A weekly periodical examining a rather extraordinary clinical encounter.
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]