAmps didn't go up as high; it only went up to 160MA.

All the best....