# Versed + hypotension



## zzyzx (May 16, 2012)

I'd like to get some opinions on this: say you had a patient in VT with pulses who was 80 systolic but still fully alert and oriented, would you use Versed 1 - 2 mg prior to cardioversion? How much impact could that amount of Versed have on the BP, esp. considering a scenario where after you shock the patient he/she does not convert out of VT?


----------



## NomadicMedic (May 16, 2012)

zzyzx said:


> I'd like to get some opinions on this: say you had a patient in VT with pulses who was 80 systolic but still fully alert and oriented, would you use Versed 1 - 2 mg prior to cardioversion? How much impact could that amount of Versed have on the BP, esp. considering a scenario where after you shock the patient he/she does not convert out of VT?



Is Versed the only choice? Because I'd go to the Etomidate.


----------



## crazycajun (May 16, 2012)

n7lxi said:


> Is Versed the only choice? Because I'd go to the Etomidate.



Why etomidate? No analgesic effects and causes hypotension. Just curious.


----------



## crazycajun (May 16, 2012)

zzyzx said:


> I'd like to get some opinions on this: say you had a patient in VT with pulses who was 80 systolic but still fully alert and oriented, would you use Versed 1 - 2 mg prior to cardioversion? How much impact could that amount of Versed have on the BP, esp. considering a scenario where after you shock the patient he/she does not convert out of VT?



Versed or Valium. The only problem is it still will not help for pain much and the PT is still going to feel it. If it is my PT and they are not symptomatic (chest pn, nausea, etc) I wouldn't cardiovert unless absolutely necessary.


----------



## Frozennoodle (May 16, 2012)

crazycajun said:


> Versed or Valium. The only problem is it still will not help for pain much and the PT is still going to feel it. If it is my PT and they are not symptomatic (chest pn, nausea, etc) I wouldn't cardiovert unless absolutely necessary.



I saw a guy having a STEMI in my ER rotations with a bp of 54/30 fully A&O.  A&O isn't the only indicator of stability or hemodynamic stability.  If you have hemodynamically unstable V-Tach with a pulse it wont be with a pulse much longer unless you do something.


----------



## crazycajun (May 16, 2012)

Frozennoodle said:


> I saw a guy having a STEMI in my ER rotations with a bp of 54/30 fully A&O.  A&O isn't the only indicator of stability or hemodynamic stability.  If you have hemodynamically unstable V-Tach with a pulse it wont be with a pulse much longer unless you do something.



54/30 with a STEMI is unstable and requires immediate intervention. 80 systolic may be PT norm and if there are not symptomatic why cause the PT unnecessary pain? Or risk sending them into Asystole? I am not saying don't put on the combi-pads and be ready but hospitals have options with anti-disrhythmics as where we do not.


----------



## Hunter (May 16, 2012)

This is going to sound cruel but who cares, shock him and keel the guy alive, sure it'll hurt but he's gonna be alive right?


----------



## crazycajun (May 16, 2012)

Hunter said:


> This is going to sound cruel but who cares, shock him and keel the guy alive, sure it'll hurt but he's gonna be alive right?



Hunter you are missing the point. Not every PT needs electricity. You could very well cardiovert him and kill him at the same time. It happens all of the time. Sometimes it is out of your control but sometimes it could have been avoided.


----------



## NomadicMedic (May 16, 2012)

crazycajun said:


> Why etomidate? No analgesic effects and causes hypotension. Just curious.



Versed has no analgesic effect. And etomidate is more hemodynamicly neutral than versed. Once he's stable he gets some Fentanyl. 

http://m.emj.bmj.com/content/21/6/700.abstract


----------



## Handsome Robb (May 16, 2012)

crazycajun said:


> 54/30 with a STEMI is unstable and requires immediate intervention. 80 systolic may be PT norm and if there are not symptomatic why cause the PT unnecessary pain? Or risk sending them into Asystole? I am not saying don't put on the combi-pads and be ready but hospitals have options with anti-disrhythmics as where we do not.



I'd be more worried about hypotension secondary to hanging an amiodorone drip more than I'd be worried about it from versed. Depending on where I am and my transport time is going to decide what I'd do. 

What's their diastolic pressure? I want to know this person's MAP. 80 SBP is pretty low to be "normal" for a patient but weirder things have happened. 

"stable" VT is a crap term, no one stays stable in VT. The last guy I saw in VT dropped 90 points SBP in <10 minutes, but I'm pretty sure the amio I hung had something to do with it as well. 

With the pressure provided by the OP I'd be leaning towards cardioverting this guy sooner rather than defibrillating him later but my instructors have always stressed the point that we shouldn't be scared of electricity. I've seen more than a few patients get cardioverted in the hospital and had one man's AICD cardiovert him on my gurney as we were capturing a 12-lead. 

Never seen someone cardioverted from VT with pulses into asystole. Not saying it can't happen though. 



Hunter said:


> This is going to sound cruel but who cares, shock him and keel the guy alive, sure it'll hurt but he's gonna be alive right?



Retrograde amnestic effects from versed are a wonderful thing.


----------



## crazycajun (May 16, 2012)

n7lxi said:


> Versed has no analgesic effect. And etomidate is more hemodynamicly neutral than versed. Once he's stable he gets some Fentanyl.
> 
> http://m.emj.bmj.com/content/21/6/700.abstract



I can agree with that. i prefer the Valium in hypotensive PT's but you know as well as I nothing really helps as it still hurts like hell!!!


----------



## blindsideflank (May 16, 2012)

Ketamine would be my choice. 0.5 mg/kg
I wouldn't delay shocking him for this though but the whole amnesia thing is nice too, we can titrate fentanyl for procedural sedation in a hypotensive patient if we are careful. But you don't have time for this if you feel the need to shock. Don't think any of this will really help the pain though.

But I may not zap this guy


----------



## blindsideflank (May 16, 2012)

So if you decide he is stable then  amiodarone or if polymorphic would you give mag?
The mag question is for those of you saying he is stable at 80 mmhg. Doesn't seem too stable now


----------



## Handsome Robb (May 16, 2012)

blindsideflank said:


> So if you decide he is stable then  amiodarone or if polymorphic would you give mag?
> The mag question is for those of you saying he is stable at 80 mmhg. Doesn't seem too stable now



I've been on the "unstable" side of the table from the get go. 

If it's polymorphic I'm not screwing around with mag and I'm cardioverting him. I don't want that degenerating into VF.


