ACLS : Transcutaneous Pacing

6 02 2021

Pacing 101.

  1. Sedation and analgesia.
    My personal preference is a combination of fentanyl and midazolam. If your patient is awake – briefly explain the procedure to them and get their consent if possible.
  2. Use the pads.
    The paddles are going to be harder to hold. Make sure that the pads and the 3 leads are via the same machine. If your bay/bed has a monitor + defibrillator and you separate the monitoring and pacing – it won’t work. Also prep the chest for appropriate contact – clip excess hair (avoid shaving), wipe off excess fluids, move jewelry aside, keep medical devices away and remove any drug patches. Anterior Posterior position is preferred.
  3. Switch to pacing mode and choose fixed.
    I cannot find any sources mentioning which mode is superior. Demand mode is useful if the patient has an intermittent perfusing rhythm, in the ED we often just use fixed mode. The pacing mode is also sensitive to good sensing eg if there’s artifacts because of poor contact with the pads, this might go haywire.
  4. Set a rate.
    I like to use 60-80bpm.
  5. Set an output.
    The sicker your patient, the higher you want to start, you can do 70-80 mA and adjust accordingly. Aim to be 10-20 mA above the minimum to maintain that pacing (eg if the patient moves and there’s poor contact etc)
  6. Check for capture.
    This should be both electrical (a pacing spike is consistently followed by a waveform) as well as mechanical (a consistent pulse is felt – preferably distally to avoid the confusion from the muscle twitch, as well as an improvement in the hemodynamics)
  7. Call your friendly cardiologist.
    The patient may need to be on transvenous pacing, an urgent angiography / angioplasty or even a permanent pacemaker. Most of these patients need to be in a cardio High Dependency or Intensive Care Unit anyway.

Further Reading :

Physio-Control Manual on Non-invasive Pacing

Internet Book of Critical Care – Bradycardia

“I have more morphine than you have pain”

14 06 2015

… said the lecturer to a hypothetical patient during our lecture on kidney stones. He indirectly admonishes our management of pain, an issue that is well studied and one which I had fruitful discussion with Andrew Coggins online. It is extremely satisfying to have a person, screaming and shouting in pain, respond to a good dose of morphine.

So now, I’m at a point in my career where you start taking things for granted. Where, you tend to start seeing things as “work” and the time when you first put your stethoscope to someone’s chest and gushed about being able to hear a heart beat are long gone.

This documentary shakes your out of that complacence and reminds you of the discoveries that changed the course of human history and medicine. How chemists worked hard distilling opium into a reliable morphine and tried it out on their pets, assistants and themselves, about the patients who gladly (and sometimes reluctantly) offered themselves as test subjects. It covers a whole lot of ground from the history of pain management, the surprising butterfly effects triggering(coca cola anyone?) their discoveries and the story of how these drugs eventually got out to the public.

Early on in the documentary, Druin Burch talks about his impressions of an early, failed demonstration of inhaled anesthesia –

“No one had imagined that anesthesia could exist and I think that’s why Wells failed in his demonstration of nitrous oxide because they found the very idea that pain was optional, that pain could be deleted, erased from the world, so intrinsically fraudulent that they were predisposed to reach that conclusion.”

Which makes you wonder, what blind spots might we be having today?

Thought Train – What does it really mean to settle down?

27 08 2014

Source – lorenzaccio on flickr

I used to think that to be truly settled down in a place, you need to be comfortable taking the bus. Looking back at my stay in Bangkok where I took a bus to work in an
absolute foreign country and then rented a place where I would start my day with a delightful boat ride to work, I suppose there is some truth to the naivete. Though I
wonder if planning a trip by public transport to a new place is more of a step in growing up rather than settling down per se. When I was much younger, my benchmark for
having grown up, and being able to take care of myself, meant being able to take a bus or train independently in Mumbai.

Taking the train in Mumbai seems like such a struggle in contrast to the ease of movement back at home. 

Thought Train: On going home

26 08 2014

I wonder if home means something else to people who travel a lot. Is it something more special because they have limited access to it? Do they find it easier to make a place their home or harder? I sometimes find it easy to be at home almost anywhere, but I wonder if it has got to do with having stayed in a single spot for many years and it feels like you can relax and make yourself comfortable anywhere because on some instinctual level you know that abode is only temporary.

Which begs the question.

What does it really mean to settle down?

Books! Emperor of All Maladies

3 08 2014


I’m paying a bomb in overdue fines for this book, but it’s worth it. The book has been on my radar from a few years ago after a close friend recommended it, but it wasn’t available on the library’s otherwise fantastic e-book portal so it took a bit of a coincidence to finally get my hands on it.

i started reading it way back in June when I started my surgical oncology rotation. As I was doing a takeover of the patients before starting, one of my colleagues jokingly spoke of the field as being almost Halstedian (a reference that is easy to misconstrue). Halsted is famous for proposing the radical mastectomy, a major, disfiguring surgical procedure involving removal of the breast, the pecs, and lymph nodes in the arm pits. Surgeons of that era noticed a trend of breast cancer recurring in the margins of the previous surgery and this drove them into a frenzy of more and more invasive surgery (including removing lymph nodes around the collarbone, the chest and so on). This turned out to be a bad idea and looking at the data, it didn’t seem to improve life expectancy, yet the story goes that Halsted dogmatically persisted with aggressive surgery against consensus. Despite that Halsted is famous for a number of this as his wikipedia entry attests to.

