eprn

Syncope is tricky, and there are many, many causes for it. Like I said, it can be an extensive workup. As far as your axis deviation, it's generally meaningless by itself. Let him continue his workup and hopefully they will come up with an answer for you. Good luck.

Yeah, you may need an extensive workup, such as the ol' tilt table or an EP study. If they just can't figure it out (even after the event monitors, holters, studies, etc.), they may implant a loop recorder. It's a small implantable device that can monitor your heart rhythm for a year or so. I've seen them used in cases of syncope that really don't have a cause they can readily identify. Of course, the loop recorder is only going to rule out an arrhythmia. There are plenty of other reasons behind syncope. Hope this helps...

SVT is one of those things that many people treat as a nuisance. However, it also tends to get worse (i.e. more frequent and longer episodes) as time progresses. Eventually, most people get sick of dealing with it and wind up getting an ablation. I'm glad he may get cryo. The fact that your EP is using it speaks volumes. It's painless and is MUCH safer than traditional RF energy (although RF really isn't that dangerous, really). Good luck!

Yes, I want to know what happened, too. SVT ablations come in many flavors. The most common is AVNRT or AV nodal reentrant tachycardia where there are essentially two pathways an impulse can take down the av node. Basically, the impulse goes around in circles and rapidly conducts to the ventricles, hence the high heart rate. This is the most common type of ablation as well. The EP just ablates the extra pathway. It's the most common ablation, and it's relatively safe. There is a slight (my docs always quote 1%) chance that the av node can be knocked out, requiring a pacemaker implant. Some of the more progressive centers are using cryo for these ablations, and they (supposedly) have never inadvertently destroyed the av node with cryo. There are other types of SVT and SVT ablations out there. Give us some particulars!

Whoa, boss: I'm not saying that you can't put a magnet on it. I just think it's kinda irresponsible to assume that the magnet will magically take care of the problem. An ICD (or even a pacemaker) is a complicated device--it's a computer. It's just not always as simple as putting a donut magnet on it. These devices become more complicated each month and they need someone who is trained to interact with them. It's a specialty in it's own right. If you need to turn the thing off, you should be sure and have someone who knows what they're doing--be it a tech, an RN, or a rep who has been trained (and has the equipment) actually turn detection off. Most hospice nurses that I know are totally aware of this. Also, 1. You absolutely need an order to turn detection off, period. There's a difference between being a good patient advocate and going way outside one's scope. I doubt the Board of Nursing will accept that argument for overstepping your boundaries, it's just not worth your license. That being said, a properly trained person (including an RN) can do it with a programmer with a proper order. I mentioned turning pacing off earlier. It's radically different. 2. Every company and many large hospitals have people on call for pacers and defibrillators 24/7. I've never had a problem finding somebody to take care of something, if I needed it. If someone won't come in the middle of the night, then you need to address their crummy service. Yes, if you're in the middle of Alaska, that can be a problem. But for most, especially those closer to large cities, it's not. 3. A magnet will not "shut the whole system down." All defibrillators made within the last several years have pacemakers built in. As I've pointed out, placing a magnet on such a device may "blind" the device to VT or VF but it will not stop pacing. It can't. If you place a magnet on a pacemaker (a plain ol' pacemaker), it will force the pacemaker to pace at the magnet rate (which varies by manufacturer). It ABSOLUTELY will not turn a pacemaker off. The reason I said these things is because I've been involved in this situation plenty of times. If the time has come to turn the detection off, then the patient deserves to have it done correctly. That's my point. I did not intend to argue end-of-life issues, or anything like that. I agree that nurses are often too passive when it comes to end-of-life issues (and many issues in general), but for crying out loud, let's make sure stuff is done right--especially in situations like this. Thanks:saint:

With the recent problems with some Guidant devices, many of the magnetic reed switches were turned off, meaning that they will not respond to a magnet in any way. In Guidant devices, this feature is programmable. In Medtronic devices (and most devices are Medtronic devices), a magnet will disable detection. As an interesting twist, devices made by CPI (a predecessor to Guidant) will have their detection disabled permanently by magnet application UNTIL a person with a programmer turns it back on again. This isn't an issue in folks who are DNR, but it is an issue with the OR. It really is easier to get an order to have a rep turn the detection off if the patient desires it. It usually isn't a big deal. Remember that turning detection off is quite different from turning pacing off. The two are not related in an ICD. Does this make sense? I hope this clears it up.