----------



## usalsfyre (May 16, 2012)

Give the midazolam. Even if it causes a bit more hypotension your about to fix it right?


----------



## Handsome Robb (May 16, 2012)

usalsfyre said:


> Give the midazolam. Even if it causes a bit more hypotension your about to fix it right?



That's a very good point especially if you have a big line running WFO as you give it. 

Unfortunately I would be hung out to dry by QA/QI for giving someone with a SBP <90 mmHg midazolam.


----------



## mycrofft (May 17, 2012)

*would you use Versed 1 - 2 mg prior to cardioversion"*

No, it would probably make you too drowsy to complete the procedure.
:rofl:
(I couldn't resist, good answers and discussion above already).


----------



## Hunter (May 17, 2012)

crazycajun said:


> Hunter you are missing the point. Not every PT needs electricity. You could very well cardiovert him and kill him at the same time. It happens all of the time. Sometimes it is out of your control but sometimes it could have been avoided.



I know but that's not what the op asked, assuming he does need it, I'm not going to wait to save this guys life


----------



## fast65 (May 17, 2012)

NVRob said:


> That's a very good point especially if you have a big line running WFO as you give it.
> 
> Unfortunately I would be hung out to dry by QA/QI for giving someone with a SBP <90 mmHg midazolam.



Unfortunately this my problem as well. I hate to have such a thing factor into my decision making, but it's simply unavoidable.

That being said, I agree with usalsfyre. You're going to more than likely fix the current hypotension with the electricity, so why not make the procedure a little easier on them? Besides, a good fluid bolus should resolve any hypotension that the Versed caused, at least I believe so.


----------



## Veneficus (May 17, 2012)

*could I just ask?*

What is your endgame?

If you have a guy who is A&O and having a STEMI, doesn't he need some kind of reperfusion therapy?

So long as he was mentating, both his heart and his brain are receiving blood.

Look at the potential outcomes of treating  numbers.

A. You could cardiovert him and it would restore a normal rate/rhythm.
B. You could cardiovert him and kill all of the stunned cells reducing future cardiac output.
C. You could cardiovert him into asystole.
D. You could cardiovert him into a normal rate/rhythm which might last a few minutes, increase ischemia, and then watch him decompensate.
E. You could watch and if he starts to mentaly deteriorate take action then, and not have to worry about sedation/analgesia.

His BP might be that low and vtach his rhytm because he lost the intrinsic pacemakers from hypoxia.

Sometimes discretion is the better part of valor.


----------



## mycrofft (May 17, 2012)

Knowing "when not" is more valuable than just knowing "How".






trademark


----------



## Christopher (May 17, 2012)

Veneficus said:


> C. You could cardiovert him into asystole.



That's the most common post cardioversion rhythm too. Last lady we cardioverted for flutter had a nice 8-9 second run of asystole...not a fun feeling for all parties involved :wacko:


----------



## mycrofft (May 17, 2012)

I can just see the face of anyone in the compartment with the pt...


----------



## blindsideflank (May 17, 2012)

Well if a stemi and you can recognize it then for us it would be olmc to decide if tnk was appropriate. Unfortunately I don't really understand the basis for this. It'll be nice when we are testing for troponin and bnp on car (in a few months I think!)

Converting him may reduce ischemia though. Sure his heart is doing it's job right now but are you just allowing more ischemia when you have an available treatment. I guess this comes down to your observations since hove been on scene. Has he deteriorated at all, in any way. If so I shock.

Sorry if the thread has veered from the op but its all a good discussion


----------



## jwk (May 17, 2012)

I think a little versed is fine here.  If he converts to a better perfusing rhythm, hypotension isn't going to be an issue, and if he crashes, the versed hasn't hurt you.  Your object here is not to get rid of pain - it's to provide a short-term amnestic effect.  They don't have to be unconscious.  Good chance the next day that they won't remember it.

Etomidate is a garbage drug that is rapidly falling out of favor - I've stopped using it altogether.  It's a poor choice for cardioversion.  Assuming your patient converts, you'll still be able to talk with your patient and further assess them.  Not so with etomidate.


----------



## Smash (May 17, 2012)

Leaving aside Vene's point (which is a very good point) and going simply with the idea that the decision to cardiovert has been made, then yes, a little bit of midazolam is probably not going to do any harm and is the humane thing to do.

However, I have to agree with Vene about the need to sometimes sit on your hands and leave well enough alone.  Not an easy thing to do sometimes!


----------



## STXmedic (May 17, 2012)

jwk said:


> Etomidate is a garbage drug that is rapidly falling out of favor - I've stopped using it altogether.  It's a poor choice for cardioversion.  Assuming your patient converts, you'll still be able to talk with your patient and further assess them.  Not so with etomidate.



Jwk, what makes you say this? Not doubting you, merely curious. We're just now getting etomidate and would love to hear what cons you find with it.


----------



## mycrofft (May 17, 2012)

Think about what may be need to be given later when giving a drug which is not directly saving a life. Especially anything that will get an anesthesiologist mad at you.


----------



## DPM (May 17, 2012)

I'm still new to this... Would the versed still have the required effect if given after cardioverting? I.e. you light up the PT, then if the new rhythm is stable you give a little versed...?


----------



## usalsfyre (May 17, 2012)

DPM said:


> I'm still new to this... Would the versed still have the required effect if given after cardioverting? I.e. you light up the PT, then if the new rhythm is stable you give a little versed...?


Not nearly as well or reliably. What they need post cardioversion is analgesia. Why chance it?


----------



## STXmedic (May 17, 2012)

There's supposedly a small amount of retrograde amnesia with Versed. However, I've been bedside with several family members who have received Versed. So far, they have all had full recollection up until about 30 seconds to a minute POST administration. So I have my doubts.


----------



## NomadicMedic (May 17, 2012)

jwk said:


> Etomidate is a garbage drug that is rapidly falling out of favor...




I was lead to believe that long term (>6 hours) adrenal insufficiency, the number one side effect of etomidate, was only a factor in patients receiving long term (>48 hours) infusions of the drug, such as continued sedation in the ICU, a practice which has stopped in most places. Patients receiving a single dose of 0.3mg/kg had normal adrenal function 12 hours after the drug was administered. 

Are there new studies that show etomidate is a “garbage drug” that we should be avoiding? In systems that don’t use Ketamine or propofol, what is your suggestion for induction with RSI or rapid sedation for cardioversion?


