Case Review: Feel It Kick

"This thing keeps kicking me," the man says, pointing to his chest, where he has a small, hard object in the place where a cardiac pacemaker usually resides.

Attack One was dispatched in the middle of the afternoon for a "cardiac problem," so the crew is prepared for a cardiac emergency of some type. But before they can ask any further questions or begin to apply their cardiac monitor, the man winces again, screams and yells, "Stop kicking me like that!"

He's lying on the couch and seems to be uncomfortable. Quickly, the Attack One crew places the three-lead cardiac monitor and matches a monitor appearance of normal sinus rhythm with a regular, full pulse in both wrists.

"It's already kicked me five times, and I called my heart doctor," the man relates. "He told me I had to call you guys. I don't feel bad, and I told him I think I was too close to the microwave oven, and it set this thing off!"

The man and his wife can answer all the crew's questions about the device. It is an automatic implantable cardioverter defibrillator (AICD), which the man has had in place for the last six months, following a severe heart attack. It has not functioned before. The patient has no symptoms of chest pain, shortness of breath, irregular heartbeat, passing out, nausea or vomiting. His medicines have not changed recently. He says he feels fine, except when the defibrillator discharges, and then he feels like he's being kicked inside his chest.

His vitals are stable, and his monitor now shows a continuous sinus rhythm. He is preparing to move from the couch to the ambulance stretcher when his rhythm suddenly changes to a ventricular tachycardia, and the device discharges and cardioverts him back to a sinus rhythm again. Just like before, the man screams and yells, "Ouch! Stop kicking me like that!"

The Attack One crew asks him to lie back down and repeats the same questions as before. The patient confirms he has no pain anywhere, especially in his chest. He is back in a sinus rhythm and appears to be perfusing very well. The paramedic advises the patient that his device is operating properly, and has just saved him from a rhythm that otherwise would have resulted in him going unconscious and forced the Attack One crew to defibrillate him externally.

"Sir," the paramedic says, "this isn't from you being too close to the microwave oven. Something is wrong that is causing your heart to suddenly develop a life-threatening rhythm, and the device is saving you."

The paramedic phones online medical direction and reports the sequence of repeated discharges of the implanted device in a patient who is asymptomatic except for the pain when he is shocked. He reports that the patient had one episode while on the monitor, and at that time he'd had sudden-onset ventricular tachycardia. His perfusion, blood pressure, pulse oximetry and mental status were all normal.

Medical control asks that the crew initiate therapy with procainamide, starting with a bolus and then continuing a drip. The crew starts an IV line, mixes the appropriate dose and begins the 30-minute infusion. They explain to the patient that this older medicine has regained favor in the past year, since the American Heart Association's 2010 emergency cardiac care guidelines were published. They advise him to let them know if he feels poor in any way, and that they will monitor him closely as they transport him to the cardiac center where he received his prior heart care and had his IACD implanted.

Hospital Course

Transport time to that hospital is about 25 minutes, and the infusion of procainamide is about complete on arrival. The emergency physician who delivered medical direction is there to greet the patient. No further dysrhythmias have occurred, and the device has not discharged again. The crew shares the rhythm strip showing the cardioversion.