4 ms·

Question. It seems like V-tach is not something that overwhelms you in an instant--the first time, Endicott was able to stand for at least several minutes, and

Question. It seems like V-tach is not something that overwhelms you in an instant--the first time, Endicott was able to stand for at least several minutes, and it took him several hours after that to reach medical attention. He would have died without it, but there was some time. So why does the ICD strike without warning? Falling over unexpectedly is pretty dangerous even if you're just standing or walking, and can easily be crippling or deadly if you're older, as I imagine many patients are. Wouldn't it be a lot safer if it gave you some kind of warning so you can stop and sit down before the big jolt--a mechanical nudge or tiny tickle of current to some heart-adjacent tissue?

Herodotus38 10y ago
There is a slight warning, about 5 seconds where you can hear a "whining" sound as the device charges up. It's not very loud though I've heard it being in the same room as patients. I could see it being missed if you were doing something loud/active. The reason there isn't more warning is that you want to shock VT before it degenerates into ventricular fibrillation, which is much more serious. Your question about falls is a good one and it comes down to how much of a trade off you strike with risks of VT/VF vs risks of the shock.
- zkms 10y ago
  > you can hear a "whining" sound as the device charges up. Ahhh, the good old DC-DC converter whine: https://en.wikipedia.org/wiki/Coil_noise https://en.wikipedia.org/wiki/Coil_noise
- Cthulhu_ 10y ago
  Couldn't they make it so it starts beeping alarmingly before triggering? Giving you a few seconds to e.g. pull over, sit down, assume a fetal position, etc. Or would that cause sudden stress and make it worse?
paddedsmokes 10y ago
Intensivist here. We consider sustained V-tach (defined as 30 seconds duration or greater) to be an emergency (which I define to mean that if we don't do something immediately, really bad stuff could happen within seconds/minutes). Some with V-tach get goofy, some get palpitations, some get woozy/faint, some have chest pain, some have visual blurring, some get shortness of breath, some die very quickly. So while all V-tach is an "emergency", there's quite a range in its presentation. Some get no symptoms at all and can just cook along like that all day. This doesn't happen often, but I do see it from time to time. Usually my first thought is "it's not V-tach," but we usually have a good telemetry record of it. Of course, telemetry is supposed to pick that up and sound an alarm, but it isn't perfect and there are rhythm alarms going off all the time. It's a tricky situation sometimes. The ACLS guidelines are pretty good. They basically say: if someone with V-tach is "unstable" or having a lot of symptoms then shock them right away. That's generally the right approach, but it's a mean thing to do to somebody who's wide awake, but has some shortness of breath and a dip in their blood pressure. So depending on where the patient is (surgical unit, regular hospital bed, etc), some tricky logistical issues can arise (do you sedate them on the spot, which most doctors are uncomfortable doing; do you transfer them to another unit first,; do you call a code blue; do you call a rapid response team). It's why we can't put every patient into a perfect algorithm. You have to be a thoughtful human being to access the need for immediate intervention sometimes.
- chrisbennet 10y ago
  I had to look up "intensivist". To save others the trouble: "An intensivist, also known as a critical care physician, is a medical doctor with special training and experience in treating critically ill patients. An intensivist completes a fellowship in critical care medicine after finishing a residency in internal medicine, pulmonary medicine, anesthesia or surgery."

Herodotus38 10y ago

There is a slight warning, about 5 seconds where you can hear a "whining" sound as the device charges up. It's not very loud though I've heard it being in the same room as patients. I could see it being missed if you were doing something loud/active. The reason there isn't more warning is that you want to shock VT before it degenerates into ventricular fibrillation, which is much more serious. Your question about falls is a good one and it comes down to how much of a trade off you strike with risks of VT/VF vs risks of the shock.

zkms 10y ago
> you can hear a "whining" sound as the device charges up. Ahhh, the good old DC-DC converter whine: https://en.wikipedia.org/wiki/Coil_noise https://en.wikipedia.org/wiki/Coil_noise
Cthulhu_ 10y ago
Couldn't they make it so it starts beeping alarmingly before triggering? Giving you a few seconds to e.g. pull over, sit down, assume a fetal position, etc. Or would that cause sudden stress and make it worse?

paddedsmokes 10y ago

Intensivist here. We consider sustained V-tach (defined as 30 seconds duration or greater) to be an emergency (which I define to mean that if we don't do something immediately, really bad stuff could happen within seconds/minutes). Some with V-tach get goofy, some get palpitations, some get woozy/faint, some have chest pain, some have visual blurring, some get shortness of breath, some die very quickly. So while all V-tach is an "emergency", there's quite a range in its presentation. Some get no symptoms at all and can just cook along like that all day. This doesn't happen often, but I do see it from time to time. Usually my first thought is "it's not V-tach," but we usually have a good telemetry record of it. Of course, telemetry is supposed to pick that up and sound an alarm, but it isn't perfect and there are rhythm alarms going off all the time. It's a tricky situation sometimes. The ACLS guidelines are pretty good. They basically say: if someone with V-tach is "unstable" or having a lot of symptoms then shock them right away. That's generally the right approach, but it's a mean thing to do to somebody who's wide awake, but has some shortness of breath and a dip in their blood pressure. So depending on where the patient is (surgical unit, regular hospital bed, etc), some tricky logistical issues can arise (do you sedate them on the spot, which most doctors are uncomfortable doing; do you transfer them to another unit first,; do you call a code blue; do you call a rapid response team). It's why we can't put every patient into a perfect algorithm. You have to be a thoughtful human being to access the need for immediate intervention sometimes.

chrisbennet 10y ago
I had to look up "intensivist". To save others the trouble: "An intensivist, also known as a critical care physician, is a medical doctor with special training and experience in treating critically ill patients. An intensivist completes a fellowship in critical care medicine after finishing a residency in internal medicine, pulmonary medicine, anesthesia or surgery."