----------



## CANMAN (May 17, 2012)

I haven't heard of Etomidate falling out of favor, I think people just need to utilize it appropriately and consider other drugs when contraindicated. As far as cardioversion, if I felt so moved to give the pt. some juice then I would go Versed > Etomidate and hang a 500cc NS bolus while at it. 

Induction agents at my service include:
Etomidate
Versed
Thiopental
Ketamine


----------



## blindsideflank (May 17, 2012)

I'm newer and still dumb but how can you compare versed and etomidate? We are talking about analgesia here no? Amnesia, I don't know the comparison.
Am I the only one that like ketamine here?


----------



## STXmedic (May 17, 2012)

blindsideflank said:


> I'm newer and still dumb but how can you compare versed and etomidate? We are talking about analgesia here no? Amnesia, I don't know the comparison.
> Am I the only one that like ketamine here?



Not at all. Many love ketamine. Good luck getting on a service that carries it, though.


----------



## ZootownMedic (May 17, 2012)

So some people  have said that if they were in V-tach with pulses and stable then they wouldn't cardiovert...... What are your transport times? I am just curious because from everything I have been taught a patient is not going to be able to maintain that rhythm for very long. Are you saying that you just wouldn't cardiovert or are you saying that you wouldn't perform any intervention chemical or electrical.....

I would think that if they are stable then lidocaine or amiodarone would be the way to go but the second I thought they weren't it would be cardioversion time. Correct me if I am wrong or maybe I just misunderstood....


----------



## usalsfyre (May 17, 2012)

I'm more ok with electricity than cardioversion.

Yes we're taught "lethal rhythm". I've also seen an elderly male sustain it for 6+ hours with no outwardly apparent ill effects other than "I'm a little light headed".


----------



## NomadicMedic (May 17, 2012)

blindsideflank said:


> I'm newer and still dumb but how can you compare versed and etomidate? We are talking about analgesia here no? Amnesia, I don't know the comparison.
> Am I the only one that like ketamine here?



We're not talking about analgesia at all. We're talking about sedation prior to cardioversion.


----------



## Hunter (May 17, 2012)

This is veering a little off the original question but I just thought of something; in school I was taught that electrical therapy was for unstable and medications were for stable patients, only sign of being unstable I see here is the bp. However assuming the decision to shock has already been made I was told to not delay cardioversion to drafter a patient. Regardless of bp.


----------



## Akulahawk (May 17, 2012)

Versed does have some retrograde amnesia effects, however, I suspect that effect greatly depends upon how it's administered. I don't have a whole lot of experience with giving Versed, however. I just haven't had a chance to really get to observe that effect myself. A few people I've worked with have observed the effect though.


----------



## TYMEDIC (May 17, 2012)

NVRob said:


> I'd be more worried about hypotension secondary to hanging an amiodorone drip more than I'd be worried about it from versed. Depending on where I am and my transport time is going to decide what I'd do.
> 
> What's their diastolic pressure? I want to know this person's MAP. 80 SBP is pretty low to be "normal" for a patient but weirder things have happened.
> 
> ...



----------------------
why do you think that the amio caused that sig. of a drop in systolic bp? Did you provide a loading does prior to the drip? Never heard of that causing such a drop like that.


----------



## TYMEDIC (May 17, 2012)

second that


----------



## Handsome Robb (May 17, 2012)

TYMEDIC said:


> ----------------------
> why do you think that the amio caused that sig. of a drop in systolic bp? Did you provide a loading does prior to the drip? Never heard of that causing such a drop like that.



Unfortunately I can't explain the patho behind it. I've hung amio twice on VT with pulses, once post ROSC, and seen it multiple times in the ER during clinicals and every time there was a significant drop in SBP after the amio was administered. 

I suspect that drop also had something to do with the VT since my amio didn't convert it. 

No loading dose on pulsatile VT.


----------



## usalsfyre (May 17, 2012)

Look at the overall depressant effect on the cardiac cycle of amio and there's you answer.


----------



## Handsome Robb (May 17, 2012)

usalsfyre said:


> Look at the overall depressant effect on the cardiac cycle of amio and there's you answer.



That was my guess at it. 

It's labeled as a Class III however acts on all the classes. Reducing force of contraction secondary to Ca+ blocking effects would be the top on my list of answers for ya Ty.


----------



## TYMEDIC (May 17, 2012)

NVRob said:


> Unfortunately I can't explain the patho behind it. I've hung amio twice on VT with pulses, once post ROSC, and seen it multiple times in the ER during clinicals and every time there was a significant drop in SBP after the amio was administered.
> 
> I suspect that drop also had something to do with the VT since my amio didn't convert it.
> 
> No loading dose on pulsatile VT.



hmm. strange. I cant count how many times ive used it. Although I prefer Lido. Your supposed to use a loading dose of 150mg. over ten min. Then hang a maintenance drip/infusion. Never heard of someone jumping to an infusion off the bat. Im guessing theres additional pathologies going to to cause that sig. drop in bp.


----------



## Handsome Robb (May 17, 2012)

TYMEDIC said:


> hmm. strange. I cant count how many times ive used it. Although I prefer Lido. Your supposed to use a loading dose of 150mg. over ten min. Then hang a maintenance drip/infusion. Never heard of someone jumping to an infusion off the bat. Im guessing theres additional pathologies going to to cause that sig. drop in bp.




That's what I've been hanging. Sorry for the confusion. My transport times are so short that we barely get our 150 in before getting to the ER. 

I've never used lido, had the opportunity the other day but deferred it since we were backing into the ER. Only time we can use it is R-on-T PVCs.

I'm not doubting your experience at all, I'm just basing my comments on my experiences and *limited* understanding of the pharmacology behind it.


----------



## TYMEDIC (May 17, 2012)

NVRob said:


> That was my guess at it.
> 
> It's labeled as a Class III however acts on all the classes. Reducing force of contraction secondary to Ca+ blocking effects would be the top on my list of answers for ya Ty.



copy that. true that. it does Possesses some vagolytic and/or calcium channel blocking activity.


----------



## Fish (May 17, 2012)

crazycajun said:


> Versed or Valium. The only problem is it still will not help for pain much and the PT is still going to feel it. If it is my PT and they are not symptomatic (chest pn, nausea, etc) I wouldn't cardiovert unless absolutely necessary.



