Household Words Chapter 3

Household Words

A weekly periodical examining a rather extraordinary clinical encounter.

Chapter 3

Fair reader.  We left this most difficult ethical situation watching the end of the patient’s trolley disappearing, being wheeled off and upstairs to the coronary care unit, leaving the ED staff, looking on, somewhat bewildered and introspective.

The Psychiatrist’s role was discussed in the comments after the last Chapter. They were acting under the very broad umbrella term of ‘duty of care’.  This is quite separate from the Mental Health Act, and in layman’s terms, simply behooves the medical practitioner to always act in the best interests of the patient, to the very best of his/her ability and experience, and in accordance with the situation as it presents itself. Now one may argue one way or the other, in this case, where the duty of care fell, but the point is that neither could have been completely right. There is no binary test that could tell us whether he did, or did not, have capacity at that point, simply a vast spectrum of opinion.

I have included a reference (1), that covers some of the Australian take on this term, a small excerpt of which is reproduced here;


There are circumstances in which treatment must be given as a matter of absolute emergency and failure to do so would amount to negligence. Croom-Johnson, in Wilson v Pringle38 reviewed the role of the casualty medical officer within the accident and emergency setting and acknowledged that the unconscious patient cannot give consent and next of kin may be unavailable to provide same. Within this context “…consent is to be implied, otherwise it would be a battery on the unconscious body…”.

Like so many of these complex situations, they are highly individualized, and depend on the input of experienced clinicians.

But, let us climb out of the mire of the unanswerable, and return to the rather fascinating therapeutic modality in use here.

Assault as a therapeutic modality?  Rhythmically punching the chest to achieve cardiac output. Fist (not fisting, Tim Leeuwenburg @KangarooBeach) pacing, or percussion pacing. This was also recently mentioned on the amazing EMCRIT podcast ‘Inside the mind of the resuscitationist’ with @emcrit and @cliffreid with additional BJA reference (3)

The most recent ILCOR guidelines (2010) whilst de-emphasising the precordial thump (sorry Chris), retains the statement

“fist pacing may be considered in hemodynamically unstable bradyarrhythmias until an electric pacemaker (transcutaneous or transvenous) is available.” (4)

The difference between a precordial thump and percussion pacing is that a precordial thump can theoretically impart 20-30J of energy and may be effective in terminating very early VF/VT (equivalent to defibrillation) but has never been prospectively validated. It requires a greater force of contact and is supposed to be applied over the centre of the sternum.  The proposed difference between the thump and percussion pacing is that lesser energy is required to electrically stimulate a non-fibrillating myocardium, and the whack is applied to the lower sternum, more over the left side, presumably over the right ventricle, rhythmically at 50-70 times a minute.  Evidence, again, is sketchy, and based on case studies.  Personally though, having seen it work so effectively in this case, I believe it may play a temporizing role.

But WHAT, you may well ask (particularly those who have skipped over the reflective ethical considerations, and scientific discourse), happened next to the patient??

As many of you surmised, this gentleman required some light sedation, in order to facilitate the placing of a pacing wire, done under duty of care, in order to reassess his mental state when he was of deemed normal capacity.

On the second night of his stay in CCU, he became delirious. This was almost definitely multifactorial in nature, with the environment, drugs and interventions playing a role.  A companion guard was ordered to sit by his bedside, to assist with avoiding falls and other misfortunes.

During the third night, as his companion guard sat engrossed in his copy of ‘The Da Vinci Code’ (yes, I just made that up, but it was imperative to slip one ‘literary’ reference in here), our patient carefully, and methodically, with his hands discreetly hidden under his blanket, unpicked the sutures over his chest, and pulled out his pacing wire.

To be continued…………..


(1) Duty of care and medical negligence [full text]

(2) Inside the mind of the resuscitationist [emcrit podcast]

(3) Percussion pacing—an almost forgotten procedure for haemodynamically unstable bradycardias? [full text]

(4) 2010 International Consensus on CPR [ILCOR]

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  1. Minh Le Cong says

    Use the defibritazer on him
    I take it you are implying this was a deliberate act rather than delirious flailing?
    Patients complete suicide in hospital all the time
    Run the code , put the wire back in
    Two things can only happen
    You get him back and start all over again
    You don’t and move on

  2. Jimmy D says

    In one of my own anesthestic cases, a patient under my care suffered a Vfib arrest. As we called for the defib unit, I asked the surgeon’s assistant to begin CPR. Following 4 chest compressions, the patient converted to a perfusable sinus rhythm. Yes, this is an N=1, but I challenge you all to consider the type of mayhem you be unleashing with sternal strikes.

    I would use caution with the type/sort of force used to the human sternum—a strike may break it, however, compression/decompression may leave it intact. Thus, I challenge the idea of precordial thump or pacing. Just do CPR. My opinion.

    • Minh Le Cong says

      actually thats a valid point Jimmy raises. Why not just do CPR like any other pulseless rhythm?
      I mean in neonatal resus, we dont do percussion fist pacing when the babes brady down below 60 bpm…we just start CPR!
      is there a sound physiological or anatomic reason to do it differently in brady asystolic arrest in adults?

