Description of Event or Problem · 1
THIS PT WAS A 78 YO MALE WITH NYHA CLASS IV CHF, THOUGHT TO BE IDIOPATHIC OR ETOH RELATED, MULTIPLE PREVIOUS HOSP ADMISSIONS, WITH EJECTION FRACTION OF AT 16%, WITH SEVERE MITRAL REGURGITATION, WHO WAS ADMITTED ON 5/11/96 FOR WORSENING OF HIS CHF SYMPTOMS. THE PT WAS ADMITTED TO THE CCU WITH SOME, BUT NOT FULL IMPROVEMENT OF SYMPTOMS AFTER INTRAVENOUS DOBUTAMINE AND DOPAMINE THERAPY. PT AGREED TO TRIAL OF THE STUDY DRUG A CALCIUM AGONIST ADN, AFTER PA LINE PLACEMENT, UNDERWENT A 2 HR INFUSION OF THE INVESTIGATIONAL DRUG FROM 2:25 PM TO 4:35 PM ON 5/21/96. PT TOLERATED THE INFUSION WELL AND HAD IMPROVEMENT OF HEMODYNAMICS DURING THE 2 HR INFUSION. AFTER THE INFUSION, THE PT CONTINUED TO RECEIVE USUAL THERAPIES FOR CHF WITH CLOSE MONITORING BY CARDIOLOGY SVC AND THE HOUSESTAFF. ON THE MORNING OF 5/24/96, PT FELT SOMEWHAT IMPROVED WITH REGARD TO HIS USUAL SHORTNESS OF BREATH AND ENERGY LEVEL. AT APPROX 1:325 PM THAT DAY, AFTER A BOWEL MOVEMENT, THE PT DEVELOPED PULSELESS V TACH, UNRESPONSIVE TO IMMEDIATE PRECORDIAL THUMP, THEN V FIB. A "CODE BLUE" WAS CALLED. THE PT UNDERWENT THE USUAL ACLS PROTOCOL FOR V FIB. AFTER THE THIRD SHOCK, THE PT HAD A BRIEF RUN OF SINUS RHYTHM WITHOUT A PALPABLE PULSE THAT QUICKLY DEGENERATED INTO V TACH THEN V FIB. AT SOME POINT, LESS THAN ONE MIN AFTER THE THIRD SHOCK, THE SCREEN ON THE DEFIBRILLATOR WENT "BLANK" AND DID NOT SHOW ANY IMAGE. TURNING THE "ON/OFF/ENERGY SELECT" DIAL DID NOT "TURN ON" THE MACHINE. THE UNIT WAS THEN PLUGGED INTO THE ELECTRICAL OUTLET IN THE ROOM, BUT NO EKG SIGNAL, NO LIGHTS, OR ANY EVIDENCE THAT THE UNIT WAS ELECTRICALLY FUNCTIONAL WAS EVIDENT. THE UNIT WAS REMOVED, AND THE PT WAS ATTACHED TO SECOND DEFIBRILLATOR AND UNDERWENT THE REMAINING PORTION OF THE ACLS PROTOCOL, INCLUDING 7 ADD'L SUCCESSFULLY DELIVERED DEFIBRILLATIONS. THE PT NEVER REGAINED A PULSE OR BLOOD PRESSURE AND THE "CODE BLUE" WAS TERMINATED AT 1:49 PM. THE TIME BETWEEN THE THIRD DEFIBRILLATION AND THE FOURTH DEFIBRILLATION WITH THE SECOND MACHINE WAS 5 MINS. IT IS IMPOSSIBLE TO ASSESS THE EFFECT OF THE FAILURE OF THE DEFIBRILLATOR TO DELIVER A FOURTH DEFIBRILLATION ON THE FINAL PT OUTCOME. THE TIME BETWEEN RECOGNITION OF A POTENTIAL PROBLEM WITH THE FIRST DEFIBRILLATOR AND DELIVERY OF A SUBSEQUENT SHOCK BY THE SECOND DEFIBRILLATOR WAS SHORT, AT 5 MINS. ALSO, FAILURE TO RESPOND TO THE ACLS PROTOCOL WAS NOT UNEXPECTED GIVEN THE PT'S AGE AND THE WELL DOCUMENTED END-STAGE DILATED CARDIOMYOPATHY. OF NOTE, PER THE ICU POLICY, THE BATTERY CHARGES ON DEFIBRILLATORS ARE CHECKED TWICE PER DAY. THE DEFIBRILLATOR IN QUESTION WAS CHECKED THAT MORNING AND FOUND TO BE FUNCTIONAL.