When did Converting Vtach not become absolutely necessary whether it be chemically or electricity? I feel like I am missing something here.


----------



## Fish (May 17, 2012)

PoeticInjustice said:


> There's supposedly a small amount of retrograde amnesia with Versed. However, I've been bedside with several family members who have received Versed. So far, they have all had full recollection up until about 30 seconds to a minute POST administration. So I have my doubts.



I remember everything after the versed admin, however I only received 2.5mg

I once received 7.5mg during a different procedure, I don't remember anything from that one.


----------



## Akulahawk (May 18, 2012)

Fish said:


> I remember everything after the versed admin, however I only received 2.5mg
> 
> I once received 7.5mg during a different procedure, I don't remember anything from that one.


IIRC, out here, the dose of versed we give IV/IO or IM is 0.1mg/kg up to 6 mg for sedation for pacing or for seizure. Basically, most adults will get close to or right at 6 mg, so their recollection of events will likely be quite limited, if the retrograde amnesia is dose-related rather than route-related.


----------



## Handsome Robb (May 18, 2012)

You have to take into account that we are all healthier, younger(ish)  individuals so we can process me meds much better than an older person who you'd more than likely see this person in can. 

With that said I watched 2 mg IV put a decent sized 35 year old on their ***. On the other hand I've seen an angry, delusional 60 year old take 4 mg IV 2mg x2 and keep fighting with us. It depends on the person. That's assuming you have IV access though and you aren't going IM.


----------



## Veneficus (May 18, 2012)

Fish said:


> When did Converting Vtach not become absolutely necessary whether it be chemically or electricity? I feel like I am missing something here.



When the potential risk outweighs the potential benefits.

As was mentioned before, some people can remain in v-tach for hours.

I have even paced a person out of v-tach and no idea how long he was in it, but it had to be at least an hour. 

I have said many times, medicine is not an if:then type of situation.

Just because paramedics are drilled on what they can do, doesn't always make it the right thing to do.


----------



## mycrofft (May 18, 2012)

Can the average paramedic decide when the benefit outweighs the risk?


----------



## NomadicMedic (May 18, 2012)

mycrofft said:


> Can the average paramedic decide when the benefit outweighs the risk?



The average paramedic? No. 

That is why we continue to operate under if:then protocols and on line medical control.


----------



## Veneficus (May 18, 2012)

mycrofft said:


> Can the average paramedic decide when the benefit outweighs the risk?



I think so.

The question is "will they?"


----------



## FLdoc2011 (May 18, 2012)

Veneficus said:


> When the potential risk outweighs the potential benefits.
> 
> As was mentioned before, some people can remain in v-tach for hours.
> 
> ...



What do you consider hemodynamically stable??

I certainly wouldn't sit on this guy too long.  And I don't necessarily agree that the risks would outweighs the benefit in this case.   

 are other factors that I would want to know as well.... is he symptomatic at all, diaphoretic, chest pain, cardiac history?  

He can still be AOx3 but with a BP of 80 and having active chest pain, something like that I'm not going to sit on.  Yea, there's always the risk of putting them into VF which you would then shock out of it, but if you're waiting and watching and he then codes you bet you're going to be questioned on why you sat on a hypotensive Vtach.......

Do you have any data/guidelines/studies you're going off of? 

Admitted a pt here just in past week who presented with weakness, found by EMS to be in VT, was diaphoretic/weak.  Don't think he was hypotension but I'll have to check.   Was urgently shocked in field after some versed and then found to be a STEMI in the ED.


----------



## Veneficus (May 18, 2012)

FLdoc2011 said:


> What do you consider hemodynamically stable??.



The maintaining of perfusion to the heart and the brain without decompensation. 



FLdoc2011 said:


> I certainly wouldn't sit on this guy too long.  And I don't necessarily agree that the risks would outweighs the benefit in this case.



What case? You have 1 sentence and a host of information missing. U submitted that always jumping on a patient and cardioverting may not always be the best thing EMS can do. Particularly with a short transport time. 



FLdoc2011 said:


> are other factors that I would want to know as well.... is he symptomatic at all, diaphoretic, chest pain, cardiac history?



Yea, me too.




FLdoc2011 said:


> He can still be AOx3 but with a BP of 80* and having active chest pain*, something like that I'm not going to sit on.



That is not in the evidence here.



FLdoc2011 said:


> Yea, there's always the risk of putting them into VF which you would then shock out of it, but if you're waiting and watching and he then codes you bet you're going to be questioned on why you sat on a hypotensive Vtach........



Shouldn't sometime in that waiting and watching, especially in the 1 on 1 patient ratio of EMS, wouldn't you notice if there were any signs of decompensation?

I mentioned pacing a pt in vtach earlier. That patient had a pacemaker that failed. Could this patient also have the same condition? from the 1 sentence given, let us not add "what if's"



FLdoc2011 said:


> Do you have any data/guidelines/studies you're going off of? .



Data for what?

Listening potential outcomes of cardioversion?



FLdoc2011 said:


> Admitted a pt here just in past week who presented with weakness, found by EMS to be in VT, was diaphoretic/weak.  Don't think he was hypotension but I'll have to check.   Was urgently shocked in field after some versed and then found to be a STEMI in the ED.



So you shocked an unstable patient in vtach, based on more than just a blood pressure number. So what?


----------



## FLdoc2011 (May 18, 2012)

That's why I said I wanted more information in this case.   All I have to go on is hypotension so right off the bat I'm leaning towards earlier treatment since that's all I have to go on.   I was just playing a little devil's advocate since you had taken more of the opposite stance with the same limited information.

It's hypothetical anyway since we would have more information than just what was presented so its kind of a mute point.


----------



## NomadicMedic (May 18, 2012)

FLdoc2011 said:


> ...so its kind of a mute point.



Does that mean you have nothing else to say? 

It's *moot* point, doc.


----------



## Veneficus (May 19, 2012)

FLdoc2011 said:


> That's why I said I wanted more information in this case.   All I have to go on is hypotension so right off the bat I'm leaning towards earlier treatment since that's all I have to go on.   I was just playing a little devil's advocate since you had taken more of the opposite stance with the same limited information.
> 
> It's hypothetical anyway since we would have more information than just what was presented so its kind of a mute point.



I wasn't trying to take the opposite stance, I was attempting to point out that it is important to consider why and the potential outcomes of deciding on a specific course of action.

In a a patient *not* deteriorating, in a short transport, it may sometimes be a better choice to let the hospital handle it and just drive the pt in.