      • says

        It is a very interesting point, indeed. The three modalities are pathophysiologically speaking, trying to achieve 3 different things -- precordial thump, enough energy to defibrillate, the percussion pace enough energy to cause membrane depolarisation, presumably by opening voltage gated sodium channels, thus sparking off a macro-depolarisation wave and myocardial contraction, and chest compressions are designed to get flow to coronary arteries using the thoracic pump theory, without imparting an energy transfer. Presumably. All speculative really, and with no evidence to back it up. Did Jim’s patient get ROSC because it was so early in the VF period that coronary flow produced enough substrate to the not yet deteriorated myocardium, or was it a small defibrillating energy transfer?? As aggressive, and potentially dangerous as percussion pacing sounds, I would counter that CPR would also be painful and potentially bone breaking in the semi-awake patient, plus we are so used to going hard, fast, not stopping now, I would think that having a life or death conversation contemporaneously would be just as difficult.
        I’m certainly no expert, and would greatly welcome the opinions of others.

      • Tim Bowles says

        Presumably in theory, if you get good capture with percussion pacing and go at the right rate, you’d get a fairly normal cardiac output- similar to a ventricular TPW?

        Compared to what we know for CPR- that although you get some output, it is nowhere near normal. ..

  3. says

    Ay carumba. We are now in serious trouble !

    If one is going to treat a patient against their will, invoking “duty of care” or whatever local law applies then you must absolutely provide impeccable, rigorous and unimpeachable care. It is called duty of care for reason!

    This is a disaster scenario! So often a ‘simple’situation can turn complex and ugly after a series of medical interventions. Especially true in the elderly, mad and vulnerable.

    I think we are beyond competence now. He has been through the inpatient wringer and now must get the best care available.

  4. says

    Oh, on a less preachy, more specific note.
    I imagine this is exactly the type of slow, unpleasant demise that our patient had in mind when he signed up for a DNR card and put it in his wallet.
    Why do we as a profession, or whole culture insist on a prolonged “well documented death”?
    In Miami now 60% of people die in a ICU -- again, ay carumba

    • says

      I so agree with you Casey, and feel that we are such a long way from managing death well in the critical care setting. I wrote about this case, somewhat out of sadness and confusion at the whole business.

  5. says

    What a great result

    He’s been reduced from a competent adult making a decision with dignity to a piece of protoplasm for whom now ‘the machine’ of critical care will trundle inexorably on in bone-crunching DC-shocking merciless end, one way or another

    Ay, carumba

    On a different note, I remember as a resident (or SHO as it was in the UK) covering one of the larger London teaching hospitals. These were the days of FRi-Sat-Sun-Mon oncalls, 96 hrs of gut-wrenching agony. To break the tedium I would dress as Santa Claus…

    …so I was called to one ward after Xmas dinner, for a ‘cardiac arrest’. Arrived as a slightly sweaty Santa. The patient was an old fellow with a severe bradyarrhythmia…I got some output back with fisting (sorry, sorry, fist-pacing)….and he was able to perfuse his brain

    …in time to wonder why in the hell Santa was punching him on Xmas day. After a while I tired and he deteriorated.

    I guess he’d been a naughty boy for Xmas.

  6. franno says

    Jeez, Michelle -- the case is getting more tragic (though, if the essence of a tragedy is its predictability, i don’t believe that it started out as one…)
    It seems to me that our medical system lost sight of the very specific target of the emergency therapy: ie. maintain persfusion so that all other efforts can be aimed at quickly ascertaining that this patient was indeed fully informed and of unclouded mind. Many of the above comments suggest that some people were already convinced of this, but i would err on the side of being absolutely sure before letting someone die that I’ve only just met (in the context of abnormal perfusion.)
    Why was he on CCU for 2 days and chemically sedated, i wonder, when the whole point of treating against his wishes was to ascertain capacity to refuse treatment. My preference would have been for the minimum required physical restraint to stop him pulling out his wire (using chemical sedation minimally, or not at all after the initial placement of the wire), whilst senior experienced clinicians worked tirelessly to clarify that this was not a beta blocker overdose, depression/acute adjustment disorder (to his recent eviction from his house of many years, or death of childhood sweetheart etc…), UTI/chest infection/hypothyroidism blah blah blah. When all of this is excluded, and we are dealing with someone whom we now confidently know is informed and competent -- then pull out the pacing wire and let him go. As Casey suggested -- once embarking upon the road chosen -- there is a window of opportunity to provide targeted optimum care to avoid what is now becoming a tragedy. That opportunity seems to have been missed…
    You may have felt relieved, rather than disillusioned, if one of these alternate outcomes eventuated…

  7. Seth Trueger says

    These cases are tough and there are no easy answers. Given the time constraints and the question of capacity vs suicidal depression, I think what you did was incredibly reasonable to buy some time to work it out. After all, I’m told that ethicists consider withdrawing therapy equivalent to withholding it in the first place — it’s just harder to wrap our head around withdrawal.

  8. Amanda says

    Well said Franno.

    Just a quick note- do you act in the patient’s best interests or in his or her’s best desires?

    This is why it’s so important to encourage our aging population to have advanced care directives & appoint guardians with whom they can have frank discussions about what they would want.