A Pacer Puzzler

Sometimes we see things on the monitor that while they look like things aren’t working correctly they actually are doing what they should.  Case in point from awhile ago.

The tech calls me and says, “Your patient in 75, they keep alarming for missing beats and pacer not pacing.  You going to call the doc?” as he hands me the following strips:


I looked down, double checked and said, “Nope.  It’s working perfectly.”

In both strips you can see spots where it appears that the pacemaker is failing to pace, after 1st and 7th QRS complexes in strip #1 and after the 4th QRS in strip #2.  In each case you have a spike then a p-wave and nothing until a odd appearing PVC-like beat.  The tech pointed these out and I further reiterated that, “Yes, it’s working just fine.

But I had a cheat, I had read the interrogation report from when the patient had been admitted and knew what mode the device was set for, the tech hadn’t.  This is a pretty good example of a mode known as MVP, or managed ventricular pacing.  Basically this is a mode designed to reduce ventricular dysynchrony by allowing the heart’s natural conduction system to function while providing back-up in case of failure.  Excessive right ventricular pacing has been shown in studies to lead to congestive heart failure, increased incidence of atrial fibrillation, increased left atrial diameter and changes to hemodynamics and ventricular remodeling all of which can have detrimental effect on the patient and their quality of life.

In MVP pacing the pacemaker operates in AAI/R mode, as shown in both strips, with a set duration of time to allow for a ventricular beat.  If no beat arrives in the programmed time span the device will initiate a ventricular beat then return to the AAI/R.  If a beats are frequently dropped, usually 2 out of 4 complexes, the device shifts to DDD/R mode.  It will continue this way for a minute then attempt to return to AAI/R to detect AV conduction.  If beats are still dropped it will remain in DDD/R mode for increasing amounts of time, periodically checking for the return of AV conduction, at which point it will switch back to AAI/R mode.

Let’s break each strip down.

Strip #1:  starts with normal AV conduction in AAI/R mode and almost immediately, a beat is dropped and the device iniates the rescue beat.  It continues for 5 more QRS complexes until there is another dropped beat.  There is normal AV conduction for one more QRS then another dropped beat after which the device switches to DDD/R mode (it was too long to scan).

Strip #2: a little simpler.  4 normal QRS complexes then a dropped beat followed by a PVC, then another dropped beat.  Here you can see the device then switch into DDD/R mode due to dropping 2 out of 4 beats.

So, yes, the pacer was working exactly as it was supposed to.  I explained this to the tech and went on my merry way.  The next time he sees this he’ll stop to ask if they are set to MVP from now on.  Good learning moments come when you least expect them!


Sweeney, M., Ellenbogen, K., Casavant, D., Betzold, R., Sheldon, T., Tang, F., & … Lingle, J. (2005). Multicenter, prospective, randomized safety and efficacy study of a new atrial-based managed ventricular pacing mode (MVP) in dual chamber ICDs. Journal of Cardiovascular Electrophysiology, 16(8), 811-817. Retrieved from EBSCOhost.

 Gillis, A., Purerfellner, H., Israel, C., Sunthorn, H., Kacet, S., Anelli-Monti, M., & … Boriani, G. (2006). Reducing unnecessary right ventricular pacing with the managed ventricular pacing mode in patients with sinus node disease and AV block. Pacing & Clinical Electrophysiology, 29(7), 697-705. Retrieved from EBSCOhost.






The Great and Mighty EMR

TeleMedicine icon
Image by nffcnnr via Flickr

For the last 2 years I’ve been involved with helping (not quite so)Mammoth Health Systems build and roll-out a new Electronic Medical Record.  It has been a time fraught with elation, despair, doubt and a good dose of “meh” followed by “WTF?”  When the cards are down, the reality is that our new Skynet is better than our old WOPR, but they’re both equally broken.  Why?  They are built to be everything for everyone.  But Skynet actually works and once you get used to it, truly is the wave of the future.

So our site rolled out a little over a week ago.  It wasn’t as big of a cluster-fuck as I was expecting.  The gods of medicine smiled kindly on us, no codes or RRTs that first 2 days/night, excellent staffing and relatively low census.  Then the storm clouds rolled in.  The house census went up and there wasn’t enough resource pool nurses to go around so places started going “short”.  Truth is, they weren’t really short, in fact they were at staffing levels that we normal run at, but for learning to use a new system with all of its foibles, we were short.  This was compounded by piss-poor planing by other shifts and other floors.  Our manager told the schedulers to post for extra shifts all three weeks of implementation.  The night shift scheduler did that, opened 3 extra shift slots a night for the duration and we’ve had really good results and have been staffed very well.  There were 11 of us the other night for 21 patients (although 2 were orientees and one was a “superuser”).  Day shift not so much.  They didn’t have slots for every day, and only 1-2 each day.  They’ve been getting mauled when it comes to staffing because most of the other units did the same thing so every unit in the hospital is scrambling to split up the few nurses in the float pool – day shifters are not happy – especially since many of them thought our manager had said that the ratio was going to the 2:1 (yes, 2:1 on a tele floor) for the roll out.  She never did.

