Clear!!!

American ER Doc Gone Walkabout Episode 006

We cardioverted a few Tassies with A Fib and defibrillated (attempted) some cardiac arrests.  I double gloved, and used my gloved hands to assure good contact of the pads — in the case of the cardioversion, and briefly took over the CPR myself to continue CPR, with no interruption during the defibrillatory shock — so called “hands-on” CPR.

Interestingly, the Tassie crew didn’t freak out as much as my American compatriots on first being introduced to this option.

So, where did such insanity come from?

Many years ago, I worked at a community hospital where anesthetics were a tough crew to work with, and as a favor we’d sometimes do the procedural sedation for our cardiologist and electrophysiologist colleagues when they had a somewhat urgent outpatient cardioversion to do (or, they’d just send them to the ER and we’d do the whole shebang).(Another weird part of American health financing:  We had no way to charge for “just” doing the procedural sedation, so we’d do the procedural sedation and the cardiologist would handle all the other electrical stuff.  But, at the climax, we’d “push the button” on the defibrillator.  The cardiologist would charge some other acceptable charge, and we’d charge for the cardioversion itself.  Technically correct, but…..  weird.  Gaming the payment system is part of every day in the US.)

Anyway, one fine day, I did this with an electrophysiologist, who pulled on a second pair of standard exam gloves, and held some pressure on the stick-on defibrillator pads to assure good contact.  At the time, many cardiologists would hold pressure, but using the disconnected old-style paddles.  The evidence doesn’t support the necessity to do this, but it seems like a good idea — especially on hairy chests.  The electrophysiologist had been doing that for years — but using a gloved hand rather than a paddle, and had once gotten a little shock through a hole in a glove, so had taken to the double gloving technique.

I took up doing the same for routine cardioversion.  Shortly thereafter, when the evidence became more clear that even very brief interruptions in CPR were detrimental to coronary perfusion and survival, I took up — rather too casually to be a good idea — continuing CPR while defibrillating.   I’d change out with whoever was physically doing CPR (the old “change on 3 next time”), continue doing the CPR myself while the nurses pushed the button, and then change back out.  Kinda freaked out a few folks, and I did get written up on occasion for doing dangerous stuff.  One has no perception of electricity at the time of the defibrillators shock — though the patient muscular contraction gives a little kick under the hands doing CPR.

Later, a formal study appeared in Circulation (Lloyd et al, 2008) supporting the safety of maintaining hands-on during defibrillation. On the other hand, a follow-on letter by Sullivan (2008) pointed out the inadequacies of the study from an engineering point of view — especially the potential for breakdown of the glove material caused by the electrical exposure.  Finally, one recent review found only 29 documented injuries during defibrillation — all of a minor nature — tingling or minor burns (Hoke et al, 2009).  Admittedly, I suspect we’ve all heard the stories of a mate of a mate of a mate (in the US, if I said that, I’d get investigated for bigamy) who accidentally fibrillated himself, and had to be defibrillated in order to continue the resuscitation attempt. I’ve never actually met the guy.

Having been doing hands-on defibrillation in a casual, though presumably reasonable way, for quite a long time, I’d make a guess that I’ve personally been “hands-on” during the shock somewhere north of 100 times including both CPR and cardioversion. Thus far, no injuries or fatalities among myself or others.

From personal communications, I know that a few other ER Docs have been doing this. A few of our residents and paramedics are doing it. When supervising, I do not allow medical students, nurses, or interns do it — not because I expect them to die, but because of the perception of danger. The residents can choose to do so or not. Thus far, no issues have arisen — except for administrative repercussions in the early days.

A couple caveats:

• Double glove is not evidence based, but seems like a good idea.
• Changing to new gloves, if a second defibrillation will be done, seems reasonable based on the Sullivan letter concerning degradation of the glove when exposed to high voltage.
• I try not to lean against or otherwise touch the gurney during the shock, but the Lloyd study actually assumed such contact, and was OK.

Hands-on defib, plus using end-tidal CO2 monitoring to identify return of spontaneous circulation, means that you’ll never have to interrupt CPR, except for analysis of electrical rhythm.

And, of course, accidental ‘full on’ defibrillatory shocks are also survivable. During clean up after a relatively routine A Fib cardioversion, a machine test was run while the patient (waiting for his discharge paperwork) was still connected. Non-synchronized. He got a good buzz out of it, and thought — rather amazingly — that it was kinda funny: he was a physics teacher who shocked himself intentionally yearly during the Van de Graff generator demonstration, and thought that was worse than the inadvertent awake cardioversion. His wife, at the bedside at the time, thought it was even funnier, and perhaps well deserved. I still have occasional nightmares about that one.

Hands-on defib has generated some interest in the States, though is certainly not standard of care, and still seems to worry quite a few because of safety issues. But, it does have potential for benefit. And, has been introduced into the lower right corner of Australia. Wonder if it will spread?

Next time: All I need to do is write a final diagnosis, right?

References

• Hoke RS, Heinroth K, Trappe HJ, Werdan K. Is external defibrillation an electric threat for bystanders? Resuscitation. 2009 Apr;80(4):395-401. Epub 2009 Feb 10. Review. PMID: 19211180.
• Lloyd MS, Heeke B, Walter PF, Langberg JJ. Hands-on defibrillation: an analysis of electrical current flow through rescuers in direct contact with patients during biphasic external defibrillation. Circulation. 2008 May 13;117(19):2510-4. Epub 2008 May 5. PMID: 18458166.
• Sullivan JL. Letter by Sullivan regarding article, “Hands-on defibrillation: an analysis of electrical current flow through rescuers in direct contact with patients during biphasic external defibrillation”. Circulation. 2008 Dec 2;118(23):e712; author reply e713. PMID: 19047587.