My recent ER experience...a bit unsettling

The wisdom imparted here is that one is responsible for one's care. Inherent is the learning that must come during or prior to submitting to any possibly damaging care. I have done a lot of reading, and am somewhat learned about the topic of AF and its treatment. I try not to annoy people, and that might sometimes be as injurious as not bothering to keep up or to learn in the first place. Or, to challenge health authorities when you suspect they are making a mistake.

I had a brief stay in my local ER last evening. It was a familiar problem, an apparently intractable run of supra VT or flutter. The steady rate showing on the ECG, and its high number, 149, told me that, for me, it was almost certainly flutter. The kind technician administering the 12 lead ECG looked closely and said she could see a 2:1 block...meaning flutter. However, when I asked the internist as she discharged me what she saw in my ECG, she said I had been up and down in rate, and that it was AF.



Okay, so a disparity there. Earlier, when she learned of my cardioversion failures two months ago, she said she didn't think it was reasonable to do another. I had understood that each ablation is almost like a renovation in a room, and that cardioversion was pretty much the first resort. But, I don't have PhD or MD behind my name, so I conceded her point and went with her 'mo' meto' approach. Which worked....eventually. I had already had 50 mg in the previous four hours, so she had me take another 25 mg white pill, and they pushed another 15 in 5 mg doses through the IV over 15 minutes. 30 minutes later, she came back, almost shrugging, and said she would call a specialist. Not eight minutes later, she came running back in and said, 'Look!", pointing at the monitor. It showed 56 BPM. When letting me go, she advised upping my EP-prescribed 50 mg/day metoprolol to 50 mg twice. Again, I wasn't in a position to argue, but I don't do well in NSR with metoprolol in too high a dose. It's Brady City for me.

So, in all of this, when I told Lindsey Ward, my AF Clinic outreach hand-holder, about my experience last night, she immediately said it was all wrong. Cardioversion was absolutely the very thing that should have taken place post ablation. And she strongly suggested I try reverting to the EP's prescription of metoprolol, adding that legally she could not contravene the internist's advice and recorded prescription.

To conclude, I chickened out when it was important not to. Don't do as I did. Learn, be confident in your learning, and when you suspect that your care could be deleterious, DO something about it!! I ought to have simply stated to the internist that I wanted her to cardiovert me anyway. She might have been a little miffed, but isn't that better than not having that important result in the first place? And then, to compound the erroneous care, she doubled my metoprolol, something the more focused Lindsey Ward knows is not the right thing in the long run.

So, my bad. I should try harder, especially not to get discouraged and go numb when things go sideways in the first few weeks after a new ablation. It just doesn't pay.

Well I’m so sorry.
I was a veteran at the ER. 12 admissions November alone. 95% of the doctors knew me from my frequent trips, 99% of the nurses too. I demanded a cardio version. It got to the point that I would come in, the ER dr would look up to see who his patient is, then say, Hi, do you want an ecv? I was ecv 54 times.

However I had problems with three er doctors. 1st (12-26--20) insisted on an adenosine challenge. I said no, I’m allergic. I then emailed (I’m surprised I was able to being sweaty, angina and dizzy) in front of him Dr Natale’s NP.,While still arguing with him not to give it to me because of two horrible reactions prior, his cell ringed and I heard he was talking to the NP. I heard him say “you are a Np so I don’t have to listen to you”. He then gave me not one, not two, but three doses of adenosine against my wishes. I had a Mi on the spot. The two RNs in the room independently (I heard later) filed a grievance against the ER dr. He no longer practices there.

Second ER dr at a different time refused the ecv. So the two nurses (different ones who treated me before) went to the ER dr and said my hr was 190. She granted the ecv and they hooked me up. Right before the ecv, the dr came in the room and had a fit because my hr was 150s. She allowed the ecv and I converted, I thanked the two nurses and went home.

The third ER dr (out of dozens and dozens and last ER in November) ) refused to treat me. I was symptomatic uncomfortable and had a 135hr flutter. He insisted I was stable and wanted to discharge me after hours of waiting and my hr was 139. I refused. He then said, ok, you can stay but we are removing all your comfort. They removed my blankets and took me out of the non contagious hallway and made me go to the coughing room. I was so dizzy I just laid down. Two hours later one of the two RNs (who wrote the grievance) talked the er dr to treat me.

