June 20th, 2011

When the Stuff Hits the Fan

CardioExchange welcomes this guest post, reprinted with permission, from Dr. Westby Fisher, an electrophysiologist practicing at NorthShore University HealthSystem in Evanston, Illinois, and a Clinical Associate Professor of Medicine at University of Chicago’s Pritzker School of Medicine. This piece originally appeared on his blog, Dr. Wes.

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?”


“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.


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. 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 had 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…

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