That is interesting. Maybe there's a scheduling conflict. On the other hand, there could be some political intrigue as well.

Oh, and I even know how to spell "Cincinnati." It helps to slow down when you're typing that word.

Okay. I'll start. I'm an RN (for 6 years now). I'm in Dearborn County (just west of Cicninnati). I've always worked in Cincinnati, OH and I don't even have an IN license yet. Oh, and I graduated from the University of Cinicinnati.

Not all cardiologists may implant pacers. A cardiologist either needs to have gone through device training or an entire electrophysiology fellowship to be an implanter. Otherwise, they will have to refer it to another implanting cardiologist, an EP, or a surgeon. Where to implant the device is a subject of much debate. Some doctors and facilities believe that the infection rate is higher in the cath lab and for this reason they prefer to have it done in the OR. I haven't seen any hard data concerning this and, for that matter, I've seen just as many infections in the OR as I have in the cath lab. Secondly, there are some who think that the cath lab staff just isn't as good as the OR staff at these implants. This shouldn't be a problem for a properly trained and experienced team in the cath lab. Then, there's the politics. In some facilities, the cath lab will compete with the OR for these implants for the $$ (although this is more of an issue with ICDs than with pacers). In other facilities, the OR believes that these cases are more of a hassle and would rather shunt them to the cath lab. Finally, there's the physician's preference. Surgeons tend to feel more comfortable in the OR, while cardiologists/EPs are more at home in the cath lab. I hope this helps, and I hope I didn't bore you.

Let me start by saying: Don't give up the ship! It sounds like your old facility had a lousy training program. These problems should've become apparent long before now and should have been addressed. The nice thing about nursing (in most areas of the country) is that there are limitless opportunites for the nurse who wants to apply him/herself and is willing to find out what they really want to do. Now, there's the hard part. You need to get some kind of basic experience under your belt before having access to all those opportunities that our profession can provide. You don't necessarily need to do med/surg, but you need to find something to do to get some basic experience. I'd suggest looking for a facility (and hopefully there are some options where you live) that is willing to provide you with an internship that will allow you to adjust to the stresses of the job. The stresses you encountered are common to most areas of nursing (at least they are common to all hospital jobs), but most of us learn to adapt to it. Once you have your skills--including those all-important time management skills down, the sky's the limit. They were wrong to simply throw you to the wolves. That sucks. I urge you to not give up and to find a place that will help you get that vital base of experience. Best of luck to you...

A few years ago one of the hospital systems here in town offered $30,000 for cath lab/EP nurses. They were required to stay for 3 years. Well, the three years just ended and now there's an exodus out of that system. As you might expect, these nurses were sentenced to three years of indentured servitude, getting trampled on regularly. Most of the ones I spoke to said that they regretted ever taking the money. It turns out that after Uncle Sam and the state took their cut, it wasn't that much at all--especially when you consider the fact that it was paid out over three years. You know what they say about things that seem to be too good to be true...

I'd have to agree with those suggesting that you find an EP. Most SVT is relatively easily induced during a study and they can usually ablate it then and there. People with these tachycardias generally tend to have more and longer episodes as time goes on--it usually doesn't go away. Hope this helps.