If the patient is unstable by multiple clinical signs, then I think the need for action is obvious.

I agree with you, it takes more than a number, If this is an elderly person, it is possible this person normaly has a systolic in the 90s. Which would make 80x not a considerable drop.


----------



## FLdoc2011 (May 19, 2012)

n7lxi said:


> Does that mean you have nothing else to say?
> 
> It's *moot* point, doc.



Ha, thats what I get for typing on my phone.


----------



## crazycajun (May 19, 2012)

Wow get slammed for a couple of busy shifts and it seems you miss everything. Thanks Vene for keeping some sanity in this discussion. For all of the newbies please remember.... Just because you have all of the gadgets, drugs and gizmo's available doesn't mean you have to use them on every PT. If you are treating your PT and not the monitor there will be instances that you don't need to do anything but monitor the PT. I have had people vagal on purpose because they knew it would drop their HR. If I were to pace this PT immediately then I would have performed an unneeded and possibly dangerous intervention.


----------



## usalsfyre (May 19, 2012)

crazycajun said:


> If you are treating your PT and not the monitor there will be instances that you don't need to do anything but monitor the PT.


As I've said again and again, why the heck even carry it if your going to ignore it?




crazycajun said:


> I have had people vagal on purpose because they knew it would drop their HR. If I were to pace this PT immediately then I would have performed an unneeded and possibly dangerous intervention.


As was stated above, there's not really enough info to make a treatment decision here. The advice you give makes sense, but there's a bit more finesse to treatment decisions than "pt not monitor".


----------



## mycrofft (May 19, 2012)

Question#1: what's wrong?
Question #2a and b: will it kill or disable the pt before we get to a hospital/can I treat enroute?
Question#3: What do I do first?


----------



## coolidge (May 19, 2012)

*why did someone write : Etomidate is a garbage drug*

Why, curious?


----------



## crazycajun (May 19, 2012)

usalsfyre said:


> As I've said again and again, why the heck even carry it if your going to ignore it?
> 
> 
> 
> As was stated above, there's not really enough info to make a treatment decision here. The advice you give makes sense, but there's a bit more finesse to treatment decisions than "pt not monitor".



I am not saying don't use the monitor however it is a diagnostic piece of equipment that can fail. That is the point I am making. With the way some medics and basics shove lead wires back in the bag, roll them tightly and just the general beating these pieces take it is very easy to look at the screen and see something that is not there. Many of today's medics are so caught up in the hype of drugs and electricity they also tend to forget to ask the basic questions and listen to their PT. I have seen medics bring PT's into an ER hooked up to a monitor with a rhythm and the ER physician ask how long the PT had been dead because someone forgot to check for a pulse. I have also seen cases where electricity was applied because the monitor showed a shockable rhythm only to hear them say the PT was A&O before and dead after.


----------



## Dwindlin (May 19, 2012)

coolidge said:


> Why, curious?



The poster who said it was jwk, and if this is who I think it is, he/she is an AA.  Etomidate has fallen out of favor with anesthesia because there are much, much better drugs to which they have access.  Some of the reasons I see cited most are it causes myoclonus, adrenal suppression (often with just a single dose), and there may be a baseline increase in mortality with Etomidate use (granted the studies are mixed at this point, but if you have better options why risk it).  Hopefully jwk will see this and post a much better explanation of why this drug has fallen out of favor, but this is my understanding currently.


----------



## Handsome Robb (May 20, 2012)

crazycajun said:


> For all of the newbies please remember....



Didn't you just finish medic school not too long ago? I might be mixed up...but I don't think so.


----------



## Farmer2DO (May 20, 2012)

PoeticInjustice said:


> Jwk, what makes you say this? Not doubting you, merely curious. We're just now getting etomidate and would love to hear what cons you find with it.





n7lxi said:


> Is Versed the only choice? Because I'd go to the Etomidate.



I wouldn't.  Etomidate is OK for emergent airway situations, but when considered in the context of critical care medicine, it's a terrible drug.

http://www.biomedcentral.com/content/pdf/cc4979.pdf

"A single dose of etomidate is a major risk factor for the development of relative adrenal insufficiency for at least 24 hours after its administration"  [Mohammad et al.]



n7lxi said:


> I was lead to believe that long term (>6 hours) adrenal insufficiency, the number one side effect of etomidate, was only a factor in patients receiving long term (>48 hours) infusions of the drug, such as continued sedation in the ICU



Not according to this article.



> a practice which has stopped in most places.



Thankfully.



> Patients receiving a single dose of 0.3mg/kg had normal adrenal function 12 hours after the drug was administered.



Not according to everything I've read and been taught.  




Frozennoodle said:


> I saw a guy having a STEMI in my ER rotations with a bp of 54/30 fully A&O.  A&O isn't the only indicator of stability or hemodynamic stability.  If you have hemodynamically unstable V-Tach with a pulse it wont be with a pulse much longer unless you do something.



I generally agree.



NVRob said:


> I'd be more worried about hypotension secondary to hanging an amiodorone drip more than I'd be worried about it from versed. Depending on where I am and my transport time is going to decide what I'd do.



I don't really agree with you, Rob.  In my experience, if the drug does its job, then the dysrrhythmia resolves, and cardiac output improves.  



> Retrograde amnestic effects from versed are a wonderful thing.





Akulahawk said:


> Versed does have some retrograde amnesia effects, however, I suspect that effect greatly depends upon how it's administered. I don't have a whole lot of experience with giving Versed, however. I just haven't had a chance to really get to observe that effect myself. A few people I've worked with have observed the effect though.



Not to be picky, but its not retrograde amnesia, its anterograde amnesia we're talking about.  Retrograde means they forget what happened before you pushed the drug.  Anterograde means they forget what happened after pushing the drug.  (This is assuming you give the drug before the painful procedure.)  People tend to speak of these terms incorrectly.



usalsfyre said:


> Give the midazolam. Even if it causes a bit more hypotension your about to fix it right?



I agree.



Veneficus said:


> If you have a guy who is A&O and having a STEMI, doesn't he need some kind of reperfusion therapy?



But doesn't he need to continue to perfuse in order to get to that point?  In my opinion, anyone in sustained V tach is in danger of losing their perfusion to     vital organs, which would make re-perfusing them a moot point.



> So long as he was mentating, both his heart and his brain are receiving blood.



