Chargeshockchargeshockchargeshock

Years and years ago, I ran an interesting cardiac arrest. Well, I’ve run a few interesting cardiac arrests, but there is one that I would like to tell you about today. It involved a fifty-something male who had chest pain, waited too long before calling, and attempted to treat the pain with Pepto Bismol or some such ineffective remedy. So he eventually arrested and fell down, which notified his family that something bad was happening. The family was on the ball. 911 was called and his adult son began effective CPR immediately.

Besides his son slamming away with some good, rib-cracking CPR, this patient had an ambulance and a fire truck relatively nearby. So the professionals (plus me) had a quick response time. Let me tell you how this went, so you can see how long ago this happened…

The paddles were gelled and pressed against the patient’s bare chest. VFib was identified. Charge to 200 joules, clear, shock. I kept watching the monitor postshock and the patient was still in VFib. Click the thumb dial to 300, charge, clear, and shock again. Still VFib. The 360 joule shock resulted in asystole. A firefighter got back onto the patient’s chest and I intubated him. My partner started an IV and pushed a milligram each of epi and atropine.

See? Long, long time ago.*

Anyway, this arrest was like a demented ACLS megacode run by an idiot who had never seen an arrest before but had read about the rhythms once. The patient kept switching rhythms like the ACLS instructor had just bought a new rhythm simulator and was just randomly pressing buttons. The epi and atropine changed the asystole to a pulseless IVR and more epi turned that into VFib again. Shock, asystole, meds, IVR, meds, VFib, repeat. I recall there was at least some VTach mixed in and there may have been a significant run of PSVT.

Bad for the patient.
By Jer5150 (Own work), via Wikimedia Commons

In any case, I found myself chasing rhythms while transporting. (Because back then we felt like we could do effective CPR in a moving vehicle, so we gave dead people a final cruise through the city.) On the way to the hospital, I contacted my base hospital to have them set up the receiving hospital. I was transporting to Hospital A, but I called my base physician at Hospital B so s/he could call Hospital A for me. Its our system. I got a certified legend on the phone.

I explained what was going on, what I had done, my plan (keep on doing what I had been doing), and that we were 5-7 minutes away from Hospital A. He stopped me and gave me instructions: “Bill, listen to me. This is what I want you to do. I want you to deliver three shocks at 360 joules to the patient as quickly as you can. Don’t even look at the monitor, don’t do anything but charge and shock. Charge-shock-charge-shock-charge-shock as quickly as the monitor will do it. I will wait on the phone so I can hear you do it. Give him all three now.”

Okay. That algorhythm wasn’t in any ACLS class that I’ve taken.

Old-school defibrillator paddles, for those who have never seen them.
By User:Tirante (Own work), via Wikimedia Commons

So I did it. booooOOOOOOOOOOOOOOOO BLAM. The firefighter on CPR leaned forward to restart CPR and I told him to hold off. booooOOOOOOOOOOOOOOOO BLAM. Number two. “What the hell are you doing?” the firefighter asked. I grinned at him wildly with a gleam in my eye and a frantic giggle. I hit the charge button again. booooOOOOOOOOOOOOOOOO (“No, please, stop! What are you doing to him! It smells like burning and hatred!”) BLAM. The very confused firefighters looked as though the first thing they were going to do when the call was done was to make sure I was charged with assault. I checked for a carotid pulse.

Well, holy shit. The patient had a pulse. He kept that pulse all the way to the hospital and maintained a decent blood pressure.  A 12-lead in the ED showed an apical MI. I later found out the patient had a CABG or four, got to know the MICU nurses, and was eventually discharged to home. He had close to 30 minutes of prehospital CPR, total.

I’m still not totally clear on how the triple shocks worked. I think each shock lowered the resistance for the next one. Keep in mind the LifePack-10 I was working with didn’t throw biphasic shocks. One way or the other, the physician on the other end of the call saved the patient’s life from miles away. If I’d have called the receiving hospital directly, those shocks wouldn’t have been delivered.

Sometimes you contact base with one expectation and get help you didn’t even know you needed.

*I still remember the VFib jingle I learned in my first-ever ACLS class in paramedic school: Shock shock shock, everybody shock. Little shock, big shock, mama shock, papa shock… For the youngun’s among my readers, that results in a stack of three shocks – 200, 300, and 360 joules. Everybody = epi. Little = lidocaine. Big = bretylium tosylate. Mama = magnesium sulfate. Papa = procainamide. You gave a 360-joule shock and an epi between each of the other meds. That’s how it went…