But as for the system, it’s pretty great.  It’s a giant technical leap from our previous archaic steam-powered claptrap.  But we loved that claptrap because we knew it.  The new one is sleek and can present a dizzying array of information and once you get used to it, pretty easy to use.  But I’ve been spending my days a superuser telling people where to click to find what they need.  Muttering under my breath saying, “It’s right there.  Yes, right there under your fucking cursor. Click the fucking link.  Yes, that one!”  And that’s from the fatigue of being asked the same question repeatedly over and over again.

The funny thing is that I had never used the new on a real live patient until early last week.  As a superuser I’m supposed to be able to figure it all out from a over-the-shoulder perspective, but when you’re doing it at the bedside for your patient it is something different.  It’s little things like having to bar code scan the patient and the medication when passing meds, muddling through all of the extra rows of the flow sheets to find where I need to chart my findings (some people cannot leave and empty cell blank, they didn’t get that memo) and ensuring I get everything charted I need to in a shift.  And guess what?  I did. It was pretty simple.  Wasn’t as fast as normal, but that will come with time.

The biggest issue is that people got themselves whipped to a frothy fury over that changes.  Nurses were telling me they couldn’t sleep because of the roll-out, they were anxious and plain scared.  It didn’t help that manglement put a count-down clock in the lobby and have been über-involved in the hour to hour running of things.  IT’s been kind of a mess.  Sometimes to much support is a bad thing.  But there is a success or two.  One, in particular makes me proud.  She’s been a nurse with use since I was in elementray shcool and is well known for her clipboard that is loaded with papaers and covered in scribbled notes.  You know they type, they rely on that like a drowning man does his life jacket.  She publicly announced at the nursing station the other night that she was leaving her clipboard behind.  We applauded as we all knew how big of a jump it was.  And leave it she did.  The only time she pulled it out was when she had to bring in lots of things to the patient. She did not use it the rest of the week.  And that my friends, is progress.

Some Random Thoughts

Some deep thoughts, random reading and questions…

Where do you draw the line between a pause and aystole?  I figure if the heart starts back up again, it’s a pause.  Looks bad though to have 5, 7, 10, 15 second pauses.  I’m going to copyright the phrase “gravitational precordial thump©” based on the following:  patient is up in the bathroom, on the way back to bed, they have a 7 second pause and fall.  On the rhythm strip you see the moment they hit the floor and it causes them to return to normal sinus rhythm, thereby self-correcting the issue.  Guess a pacemaker can do that with out the falling part.

Some typical alcoholic beverages.

Booze via Wikipedia

How much booze do you have to drink to get your EtOH level >400?

In a related bit,  according to Wikipedia, the legal limit to operate a sea vessel in Norway is 0.15%.

“You gotta let me go outside to go see all the ladies.” and “See those bottles of Scotch on the wall?  Bring me one…” and “Get me out of this box! (bed).” quotes from drunks last week.  That would be great site, “Drunks from Last Night”.

How is it that most hospital-related educational events are always in the morning?  I know no one cares about night shift, but it really sucks to work 3 nights in a row, have 1 night off and have to be at a training event at 7am.  Really, do people want to come in/get up early on their days off?

Is it wrong to have a beer at lunch when you’re in class for work?

Is it so hard to wait the 10 seconds it take for the occupants of an elevator to get off before pushing your way in?  It isn’t going anywhere until the doors close any way.  Same goes for public transit.

If you are going to try and commit suicide by giving yourself insulin, why use Lantus (very-long acting)?

I’m thinking that if you made $17 billion a year, it couldn’t hurt to pay a little bit of taxes on it, or at least not getting a refund from the government.

Could you imagine if this was your commute to work?  Watch out for the dog at 00:019!

Fun with Electronic Charting, part 2

Found some more bloopers that made me laugh, hope they do you as well.  Here is the first post on the subject.

First up…

Patient tolerating poi well.

I don’t know, that stuff looks petty dodgy, they must be feeling better if they can tolerate it!

Admission diagnosis:  sincopy.

While they probably meant syncope (fancypants for “fainting”), they might be having bigger issues depending on whom’s sins they are copying.

In a progress note:

D/C Meth!

No explanation needed here.  Wish they would have written it as an order though.

My personal favorite of late:

Bladder non-distended, uterus not identified…  …right pelvic cyst, question ovarian.

Patient was a male.  I hope you weren’t able to find a uterus and I can guarantee the cyst is not ovarian.

That’s all for this round.  Enjoy!


This and That

I’m starting to get my mojo back.  It’s slow, but the ability to write more than 140 characters (damn you Twitter!) is slowly coming back.  Lots of stuff churning, fermenting and running around in my brain.  Just not completely ready yet.


