On the relative wisdom of synchronized cardioversion without sedation

Rogue Medic and I don’t always agree, but we agree more than we disagree.

When we disagree, it’s usually because I think RM is being deliberately controversial. He is the Rogue Medic, after all.

Let’s look at how the Princeton University WordNet defines “rogue“.

Noun

(n) rogue, knave, rascal, rapscallion, scalawag, scallywag, varlet (a deceitful and unreliable scoundrel)

A deceitful and unreliable scoundrel.

Now that’s just funny and I don’t care who you are!

So now we come to Rogue Medic’s recent post Cardioversion – 2010 ACLS – Part III.

Before we go further (or is it farther?) it needs to be said that you shouldn’t start what you can’t finish. I’m filled with those awful presentiments that a commander must feel when he orders the first shots fired in an action that will certainly provoke an immediate and disproportionate response.

If you can’t tell, Tim Noonan and I are friends, although we’ve never met in “real life”. Somehow I missed him at EMS Today which was disappointing.

In this post, Rogue Medic amends his statement from Part II to read:

In what way is the electrocution cardioversion or defibrillation of an awake patient not a sentinel event that requires the medical director to justify the abuse of this patient to the state medical board?

The drama!

Here’s the problem I have with what Rogue Medic is saying (beyond the fact that it’s inflammatory).

A conscious but hemodynamically unstable patient in non-sinus tachycardia (where the signs and symptoms are thought to be caused by the tachycardia) is in a precarious position and it’s not given to us to know ahead of time whether or not synchonized cardioversion is going to work.

Let’s pause for a moment and acknowledge that there are degrees of stability/instability.

I’m talking about the peri-arrest patient.

If the patient cares that much about whether or not you are shocking them, I have questions about how “unstable” they really are.

Rogue Medic shares a comment from a reader who states, “I begged the worker not to shock me.”

If the patient begs you not to shock, you probably shouldn’t shock!

A far more egregious act than shocking without sedation is shocking against the expressed wishes of your patient, who I presume possessed decisional capacity!

Once you give a drug you can’t take it out. So if you push drugs that can negatively effect a patient’s hemodynamics and those hemodynamics are already compromised you are taking a risk.

What is the benefit?

Many things in EMS (and Fire) are risk/benefit.

I can conceive of circumstances within which I would shock a hemodynamically unstable patient who was not unconscious. I can conceive of circumstances within which that would be the best thing for the patient. I can conceive of circumstances within which that would be life-saving.

Like so many things in medicine, this is not a black and white issue.

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