30 March 2008

Grim Irony

The Chief Complaint read "Defibrillator shocks."

The patient, an eighty-something year old man, had an ICD, an implanted cardioverter/defibrillator, due to a history of cardiomyopathy (enlarged heart) which presumably had predisposed him to abnormal and dangerous irregularities in the heart rhythm and even sudden death. A small computer packet implanted in his chest wall monitored his heart rhythm and could regulate or even shock the heart if it detected certain abnormalities. He reported that he'd had half a dozen shocks from the thing in the previous eight hours.

ICD discharges are really uncomfortable. They feel, I have been told, like the proverbial "kick in the chest."

Usually, an ICD discharge is not a big deal -- it's the device working as designed. You watch the cardiac monitor, or interrogate the device's memory, and verify that the shocks were appropriate. If the thing is malfunctioning, it can be reset. Mostly, you have to ensure there's no underlying reason that the patient is having arrhythmias -- a new heart attack, or heart failure, dehydration, infection, etc. -- and treat the cause, if possible.

For this guy, the cause was actually pretty obvious. He admitted that he'd been feeling poorly, and in the ER he had a fever of 102° and was clearly septic from a UTI. His blood pressure was low, and while examining him, I saw two short episodes of ventricular tachycardia (VT) on the monitor, one of which resulted in yet another shock.

So the device was working appropriately, and we instituted standard treatment for sepsis -- antibiotics and all that good stuff -- and posted him for an ICU bed, even though he wished to be DNR. But predictably, he did not do well, and while in the ER he began to show signs that he was unlikely to survive this illness. Family assembled at the bedside and we had "the talk." They were tearful but accepting, and slowly but peacefully, the patient departed the land of the living.

Except nobody remembered to tell his ICD. The damn thing just wouldn't give up! Long after the patient had basically expired, long after his heart had lost the ability to beat in any sort of functional pattern, the silly thing kept pacing away and periodically issued a shock, which caused the patient's body to twitch in a manner most distressing to the family.

A frantic search ensued for a magnet. Placing a donut-shaped magnet over the device deactivates it, and we keep one in the ER for just such an occasion, but it was missing -- stolen, it was darkly intimated, by the ICU. They couldn't find it either. Eventually I got a cardiologist from the building next door to send one over, and we shut it off for good.

As this was transpiring, I was at the bedside talking with the family. The patient's wife pulled out his wallet and showed me the manufacturer's card for the ICD -- It was a "St Jude" model. While I know nothing about the company, St Jude Medical, I endured sixteen years of Catholic education and I know my catechisms: traditionally, St Jude is the patron saint of lost causes.

No wonder the damn thing wouldn't give up.


  1. House Whisperer3/30/2008 11:01 PM

    Great post. This is really one of your best--I can picture the search for the magnet.

  2. This is so far beyond "keys?! keys?! Who's got the keys?!"

    Nicely done, Dr. SF

  3. I'll admit it. I LOLed.

  4. Funny and creepy. A hard combo to pull off.... but bravo.

  5. Was there discussion of the ICD being deactivated at the time of DNR? I find that many patients and families have a tough time with these as two separate issues.

    It should be said that most people do not die with a ventricular tachycardia, it is often more of a bradycardia followed by asystole, so in many with ICD's who die with the ICD still active, it is unlikely to shock. But still it could happen so...

    A Fast Fact for defibrillators in end of life care can be found here for anyone who wants to know more about this.

    Thanks for the St. Jude ref, I'll have to use that in a talk about ICD's sometime.

  6. It's stories like these that make me so glad we have our magnet stuck on the doorframe of the nurse's station and another one on the side of the code cart.

  7. oh man, I'm sitting here in a coffee shop just about ready to cry; great post. Nothing to add except a choking chuckle

  8. Very interesting. If something like this ever happens at Shoreline perhaps I can impress my coleagues.

  9. I had to tell my Catholic husband about this... wow, what a story!

  10. I used to work in cardiology and help run the ICD/pacemaker clinics and on my first day, when told that St. Jude was one of the three companies that supplied the devices, I couldn't help but snicker and explain the joke to the non-Catholics.

    Your story just kind of adds an extra "ba-da-bum-bum"!

  11. I honestly feel bad for laughing about this.


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