I've been programming devices for years, and I encounter this problem often. The physician needs to write a very specific order for what he/she wants. Have the rep (or your hospital's device people) contact the physician for specifics if necessary. First, do NOT just sit a magnet on the ICD. Different devices do different things when they encounter a magnet. Call whatever company made the device. Secondly, you can just have him/her turn detection off which blinds the ICD to arrhythmias but does not interfere with pacing. Turning detection off and turning pacing off are two entirely different things. Turning pacing off is extremely controversial and would have to be done by the physician (or the HOSPITAL'S device RN/tech--as no device company will do that). I've been at places where turning off a pacer had to go through a review by the ethics board and legal affairs first. It's a pandora's box, trust me. Hope this helps.

You know, I forgot to mention a little bit of precious info about the Cincinnati market. There is no BSN differential, and that sucks. Just thought I'd share...:angryfire

The UC accelerated pathway program was great. I was there six years ago, when we had to do 25 credit hours/quarter (If you didn't go postal first, you graduated). Just watch certain faculty members--don't let them indoctrinate you into the "ivory towers" of nursing academia. When seeking career advice, go to your clinical faculty first. I'd still recommend it.

B North is pretty much a carbon copy of every other Cincy tertiary hospital. The pay scale is pretty much identical (I've worked/interviewed at most). The real plus about BN is the neighborhood, which is much, much safer than the downtown hospitals. Most of the Cincy hospitals pay exactly the same (they share information with each other regularly). I agree that St. E's really is the exception (and possibly University because they're a union shop). If you go the St. E's route, stick with St. E's SOUTH. Trust me.:)

In Cincinnati it's hovering between $18-$19 per hour.

I worked a cath lab for a few years (and I'm now in industry). Undoubtedly the worst thing was call--both getting called in in the middle of the night as well as holding patients for hours on end in the evenings when there were no beds. Otherwise, it was certainly the best nursing job in the hospital. I left the ER for the cath lab and I can say that I loved the technical aspect of it. I still miss those folks.

I double-ditto. The atrial rate for a patient in a-fib can be much greater than 300 bpm. You can't overdrive pace it. There are pacemakers that can deliver extra atrial pacing when a pt. has pac's to keep them out of a-fib, but once it's there, you have to try other things to stop it.

It's funny that you mention the reimbursement for the a-fib ablations. I think you're right. EP is not (entirely) beyond the "move the meat" mentality. Yes, the A-fib ablations are out there for some patients. It's a difficult thing to do. Many EP docs don't know how to do a transeptal puncture or don't want to do one. It can be quite dangerous. We do A-fib ablations, but we have to spend 4-5 hours doing one. They're a pain, but we're getting better at them every week. They're time-consuming, high-risk procedures, where an AV node ablation takes less than half the time (including the ppm implant).

Some people have an arrhythmia that wasn't ablatable, so we do an AV node ablation if medications don't control their symptoms. Does that make sense?

AV node ablations are pretty common, and we do it maybe 2 times a week. We usually reserve it for people who haven't responded to medical therapy or ablation AND who are totally miserable. We can usually do it in less than two hours, and it really takes more time to put in the pacemaker than to do the ablation itself. This is different from flutter ablations or a-fib ablations. Neither of those require a pacer and you are really trying to fix the problem with these.

Regarding the surgeon who was annoyed that his patient was shocked so many times: If they're in VF, they need a shock. Period. Electricity is really the only thing that fixes VF, so the surgeon's choice is simple: living patient vs. dead patient. Yes, defibrillation damages the heart. You can see cardiac enzymes elevate after someone's been shocked, and it can make pacing thresholds go up significantly. But...it beats death.:chuckle

There is no concrete number. After a number of defibrillations, however, your heart can undergo electroporation where the threshold power required to defibrillate will become much higher--and then you'll have some awfully stubborn VF/VT. I think this is really more applicable to ICDs which use internal defibrillating coils rather than external paddles (or patches)--but I suppose the same could hold true for external defibrillation. I've had ICD patients receive dozens of shocks in a few hours. If the pt. had an ICD, it might be able to pace them out of the VT without getting shocked all the time. Maybe.