EMS emergencies can develop in the blink of an eye and so subtly that an untrained layperson may not ever recognize the gravity of the emergency until it’s too late. Fortunately for one man, a very observant and well educated paramedic just happened to be in the right place at the right time to avert, what would have most probably been certain death.
The patient is an 81-year-old male and lives alone. His caregiver support network does not include family or close friends to help with his device maintenance, although he was fully screened and demonstrated he was able to manage the technical home care and maintenance of the left ventricular assist device (LVAD.)
He was excited that the LVAD had finally given him a certain amount of freedom, strength and the willpower to extend his range away from home. His previous history of congestive heart failure had been limiting his travels as well as his love of playing the clarinet. He had planned the day at a local park where he had played his clarinet at a musical social that he had missed for quite a few years. He loaded his shoulder bag with the proper equipment and batteries to sustain the LVAD for the required time away from his home unit. He traveled a number of miles and arrived at his destination.
The LVAD uses a series of different colored lights to indicate the charge status of the batteries. With each color indicated, the patient can understand how much time he has until the battery becomes completely discharged and the LVAD will cease functioning. His battery indicated he was in need of a change (yellow), so he changed the discharged battery with a spare from his shoulder bag.
However, he soon discovered he had inadvertently brought old discharged batteries instead of new charged ones. He also realized he had only about 30 minutes of battery life left, and he’s 40 minutes from home. He also knows that the only medical facility in the area that can help him is 10 minutes away.
A Level 1 Trauma facility, a large hospital, and a healthcare campus are on the way; however, none of these facilities is equipped to provide him with the batteries he needs to charge the LVAD. Feeling anxious, he decides to stop at the first hospital. At the emergency department (ED) triage room, he desperately tries to explain his dilemma to the triage nurse. At this moment, his battery indicator changes colors, begins to alarm, and he realizes he has only 15 minutes before the LVAD will cease to function.
Benefits of the LVAD
The LVAD is life sustaining. A small pump is surgically implanted into the patient’s thorax, with an intake grafted into the left ventrical and output grafted into the aorta. It is powered by a central power unit at home or can be converted to a battery pack for travel. It is primarily used to assist the work of the left ventrical with systemic circulation, often in patients waiting for an opportunity for cardio-transplant surgical procedures. Once it ceases to function, the patient will rapidly decompensate and arrest. On each intermittent beep of his LVAD battery pack, the man knows he’s only minutes from doom. He continues to try to explain his situation to the triage nurse. A paramedic who happened to be passing by after delivering a trauma patient to the trauma suite, overhears the conversation. The paramedic had, as recently as two weeks earlier, received detailed training specific to LVAD patients as part of the requirements of the medical institution in the area.
The paramedic quickly introduced himself to the patient, and almost immediately understood the dilemma. The paramedic was able to persuade the attending physician to assess the patient and obtain a quick release of care and permission to transport. The patient was then loaded to the ambulance. He then began a hasty transport to the nearby facility, where the device was originally implanted and fresh batteries would be available.
In the San Diego City 9-1-1 EMS system, paramedics are equipped with a cardiac monitor that employs voice recording technology. The patient was placed on the cardiac monitor.
During transport, the battery light indicator changed from yellow to red, and the alarm changed, indicating there were only five minutes left. The patient initiated a discussion with the paramedic about how to properly perform cardiac compressions should the battery fail. Both the patient and the paramedic had been trained to recognize the need to alter the area of the chest where hand placement is required to perform cardiac compressions.
The altered hand placement is necessary to avoid or minimize damage to surgical anastamosis and internal components of the LVAD during cardiac compressions and maximize survivability of patients implanted with the LVAD.
The paramedic called ahead, and the LVAD emergency response team met the incoming unit in the ED ambulance parking area with a fresh battery pack. The battery was quickly changed, and the patient’s certain death was averted. The patient was assessed by the LVAD emergency response team, and was subsequently released.
As medical and technological advances increase, it becomes more and more likely to the chances of encountering the products of these advances build, as well. The medical community, as a whole, holds certain requirements to ensure first responders are properly informed and trained to meet the challenges this new technology may present in the community. Although the patient in this case had demonstrated an ability to maintain his LVAD regimen, his particular circumstances presented him with stressors he was unable to manage. As with most, when this type of situation occurs, first responders are often called on for help.
Thanks to a very involved medical director, who has the ear of the local medical community, the 9-1-1 ALS paramedics—both transport and first responder paramedics—in this system, were ready to deliver the appropriate care and management of an LVAD patient. The paramedic’s situational awareness and ability to use his expertise saved this patient’s life. The paramedic was later awarded with a lifesaving award. This is awarded when a paramedic’s actions demonstrate independent thinking with selfless regard for the health and safety of another determined to be a lifesaving event.