But is his heart receiving ENOUGH blood?  If he's in V tach, we know his ventricles likely aren't filling adequately, because by definition, his heart is depolarizing in a retrograde fashion, meaning he loses atrial kick.  So if his coronary perfusion pressure is low, I would think his risk of going into V fib is significant.





> His BP might be that low and vtach his rhytm because he lost the intrinsic pacemakers from hypoxia.



Which is why I have the ability to pace.



> Sometimes discretion is the better part of valor.



I have actually used that quote in treating patients (or not providing certain treatments).  I just don't think it fits here.  I think V tach needs to be treated.  You can disagree, but that's my opinion.



DPM said:


> I'm still new to this... Would the versed still have the required effect if given after cardioverting? I.e. you light up the PT, then if the new rhythm is stable you give a little versed...?



Here's that difference between retrograde and anterograde.  If the patient stabilized, I would consider giving it after if I hadn't first.



usalsfyre said:


> Not nearly as well or reliably. What they need post cardioversion is analgesia. Why chance it?



And amnesia.




> Are there new studies that show etomidate is a “garbage drug” that we should be avoiding? In systems that don’t use Ketamine or propofol, what is your suggestion for induction with RSI or rapid sedation for cardioversion?



See study noted above.



usalsfyre said:


> I'm more ok with electricity than cardioversion.



Huh?  Isn't cardioversion electricity?




Fish said:


> When did Converting Vtach not become absolutely necessary whether it be chemically or electricity? I feel like I am missing something here.



I agree.



Veneficus said:


> When the potential risk outweighs the potential benefits.



But what are the benefits to staying in V tach?  It's not a rhythm that's generally considered compatible with life.



> As was mentioned before, some people can remain in v-tach for hours.



But should they?  Again, why wouldn't you want to get that to a better rhythm?



mycrofft said:


> Can the average paramedic decide when the benefit outweighs the risk?



Sadly, I think this is one of the downfalls of our profession.


----------



## Farmer2DO (May 20, 2012)

So, many good point brought up in this thread.  Here are some thoughts:

The decision to shock vs. medicate with antiarrhythmics is based on stability.  It's not just a BP issue; it goes to total perfusion, and you have to put it all together.  BP, MAP, change in mental status, skin color, temperature and moisture, and the ability to palpate central and peripheral pulses all come into play.  So does the relative health of the patient.  The sicker the patient at baseline, the less likely they are to tolerate this rhythm.  However, I still believe V tach needs to be terminated, no matter how you do it.

Amiodarone and lidocaine have been mentioned.  Both have the ability to cause hypotension (certainly amiodarone more), but again, it's all relative.  If the rhythm improves and cardiac output increases, isn't the patient better off?  That being said, I think amiodarone is the better antiarrhythmic.

Anyone remember using bretylium tosylate?

The next question is about sedation prior to cardioversion.  Again, depends on the situation.  Did you come upon a patient found in V tach, who doesn't yet have IV access, who is in extremis?  If so, light 'em up, and deal with the fallout.  Or, do you have a patient that you were treating, who is on your monitor, who already has a line in place, and develops V tach in front of you?  Here, it won't take long to give a little Versed if you decide to shock.

My $0.02.


----------



## EMT John (May 20, 2012)

If you really feel the need to zap them "pain free", get that BP up anyway you can (Bilateral IV bolous, legs up, whatever you need to do)  give them some MS and zap them. Done...


----------



## Handsome Robb (May 20, 2012)

EMT John said:


> If you really feel the need to zap them "pain free", get that BP up anyway you can (Bilateral IV bolous, legs up, whatever you need to do)  give them some MS and zap them. Done...



I feel like there are much better options in this situation than MS 

Maybe I'm just a youngin' but we rarely use MS here. It's all fentanyl and versed. MS is only in ACS or abdominal pain from anecdotal experience and personal preference.


----------



## EMT John (May 20, 2012)

Welcome to the wonderful state of California. All we get is MS, versed and Valium. I would love to have fentanyl. But no such luck. 

No fun stuff for us.


----------



## Handsome Robb (May 20, 2012)

EMT John said:


> Welcome to the wonderful state of California. All we get is MS, versed and Valium. I would love to have fentanyl. But no such luck.
> 
> No fun stuff for us.



Ah that sucks! Fent and versed is my favorite combination. 

With those options I'd reach for the versed for the simple fact that I'm not that comfortable with valium (we don't carry it) and I don't see MS being a viable option.

Although you did say "pain free" and versed wont help with that.


----------



## Handsome Robb (May 20, 2012)

Farmer2DO said:


> So, many good point brought up in this thread.  Here are some thoughts:
> 
> The decision to shock vs. medicate with antiarrhythmics is based on stability.  It's not just a BP issue; it goes to total perfusion, and you have to put it all together.  BP, MAP, change in mental status, skin color, temperature and moisture, and the ability to palpate central and peripheral pulses all come into play.  So does the relative health of the patient.  The sicker the patient at baseline, the less likely they are to tolerate this rhythm.  However, I still believe V tach needs to be terminated, no matter how you do it.
> 
> ...



You bring up a good point with the cardiac output improving and I agree with it. Like I said my all my experience is anecdotal. 

I love it when people point out things that I didn't really consider, it gets me thinking. 

Last time I checked bretylium was used mostly around the time I was still in middle school so I unfortunately can't comment on that one


----------



## systemet (May 20, 2012)

crazycajun said:


> is the point I am making. With the way some medics and basics shove lead wires back in the bag, roll them tightly and just the general beating these pieces take it is very easy to look at the screen and see something that is not there.



I don't think this is that likely, especially if you're doing 12-leads.  Certainly the cables can become damaged --- he early LP12s were notorious for this -- but this isn't going to make VT appear where there was no VT before.




> I have seen medics bring PT's into an ER hooked up to a monitor with a rhythm and the ER physician ask how long the PT had been dead because someone forgot to check for a pulse.



This is just terrible, but speaks more to a basic lack of competence and an inability to perform a physical assessment.  If someone doesn't understand what PEA is, and doesn't check vital signs on a patient, there are much bigger issues going on.  Hopefully the crew in question has got chewed out and remediated.



> I have also seen cases where electricity was applied because the monitor showed a shockable rhythm only to hear them say the PT was A&O before and dead after.



Not sure I understand --- are you talking about cardioverting a perfusing tachyarrhythmia into a pulseless rhythm?  Because this is simply a risk of cardioversion, that's got to be considered when you're balancing the relative merits of drug therapy versus cardioversion versus doing nothing.


