A Shocking Experience: When a "Routine" Emergency Medical Call Is Anything But

Pam Carletti began her shift just as she would any other shift. She checked her vehicle and supplies, and engaged in some chit-chat with other paramedics and firefighters. But on this day, she was to experience something she had never experienced before.

Of course, nothing in her career will ever match the day in 1998 when her husband, a firefighter in Crooksville, OH, died while fighting a fire. Pam was on the scene as an EMT and later became a firefighter and a paramedic herself.

But on this day, it was an otherwise "routine" call. As she has done at so many other calls in her career, she went through the process: patient assessment, patient history, put the patient on oxygen and hook him up to the monitor. But here's what was not "routine": as she was advancing the IV catheter into the patient's arm, she was shocked by his implantable defibrillator.

As Pam described the incident, "it hurt"; it felt as though her heart had balled up into a tight fist and was going to push its way out of her chest. Excruciating pain shot up through her neck and jaw. Her respiration was labored and her skin became cool, pale and clammy. Even so, Pam was able to continue her patient care and eventually delivered him to the emergency room staff. Then, she calmly walked over the nurse's station and told a physician that she thought she needed to be evaluated.

After some tests and an examination, the physician told her that her heart was not damaged, but that she would have muscle cramps and soreness for a couple of days. He was right. Pam said it felt like she had a bad case of the flu and she ached all over.

In looking back over the scenario, Pam thinks she knows what happened. Before she started the IV, she flushed the 0.9% sodium chloride through the IV tubing. While she was doing so, some of the fluid ran down onto her pants. Then, as she was holding the arm of the patient, who was experiencing runs of ventricular tachycardia, with both of her hands, starting the IV and advancing the catheter, the patient's hand was resting on her pants leg. Then the patient's internal defibrillator fired. It was then that Pam experienced the shock. Unfortunately, before internal defibrillators fire, they do not holler "clear."

Implantable cardioverter defibrillators (ICDs), sometimes called "the paramedics you wear," are provided to patients who suffer life-threatening heart arrhythmias. They comprise a programmable implantable pulse/shock generator plus one or more heart leads. ICDs normally are implanted in the pectoral region, but older units may have been implanted in the abdominal cavity. ICDs sense electrical heart signals associated with ventricular tachycardia (VT) and ventricular fibrillation (VF) through a lead positioned within the heart. Upon detection of such signals, corrective therapy may be delivered in the form of an electric shock.

The U.S. Food and Drug Administration (FDA) also recently approved an unusual cardioverter/defibrillator that is worn like a vest instead of being implanted. This non-invasive device is called the LIFECOR Wearable Cardioverter Defibrillator 2000 and manufactured by Lifecore Inc. of Pittsburgh, PA. It's intended for patients who need a defibrillator, but can't or won't have an implanted one.

The device is made up of an electrode belt that is worn around the chest beneath the patient's clothing. It connects to a monitor with an alarm module that is worn around the waist. The entire device is worn continuously, 24 hours a day, except when the patient is bathing. About once a week, the patient connects the monitor to a modem that relays data by telephone to the physician's computer.

There has been an explosion in the use of the ICDs. The number of ICDs implanted in Americans has more than tripled, from about 54,000 in 1999 to 168,000 last year. Sales are increasing 15% to 18% a year and are expected to continue rising as the population ages and the number of medical conditions shown to benefit from ICD use grows. Increasingly, these devices have been used not only in survivors of sudden cardiac arrest, but also in people who may be at risk.

However, three recently published studies in the Journal of the American Medical Association shed light on the hazards of ICDs. The malfunctions mainly occurred when a magnetic switch inside the device became stuck and prevented the device from providing treatment. Most of these failures did not impact rescue personnel or other bystanders. These failures resulted mainly in the device not firing when it was supposed to.

But what about accidental discharges to rescue and medical personnel? Unfortunately, there are few documented cases. There are more documented cases of mortuary workers getting shocked when removing ICDs while preparing bodies for cremation.

Most EMTs and paramedics treating patients who wear ICDs indicate that when the patient is shocked, they feel a buzz, but not a strong jolt. In Pam's case, though, the jolt was significant. Here's one possible explanation for the considerable electrical shock she received: the physics of her pants being wet helped conduct the electrical flow and both of her hands touching the patient helped complete the loop.

As with any scene, external scanning, and now in this case, internal scanning, are necessary tools for safeguarding and protecting emergency and rescue personnel. As Pam says, it will be an experience she will never forget - "Even when you think you have your patient figured out, Murphy can still make you humble."