Patient in Full V-Fib, Alert & Oriented, Asymptomatic (LVAD) - Patient Perspective

[JasonLVAD]

Found the forums searching for some LVAD topics - and wanted to share my most recent experience with EMTs - as I am an LVAD Patient - and my medics were white as a ghost during transport, and not really sure what to do with me. Hope you don't mind me sharing from a patient's point of view - and i'm curious as to your feedback.

Scenario: I'm sitting at home, AICD fires 6 times within 3 minutes, and I have no clue why. I lost consciousness for about 2 minutes after the 4th shock, regained alertness after the 6th and was able to call 911 reported ICD had fired (4 times i thought) and that i was feeling ok, unsure why it happened, and that's all the relevant info I'm able to provide. They are aware I'm an LVAD patient and have me on some sort of 'special needs' protocol i've since been told - which lets them bypass the local hospital, etc.

Response was overwhelming (Fire Engine/ Ambulance / 2 Supervisor SUVs) and arrived in about 3-4 minutes, within seconds of each other - Upon their arrival i was just worn out, slightly short of breath, slight pain from the 40 joules internally x 6, but otherwise alert & oriented. They immediately get me in the back of the ambulance, on the monitors, and realize I am in full blown vfib - just a quivering heart, not pumping, and actually torsades as it turned out. My medic turned white as a ghost and it took him a moment to realize the logistics of my LVAD pushing the blood through the quivering heart and keeping me alive and alert and awake fully. I could see the gears turning in his head as he figured it out, and I was awake so i kind of walked him through it. We did the hour long ride to my LVAD hospital and he was on pins and needles the entire time - he kept saying how amazing this technology was and that it's so out of the box for someone to be awake and talking and laughing while in full vfib in the back of his rig.

Resolution: Once at the LVAD hospital, i was cardioverted with 360 joules (WITH NO SEDATION!!! as they said there wasn't time(we disagree obviously lol)) and it put me back into rythm.

Question: Would you or your protocols allow for immediate cardioversion in the back of the ambulance instead of risking the 60 minute ride to the LVAD Center. Have you ever experienced a vfib alert and oriented - would it freak you out too? also if you have any LVAD questions, I'm a great resource, ask away! I've had mine for 16 months now (HeartMate II)

 

[Tigger]

I'd be curious to see how many places even have LVAD protocol. We learned about them, but in this situation I'd do everything in my power to call medical control and see how they want to proceed.

 

[JasonLVAD]

I'd be curious to see how many places even have LVAD protocol. We learned about them, but in this situation I'd do everything in my power to call medical control and see how they want to proceed.

Even though my local medics 'know' about the LVAD when I have to be transported they're usually super hands off approach, just pick me up and run an hour to the LVAD Center or to the Chopper (they're on pre-alert/notice when I call - strokes/TIAs are a very common side effect of the LVAD). I actually have my own Doppler BP Machine in my emergency bag because the ambulance has no way to get a BP on me and they don't carry dopplers on their ambulances, so I bring mine with so they can use(usually im the one using it as they're not that well versed on it). I'm assuming that eventually we'll be more commonplace but until then it's almost like the wild west out here it seems in LVAD land

 

[DesertMedic66]

We have an LVAD protocol. We treat all underlying heart rhythms normally per ACLS. So in our system if you were in V-Fib we would start with a 200J defib and then work our way up to 360J. Hopefully with Versed being given.

 

[EMDispatch]

In our area the protocol is pretty simple. A direct helicopter flight to the facility that placed the LVAD or cares for you. It's an automatically triggered response on dispatch for HEMS, also preferably from that hospital, usually med star for us.
The only problem we have is that sometimes SYSCOM has trouble understanding why want a non-state owned HEMS.

 

[Bullets]

I also have an LVAD patient in my primary. If you were my patient we would have treated the underlying rhythem normally, so torsades probably would have gotten mag sulfate or we would have cardioverted the you in the truck, or probably on scene. Sedation would have also been administered prior

 

[Kevinf]

Last week I had a patient transport with an LVAD, for a condition unrelated to the device. Her family was well versed on the device and provided a phone number to call were there to be issues with the LVAD, which we appreciated. That's only the second time in four years I've seen a patient with one.

 

[JasonLVAD]

curious, if I may ask - for those of you with LVAD Protocols, do you carry a doppler onboard for assessing BPs in LVAD Patients? I bring mine with as our system just won't budget them as they're rarely needed. (Me and most now have a non palpable pulse since the new VADs are centrifugal and don't create a pulse we're continuous flow).

Are there things you are still curious about with the LVAD that maybe your protocols don't cover, or you're just wondering about?

 

[DesertMedic66]

No we do not carry doppler on our rigs.

 

[RocketMedic]

We do have a Doppler, but I honestly go off of skin signs more than anything. LVAD doesn't scare me, but I also rely heavily on the LVAD specialist line for details.

 

[NUEMT]

No doppler on our rigs. We do have a protocol. I gave a presentation to a group of medics last month and was surprised at the differences in opinion between the reps at Heartmate, the local LVAD center, and the EMS doc. Small things, but most did not know we did not carry doppler, EMS doc did not know that the manufacturers put together an online certification class just for EMS. Stuff like that. We are taught to always look for the "bags" and places to check for color tags or phone numbers if pt is out.

Interestingly there was differences in whether or not to give compressions in arrest between two hospitals in the same system. Illinois. so many chiefs.

 

[JasonLVAD]

Interestingly there was differences in whether or not to give compressions in arrest between two hospitals in the same system. Illinois. so many chiefs.

THIS, SO much! There are differences in opinion on this matter between the docs even within the LVAD Floor at my hospital. ALL Rooms carry a sign now and it simply says 'no compressions unless authorized by attending on duty' - leaving it up to each one.

Personally - my opinion on it is that compressions should be used as a last resort, because DEAD is DEAD, and you can't make me any deader. I'll take the chance of a canula getting dislodged and having to be choppered to surgery asap rather than not taking a chance at all - and my directive says as much, though I seriously doubt that anyone would ever know that until after it was over, so I would be in the hands of whomever was on duty it seems and their opinion/protocol.

SOME of the manufacturers are now of the same opinion that you can't make the pt any more dead, use as a last resort - but many centers still have not adopted the position in their protocols.

 

[JIP00]

I also have an LVAD patient in my primary. If you were my patient we would have treated the underlying rhythem normally, so torsades probably would have gotten mag sulfate or we would have cardioverted the you in the truck, or probably on scene. Sedation would have also been administered prior

Carioversion of V-Fib?

 

[Bullets]

Carioversion of V-Fib?

Woops, defibrillation

 

[Handsome Robb]

Carioversion of V-Fib?

Technically Torsades is a multifocal ventricular tachycardia, not ventricular fibrillation. Not much of a difference though. But you're right, TdP should be defibrillated not cardioverted. Cardioversion would be ideal but it's difficult if not impossible for the monitor to correctly detect and time the R-wave.