----------



## Akulahawk (May 20, 2012)

Farmer2DO said:


> Not to be picky, but its not retrograde amnesia, its anterograde amnesia we're talking about.  Retrograde means they forget what happened before you pushed the drug.  Anterograde means they forget what happened after pushing the drug.  (This is assuming you give the drug before the painful procedure.)  People tend to speak of these terms incorrectly.


Not to be picky, but I actually _was _speaking of retrograde amnesia. That's why I used the term. I'm fully aware of the fact that Versed produces anterograde amnesia. The retrograde amnesia effect is, at best, limited to moments immediately prior to administration. Beyond that the immediate period prior to administration, there will not be any amnesia effect. The amount of time that encompasses "immediately prior" is not well known. Is it two minutes? Five minutes? Thirty seconds? Knowing this, I would much rather premedicate someone about to undergo a painful procedure than depend on a much less reliable ability for Versed to produce retrograde amnesia. Of course, I'd also want to premedicate someone with a good pain med as well...


----------



## NomadicMedic (May 20, 2012)

Farmer2DO said:


> I wouldn't.  Etomidate is OK for emergent airway situations, but when considered in the context of critical care medicine, it's a terrible drug.
> 
> http://www.biomedcentral.com/content/pdf/cc4979.pdf
> 
> "A single dose of etomidate is a major risk factor for the development of relative adrenal insufficiency for at least 24 hours after its administration"  [Mohammad et al.]



Interesting that you base your argument against etomidate on a study done on compromised, septic patients, when all of the other material which studied etomidate vs Versed as a rapid one dose sedative for painful, one time events (such as cardioversion) showed no significant issues with that one time dose. Most studies showed etomidate as 'a safe, effective drug." The study you quoted showed that half of the PTs had adrenal insufficiency PRIOR to etomidate! And the conclusions of the study state, "Relative adrenal insufficiency is present in most patients with septic shock after the administration of etomidate. *Caution is recommended when using etomidate in these patients.*" 

I don't think that the small study you cited is enough to class etomidate as "a terrible drug".

Try these on.

http://www.sciencedirect.com/science/article/pii/S0196064403005109

http://www.theannals.com/content/38/7/1272.short

http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2001.tb00539.x/abstract

If I had to cardiovert a PT, who had a line up, was hemodynamicly unstable ... yet I felt required sedation prior to cardioversion, I would most likely chose etomidate over midazolam.


----------



## crazycajun (May 20, 2012)

NVRob said:


> Didn't you just finish medic school not too long ago? I might be mixed up...but I don't think so.



I have been in EMS since 1985. I was a licensed medic from 1986 to 1998. I left EMS for 2 years to go into Health and Safety and came back in 2000. I stepped down to an I level cert in 1998 because it was easier to get the required IST hours. Because of my experience I remained an I for 11 years as I made the same amount of money with less headaches. I only decided to go back and renew my medic certs for reasons that would allow me to continue in the field until I decide to retire. I have trained EMT's and Medics for over 15 years.


----------



## crazycajun (May 20, 2012)

systemet said:


> I don't think this is that likely, especially if you're doing 12-leads.  Certainly the cables can become damaged --- he early LP12s were notorious for this -- but this isn't going to make VT appear where there was no VT before.
> 
> I have seen a Phillips monitor show VT when there was no VT present. I have also seen a Zoll show wide complex rhythm's because it was plugged into an AC outlet
> 
> ...



See the issues above with the Phillips and the Zoll


----------



## Veneficus (May 20, 2012)

n7lxi said:


> Interesting that you base your argument against etomidate on a study done on compromised, septic patients, when all of the other material which studied etomidate vs Versed as a rapid one dose sedative for painful, one time events (such as cardioversion) showed no significant issues with that one time dose. Most studies showed etomidate as 'a safe, effective drug." The study you quoted showed that half of the PTs had adrenal insufficiency PRIOR to etomidate! And the conclusions of the study state, "Relative adrenal insufficiency is present in most patients with septic shock after the administration of etomidate. *Caution is recommended when using etomidate in these patients.*"
> 
> I don't think that the small study you cited is enough to class etomidate as "a terrible drug".
> 
> ...



There are very few terrible drugs 

Just drugs that don't work well on all patients.

The quest to find the perfect treatment for everyone is a fools undertaking. 

There is a reason genetically based therapies are the future of medicine. 

Because unless you are an indentical twin, no two people are the same. 

Also if you hang around long enough, medicine is cyclic. (because our knowledge advances over time) It wasn't 20 years ago when we thought thalidomide was the worst drug ever developed, now it is a first line treatment in a different population.


----------



## NomadicMedic (May 20, 2012)

Veneficus said:


> There are very few terrible drugs
> 
> Just drugs that don't work well on all patients.
> 
> ...




Sure. But I'd be loath to see a medic student read this thread, go back to his/her class and say "Etomidate is an awful drug and we shouldn't use it. Ever!"

The goal of a thinking practitioner should be to research available treatment options and make sound decisions based on knowledge. There have been a couple of instances where I've cardioverted AFib with RVR and sedated the PT with Versed. Would I do that again? Depends. It's situational. Is etomidate a viable choice for me? Sure is. (Actually, it's the only sedation in the Delaware protocol for cardioversion.) If I felt I wanted to use versed instead, I wouldn't hesitate to call for the variance orders. But I'd also be able to defend my actions and explain why to the medical director.


----------



## triemal04 (May 20, 2012)

n7lxi said:


> Interesting that you base your argument against etomidate on a study done on compromised, septic patients, when all of the other material which studied etomidate vs Versed as a rapid one dose sedative for painful, one time events (such as cardioversion) showed no significant issues with that one time dose. Most studies showed etomidate as 'a safe, effective drug." The study you quoted showed that half of the PTs had adrenal insufficiency PRIOR to etomidate! And the conclusions of the study state, "Relative adrenal insufficiency is present in most patients with septic shock after the administration of etomidate. *Caution is recommended when using etomidate in these patients.*"
> 
> I don't think that the small study you cited is enough to class etomidate as "a terrible drug".
> 
> If I had to cardiovert a PT, who had a line up, was hemodynamicly unstable ... yet I felt required sedation prior to cardioversion, I would most likely chose etomidate over midazolam.