They called me back and he apologized saying he over reacted and was not familiar to the severity of my condition. I was then ecv. It only lasted 30 minutes and they wanted to discharge me. My savior told the ER not to. That’s when I was admitted (2 nights in an ER coughing mixed gender ward) until a room upstairs was available. I decided right then to get the av ablation.

Stick to your guns and be your own advocate.

Between me and Susan we have over 100 ECV experiences, plus the times they didn't convert us.

"The steady rate showing on the ECG, and its high number, 149, told me that, for me, it was almost certainly flutter. The kind technician administering the 12 lead ECG looked closely and said she could see a 2:1 block...meaning flutter. However, when I asked the internist as she discharged me what she saw in my ECG, she said I had been up and down in rate, and that it was AF."

Yes it's surprising how many ER technitions and nurses misread ECG's.

In retrospect, you could have just simply asked the Intern to call your Dr., or another specialist before letting them treat you. Your regular Dr. probably has a 24 hr emergency number, of a specialist on call, maybe not your own Dr., but of an associate with access to your records. The Internist did end up planning to call a specialist to her credit, and it sounds like she would have done the EVC if advised to. The follow-up advice on doubling he Metroprolol dosage should not be followed over the advice of your own Dr., only accepted as a suggestion. Maybe she wasn't that comfortable or experienced in doing an ECV, in that case you may not want an ECV from a her anyway.

Having said this, your main contention is valid. When I went to get get an ER ECV, I confidently told them I wanted one, that it was the right action called for, and that my regular EP had sent me there for it. This last part is very important, and having a number for them to call or even a note of recommended treatment makes a huge difference in a situation of hesitant or reluctant ER staff. In my experience 50% of the time they would prefer to discharge the patient or admit you into the hospital, and let a cardiologist handle the situation later. One time a young ER Dr. got upset and sort of kicked me out, but looking back on it, I didn't want him doing an ECV on me anyway, if he was that uncomfortable. Finally having all the experiences I have had, I always go as an out-patient through the regular Cardiology dept. if I need an EVC, if at all possible. Things go much smoother, and the error rate is way lower, and it is usually a more positive experience.

Thanks for sharing. While I do not have the Afib issues some of you have, I have noticed the different approaches the MD in the ED setting. And I had one ED doc that was annoyed that I even was there.

I had doc that immediately wanted to do ECV, to doc that gave me Cardizem got the rate below 100 and discharged me while still in afib. So I have found it difficult based on the MD response to determine when do I go and when do I stay home.

What determines when you decide to go to the ED?

Also one more questions. Your posts mentioned this. Once you have an ablation and you have rhythm issues is the ECV the first line of treatment before meds if you go to the ED?

Thanks

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JakeS
What determines when you decide to go to the ED?

I've been once - for my first afib episode in 2004. After a couple months of self converting episodes, I had a 2.5 month episode. The EP suggested I just stay out of rhythm as my afib heart rate, then, was < 100 BPM. I countered with a "Plan B" that included detraining from chronic endurance fitness, electrolyte supplementation and a script for flecainide to be used on-demand (AKA "PIP" or Pill in Pocket) to convert (study). I've successfully been following this plan since. If PIP is appropriate for you, perhaps discussing with your EP?

We are all different. I had afib for 11 years, 5 misdiagnosed and 6 years on meds. 200 episodes documented in those 6 years, longest was 72 hrs. I had one ECV, but did not go for more since I always converted on my own. HR while in afib without meds was 180. Now ablated and doing very well.

So, why so many ECVs for some of you? Can't convert on your own? If on rate control meds, why is there a rush to convert?

Cardioversion is exactly what should have happened, and for her to modify your prescription was over the line. The job of an ER is to stabilize you and prevent you from dying. That's it.

My advice in the future is just follow your EP's instructions and don't go to the ER. Relax, stay home, and wait it out. Your experience with an ER is always going to be iffy and it's going to depend on which doc happens to be on duty that day. Most ER docs won't cardiovert a rhythm in the neighborhood of 150 because that's not a dangerous rate. So all they'll do for you is give you more rate control and let you wait until it stops on its own, which is something you can do yourself from the comfort of your own home.

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JakeS
Thanks for sharing. While I do not have the Afib issues some of you have, I have noticed the different approaches the MD in the ED setting. And I had one ED doc that was annoyed that I even was there.