This whole Facebook placenta explusion drama deserves a comment.

Was it a HIPAA violation?  No.  Did it in any way endanger a patient?  No.  Was it in poor taste?  Yeah, it probably was.  I believe that the school in question over-reacted and by doing so created the social media furor that has ensued.  Give a small issue large exposure and the chances of it going away quietly is pretty slim (see Sarah  Palin…).

How this reflects poorly on the nursing profession is beyond me.  All I saw in the picture – the grainy B&W picture, was a young female in scrubs showcasing an unidentifiable thing.  If no one had mentioned it was a placenta, I never would have guessed.  Did you see the excitement in her eyes?  Could you feel the zest for learning that exuded from the picture?  It was almost palpable.  Sad that the school saw this a gross violation of, well, everything and decided the 4 students involved had to pay.  As the old saying goes, “Heads will roll!”

All we have ended up teaching these students is that nursing is reactive, vindictive, punitive and slow to change.  It’s not like they were using the placenta as a marionette, or some twisted nursing school version of “Weekend at Bernie’s”.  It was a mistake on the part of the students, but not one as grievous as the administrators would lead you to believe.

Here’s what they should have done…  Quietly ask the student to remove the post, explaining that it reflects poorly on the school – with a reason why it does so.  Give a small reprimand, make the students take a media ethics course or what-not and take the time as administrators to formulate a comprehensive social media policy that is easy to understand and adhere to.  Done, no muss, no fuss.  A simple explanation of why and a punishment that fits the “crime” would have caused far less of a brouhaha than the route they took.

But that’s just my take on it.

Saturday Linky-Linky

I’ve been holed up on the couch or 2 days dealing with a rather nasty GI issue and all of my ideas are literally in the crapper.  In the fashion of bloggers everywhere, here’s a link post.  Enjoy!

Happy Halloween!  No really, enjoy the condoms given out as trick-or-treat items by one local family.  Of course you have the debate between the progressive and pragmatic givers (both of whom are doctors) in providing prophylactics to high-school age revelers – ’cause giving a teen condoms will make them sexually active – and the prudish small town head-in-sand folks who believe that they should be the ones to teach sex to their children (but never do…).

Got MRSANDM-1 E.coli?  Got some other nasty resistant bacteria that nothing in our arsenal will cure?  Good news, the federal government is looking at subsidies tot he pharmaceutical industry to promote research in to new antibiotics.  Of course, this isn’t going to happen quickly, so by the time we have full-blown VRSA and NDM-1 MRSA we might have something to throw at it.  Maybe.  And considering the shape and mentality of the government now, highly unlikely.

Can we make up our minds?  One moment it’s good for you, the next it increases your stroke risk.  And health care providers drink it by the gallon:  coffee.  New study shows increased risk of stroke for infrequent drinkers of the stuff. So I guess if you pound cups daily you’re OK?    h/t to Sean at My Strong Medicine for this one.

Some days life gets in the way of blogging.  Some weeks that goes on for awhile as the rest of life gets in the way.  It’s not that I’ve lost the passion for writing, life just gets in the way.  It’s all about the life cycle of a blog. I’m not on life support, just trucking (slowly) along.

Finally I’ve figured out where my next vacation will be:  my own private island (for a week). Now that I have the where, I need to the figure the when and how parts.  That’s the hard part.
Enjoy the weekend!  Off to make pancakes!

For the Ears and the Squishy Organ Between Them

I like podcasts, but it seems like I don’t have enough time to listen to them.  Call it an inability to plan well, structure my time well, or more that I just like to listen to music when I exercise/commute.  When I do sit down to catch up, I flagellate myself to “keep up” but that doesn’t last for long.  The great thing about podcasts is the ability to learn whilst doing nothing.  Yes kids, learn.  Y’know, ingest, digest and evaluate new information to improve one’s knowledge thereby increasing our abilities.  Now there are podcasts not of that sort and are pure entertainment, which are just as good, but I like the ones that impart new information.

Here’s a short list of what I’ve been trying listening to.

Mark Crislip, “because the world needs more Mark Crislip”.  He’s an ID doc within my hospital system and is downright hysterical, but informative.  He has 2 that I really recommend in his media empire.

First, Gobbet o’ Pus.  Brief snippets about infectious diseases with a certain twisted sense of humor.

Second, Quackcast.  Yup, a dissection of alternative medicine.  He has no qualms about calling people dumbasses, especially here.

He’s my favorite right now.

Here are some other worthy contenders:

ICU Rounds.  Dr. Jeffery Guy’s series about ICU patients and what ails them.

Nursing Show Online.  by Jamie Davis the Podmedic. Nursing stuff, brief bites.

And I just found this one thanks to iTunes:  Freakonomics Radio.  Take the ideas from the book and make a podcast out of it.  Brilliant.

That’s all for now.  Happy listening!