I don't think that anyone is going to argue that etomidate is not one of the better prehospital choices for procedural sedation, be it cardioversion, RSI, or something else; there's a huge amount of evidence that it is.  Whether or not it does create problems for septic patients when given as a single bolus dose is debatable, and really there isn't a lot of definative info one way or the other.  

Prospective study, found no signifigant change in mortality with etomidate.  http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2008.00299.x/full

Based on kids and has some bearing.  http://jcem.endojournals.org/content/90/9/5110.short

Reversable effects.  http://www.springerlink.com/content/v587770g102w2736/

Mostly the common consencus that I've heard is that, while it may make treatement more difficult (need for more steroid administration) and may increase the amount of time spent in the ICU (something that also should be considered) the mortality isn't to changed.


----------



## NomadicMedic (May 20, 2012)

triemal04 said:


> I don't think that anyone is going to argue that etomidate is not one of the better prehospital choices for procedural sedation, be it cardioversion, RSI, or something else...



Really? Farmer2DO is arguing that *exact* point.



Farmer2DO said:


> ...Etomidate is OK for emergent airway situations, but when considered in the context of critical care medicine, it's a terrible drug.



Why would be okay for "emergent airway situations", but not for cardioversion? I'm confused by this logic. :glare:

But I'm thrashing this deceased equine. :deadhorse:


----------



## triemal04 (May 20, 2012)

n7lxi said:


> Really? Farmer2DO is arguing that *exact* point.
> 
> 
> 
> ...


I probably should have phrased that "...one of the better prehospital choices for procedural sedation_ in non-septic patients_..."  Given that both the study referenced by Farmer2DO and the rest of his comments dealt with adrenal infufficiency and/or sepsis, that seemed to be what he was getting at.  Or I'm wrong.  Either way...I could care less.


----------



## Handsome Robb (May 21, 2012)

crazycajun said:


> I have been in EMS since 1985. I was a licensed medic from 1986 to 1998. I left EMS for 2 years to go into Health and Safety and came back in 2000. I stepped down to an I level cert in 1998 because it was easier to get the required IST hours. Because of my experience I remained an I for 11 years as I made the same amount of money with less headaches. I only decided to go back and renew my medic certs for reasons that would allow me to continue in the field until I decide to retire. I have trained EMT's and Medics for over 15 years.



Fair enough.  I'll keep my mouth shut.


----------



## Veneficus (May 21, 2012)

Just my opinion, but I think the reason etomidate is falling out of favour is because it was overhyped as "one of the safer choices."

There was this idea going around it didn't have profound cardiovascular effects, and true to medical science, when something seems too good to be true, then it is not true.

Also common to medicine when opinion swings far in one direction, like a pendulum it swings back equally as far.

Moderation is key.


----------



## mycrofft (May 21, 2012)

Anytime I hear the phrase "mother's milk" in relation to a procedure, device or drug, I stay away.


----------



## mycrofft (May 21, 2012)

PS:
Re the EKG situations noted above (bad interps etc) try these:
1. Per a machines in a GP's office's ointerp, the pt has, by retrospective review by a cardiologist, A Fib times five years, whereas the machine's interp was "occasional PVC".
2. Did EKG on a pt I KNEW had an arrhythmia (it was palpable and auscable). EKG looked and interpreted WNL! Found out it was re-printing the last EKG in memory instead of taking new ones. We sent it in for repair and never got it back.


----------



## Fish (May 23, 2012)

It always seem like people are quick to point out the " I once saw..... I have seen...." in these situations, but we all need to remember that those are irregular and exceptions and are not the norm. I understand different areas of the Country expect different things out of their EMS services, I just know in the area I work if a Vtach patient is brought in that you did nothing for without justification you will certainly be getting a "what for???" from the ER Doc and your  EMS systems QA Team. Ask a Cardiologist and they will tell you that Sync Cardioversion is effective and has a great percentage of favorable outcome, the risk of converting someone to a non-favorable rhythm is low....... very low. Ammiodarone does have its draw backs I will agree, but so does remaining in Vtach for extended periods..... What do ER Docs do with Vtach that we were not able to convert in the field? They attempt to convert it as well. I am no 20yr Medic, this is my 7th year in EMS...... But in those 7 years I have never seen a Doctor "sit and monitor" any patient in Vtach for an extended period of time, they have always taken steps towards conversion whether it be Medication or Electricity. And I have never seen a Medic do this either. Anyway, my two cents. Sounds like everyone one here has different experiences in these situations. Thought I would share mine......


----------



## Fish (May 23, 2012)

n7lxi said:


> Really? Farmer2DO is arguing that *exact* point.
> 
> 
> 
> ...



Ketamine!


----------



## Veneficus (May 24, 2012)

Fish said:


> It always seem like people are quick to point out the " I once saw..... I have seen...." in these situations, but we all need to remember that those are irregular and exceptions and are not the norm. I understand different areas of the Country expect different things out of their EMS services, I just know in the area I work if a Vtach patient is brought in that you did nothing for without justification you will certainly be getting a "what for???" from the ER Doc and your  EMS systems QA Team. Ask a Cardiologist and they will tell you that Sync Cardioversion is effective and has a great percentage of favorable outcome, the risk of converting someone to a non-favorable rhythm is low....... very low. Ammiodarone does have its draw backs I will agree, but so does remaining in Vtach for extended periods..... What do ER Docs do with Vtach that we were not able to convert in the field? They attempt to convert it as well. I am no 20yr Medic, this is my 7th year in EMS...... But in those 7 years I have never seen a Doctor "sit and monitor" any patient in Vtach for an extended period of time, they have always taken steps towards conversion whether it be Medication or Electricity. And I have never seen a Medic do this either. Anyway, my two cents. Sounds like everyone one here has different experiences in these situations. Thought I would share mine......



I have seen an ER doc sit on vtach patients while they waited for cardiology to come and have a look, who ultimately cardioverted a patient.

I would not say it is a common thing to do, but I would caution people about looking at the final action and its outcome without knowing what went into the decision.


----------



## Mad Russian (May 27, 2012)

Etomidate is a useful agent for procedural sedation because it provides effective, brief, deep sedation with little hemodynamic compromise.


----------



## jwk (May 27, 2012)

Veneficus said:


> I have seen an ER doc sit on vtach patients while they waited for cardiology to come and have a look, who ultimately cardioverted a patient.



Then this wouldn't be an ER doc that I'd want treating a member of my family.


----------

