Normal heart rhythm suddenly deteriorates into ventricular fibrillation. Internet ECG

By Paul Goldfinger, MD, FACC

I was covering the all-night shift in the ER at LaGuardia Hospital in Queens. As a cardiology resident at Mt. Sinai Medical Center in Manhattan, I wasn’t supposed to moonlight, but many of us did it anyhow.

LaGuardia Hospital was the main facility for HIP (Health Insurance Plan of Greater NY)–which was one of the earliest HMO’s.   It was a run-of-the-mill neighborhood hospital.

I had read a paper in a cardiology journal called “Blind Defibrillation.” It came out after coronary care units had been invented. The CCU experience taught us that the main cause of death during a heart attack (acute myocardial infarction—acute MI) was a fatal but reversible rhythm disturbance called VF or ventricular fibrillation.

In the CCU, all patients with heart attacks wore electrodes for continuous ECG monitoring, so that is how we learned about VF. But we also learned that we could save the life of such a patient by giving them a timely electric shock to the chest using a device called a defibrillator.

Of course, you all know about that from TV, but back then, it was new and exciting. In the CCU all patients were monitored, so we always had ECG evidence of VF before we defibrillated a patient. If a patient on the med/surgical floors who was not on a monitor had a cardiac arrest, we always did an ECG before using the defibrillator, however, that did waste some time.

But what if someone out of the hospital, with a classic history of myocardial infarction (chest pain, sweating, shock) had a cardiac arrest? The ambulance crew,  who did not have access to an ECG machine, would bring them in doing CPR.

Wouldn’t it be reasonable to not waste time getting an ECG?  After all, “time is muscle” as they said then and now.   Just go ahead and shock them even without ECG documentation (ie “blind defibrillation ” as described in that journal article.)  The idea was a bit controversial at first.

Well, that night, a patient came into the ER at LaGuardia with a history suggesting an MI. He was talking to us and was placed on a stretcher, but before the ECG electrodes could be applied, he had a cardiac arrest and went unconscious with no pulse or respirations. I asked the nurse for the paddles  and shocked him even without ECG evidence (i.e. blind defibrillation). His pulse came back immediately, and he opened his eyes and looked around. It seemed like a miracle.

Looking back on it, the story would have been perfect if he said, “What’s up, doc?” But he said, “What happened?”

These days, Emergency Medical Technicians can shock people in the field, although they do get ECG evidence with current equipment. Some machines won’t deliver a shock unless it reads VF when the paddles are placed. But if the ECG reader isn’t working, they should do blind defibrillation.

Defibrillators are now available in airplanes and stadiums. Some high risk patients have internal defibrillators implanted which can sense if VF is occurring, and they will deliver a shock on their own.  And yet, even today, there might be a situation, falling between the cracks, when blind defibrillation might save someone’s life.

Another new variation on this theme is that an “ambulance drone” can be sent to the victim of an out-of-hospital cardiac arrest.  A person standing by can place the paddles on the chest, as instructed by the drone operator by phone,  and then hit the button.  This saves the time of waiting for an ambulance and it significantly improves the survival rate of sudden death outside of hospital from 8% to about 90%. But currently this technology is not widely used in the US.

www.tudelft.nl/en/ide/research/research-labs/applied-labs/ambulance-drone/

THE BEATLES:   “Across the Universe”

“Words are flowing out like endless rain into a paper cup,
They slither while they pass, they slip away across the universe
Pools of sorrow, waves of joy are drifting through my open mind,
Possessing and caressing me.”