Siddhartha Mukherjee really paints a lively, colourful picture of cancer’s history, and it looks like the secret to doing that well is to really flesh out the people who made that history. Mukherjee goes a step further to make the science accessible. Now I am clearly biased and I am reading this book as a medical professional and as the title of my blog suggests, always a student at heart. This paragraph, truly embodies how medicine should be taught. not as a bunch of dry facts but as a logical though process, with the appropriate historical context adding colour to the story.

“In 1982, a post doctoral scientist from Bombay, Lakshmi Charon Padhy, reported isolation of yet another such oncogene from a rat tumour called a neuroblastoma. Weinberg christened the gene neu, naming it after the type of cancer harbouring this gene.

The product of the neu gene in contrast, was a novel protein, not hidden deep inside the cell, but tethered to the cell membrane with a large fragment that hung outside, freely accessible to any drug. Lakshmi Charon Padhy even had a “drug” to test. In 1981, while isolating his gene, he hass created an antibody against the neu protein.

Weinberg had an oncogene and possibly an oncogene blocking drug but the twain had never met (in human cells or bodies). In the neuroblastoma cells dividing in his incubators, neu rampaged on monomaniacally, single mindedly, seemingly invincible. Yet its molecular foot still waved just outisde the surface of the plasma membrane, exposed and vulnerable, like Achilles’ famous heel”

I never imagined, during my cancer biology lectures back in med school that Cancer, something that we often see as depressing, morbid and sometimes hopeless, could have a story behind it that’s hopeful, inspiring and quite a scientific adventure.

It’s made me appreciate the training I’ve had and the value of good teachers.

Med school has ended

7 02 2014

That is an ironic thing to say considering how the title of this blog is medschneverends. Yet, today, I just finished my final end of rotation test and hung out with my group mates for a final post-test outing. I’m a very nostalgic kind of guy and thought about how I went from my first day with a stethoscope where I was convinced that all the heart sounds heard from a stethoscope were make believe to the stage where you listen to a patients chest and start making some inferences as to why the heart sounds the way it does and what treatment you can offer the patient.

It’s a long hard journey that would not have been possible without some lovely friends, patient mentors, my parents who have been very enabling and multitudes of willing patients who were kind enough to let me listen to their chest multiple times without complaining. This goes for the entire spectrum of clinical skills I’ve started acquiring and refining over the past three years.

It’s time to settle down and prep for the finals and on the bright side, it would mean some time to really digest all those years of learning and just maybe, I’ll be able to a bit of writing on the side too.

Cheers to many years of learning ahead!

On Liposuction …

29 08 2013

On Liposuction – Removal of abdominal adipose tissue with liposuction does not improve insulin sensitivity or risk factors for coronary heart disease, suggesting that the negative energy balance induced by diet and exercise are necessary for achieving the metabolic benefits of weight loss – Klein S et al, Absence of an effect of liposuction on insulin action and risk factors for coronary heart disease. N Engl J Med. 2004;350(25):2549

There you go. Read the rest of the paper here. Via UpToDate

Homeopathy taken to its logical conclusions

1 06 2013

“Drunkards would have the time of their lives in a world where homeopathy worked. Ethanol diluted in water in any amount makes the drink a spirit. The lower the alcoholic content the better. You would need a microscope to find a drunkard’s flask.”

So says Kyle Hill in a recent piece, “The Miracle of Molecular Medicine“. He also waxes lyrical on the other supposed benefits of Homeopathy. It is an amusing thought. While a homeopath might argue that that is not really what “similia similibus curenturmeans, increasing the potency of a substance by diluting it does seem to be the explanation for the increased strength of homeopathic preparations.

Here’s a Mitchell and Webb Sketch poking fun at Alternative Medicine.

Doctors without iPhones.

31 05 2013

Back at home, the iPhone seems to be the more popular choice among doctors and medical students. Over here in Mumbai, I overheard this conversation.

Dr A: Somehow my iPhone doesn’t seem to be working so well.

Dr B: Arey, get a good Samsung na?

I didn’t pay too much attention to that conversation until I saw this on my Facebook feed.



I wonder if the non-medics are seeing the same picture. I also wonder what’ll happen next, will attractive Samsung reps replace the drug reps?

“Kill the Buddha”

25 05 2013

I was listening to Alan Watt’s On Time and Death when he quoted the following.

Followers of the Way [of Zen], if you want to get the kind of understanding that accords with the Dharma, never be misled by others. Whether you’re facing inward or facing outward, whatever you meet up with, just kill it! If you meet a buddha, kill the buddha. If you meet a patriarch, kill the patriarch. If you meet an arhat, kill the arhat. If you meet your parents, kill your parents. If you meet your kinfolk, kill your kinfolk. Then for the first time you will gain emancipation, will not be entangled with things, will pass freely anywhere you wish to go. – Linji Yixuan, Chinese Zen Proponent

I think this comes from a perspective of challenging one’s own internal idolatry, which can come in many forms. As a non-believer it is crucial to stay alert and check if one is worshipping other, less conventional Sacred Cows. Happy Vesak/Buddha Purnima.