I had doc that immediately wanted to do ECV, to doc that gave me Cardizem got the rate below 100 and discharged me while still in afib. So I have found it difficult based on the MD response to determine when do I go and when do I stay home.

What determines when you decide to go to the ED?

Also one more questions. Your posts mentioned this. Once you have an ablation and you have rhythm issues is the ECV the first line of treatment before meds if you go to the ED?

Thanks

Jake, each of us has a level of tolerance to AF/Flutter, and that means anxiety, discomfort, or someone present who is even more worried and wants you to get some professional help. All three apply in my case. So, in this last instance, I waited about five hours and watched my HR climb a bit all along. Also, I did take 50 mg of meto over two doses about two hours apart, and it didn't shift the arrhythmia. I know that sleep will be almost impossible for me, and my wife would be just as bad. So, off to the ER we go...remember, with me expecting that a cardioversion wa s a reasonable and preferred intervention in my type of case...two weeks post-ablation.

My original message, and Carey, Shannon, Susan, and George shout it almost daily, is to be your own best fan, to be an educated fan, and to stick with what you know when the chips are still rattling on the table. For me, I should have said that my case was a textbook cardioversion candidate, her feelings notwithstanding. In all honesty, I think she would have been okay and done what I asked if I had simply said, 'Let's do a cardioversion because I'm a typical case after a recent catheter ablation and with two weeks of perfect NSR until just now.'

BTW, in my conversation with Lindsey Ward yesterday, I asked her, "Why isn't there a note left on my file by, of all people, my EP, saying that if x, y, or z happen (not atypically), perform the following or contact me at ..." She immediately realized that it was something that ought to be in place for the benefit of patients if for no other reason.

Thanks for the response.

Outright asking for cardioversion might have worked, but ER docs tend to be reluctant to do them. Lots of possible reasons with not being a cardiologist ranking high on the list. I encountered one ER doc who wouldn't do anything until he got someone from cardiology to come down and hold his hand (that took an hour). Another reason may be the hospital's policy on anesthesia. Most ER docs are familiar with propofol and will use it for a cardioversion, but some hospitals won't let them. So that means they have to get someone from anesthesiology to come down to administer it, and that could take quite a while.

And yeah, virtually all EPs are bad about giving complete "what if" instructions. I don't know why since the instructions would be the same or nearly the same for almost everyone.

Thank you all for posting your ER experiences. What you all have been through has been a lot of frustration, pain, and agony to say the least.

It puts my 2 recent ER experiences into perspective and makes them seem like nothing in comparison. Like many of you, my experience was frustrating and not fruitful. I will do everything I can to avoid future ER visits whenever possible. Your experiences and guidance help me know what to ask for when I do.

All of you who have found this helpful, if (cough) unsettling in your own right, are welcome. I posted it to serve as a form of reflection for my own failings, to show I'm not a bot , and to help to instruct or to enlighten others who may need some frame of reference for their own experience, or for their own fears if they haven't yet undergone any of this.

I have to say that I have always had excellent, if delayed, care in my local ER. It's busy, with lots of overdoses and up-island evacs coming by helicopter or ambulance. But when they could get to me, they were cheerful, efficient, empathetic, willing to share a laugh, and they got me turned around. Even the latest internist was not what I would call incompetent...just maybe unschooled, or uncoached because there was nothing on my record that suggested a cardioversion was the first course of action. My hope is that someone gets back to her and lets her know that her patient ought to have had that done, and pronto.

If you get into trouble, your ER is the place to be. It may be loud, smelly, and lengthy, but universally the staff still employed there after a trial are going to be pulling for you.

I carry a letter from my local ep stating please ecv my patient. It helped because even though my Ep wasn’t attending at my ER, they xeroxed the letter and ecv me. One time I had to wait. Even though I was on 5mg eliquis bid, I had flown internationally the prior ten days. I didn’t get a TEE but some sort of imaging without anesthesia and then they ecv me afterwards. That was my favorite hospital near me. I would walk in, nurses nodded saying hi and said get the crash cart ready, Susan is back!

If you don’t have a letter giving permission to ecv, take a Kardia reading the prior days. It helps.

Great idea Susan!

Yes, that should work, Susan. Maybe double up the chances by having your accessible record reflect that you should have certain treatments, and in which order. At least, with the public health system in Canada, my record is accessible to all doctors, and to others under supervision/direction. The staff a couple of nights ago were able to see my history of ECVs from two months ago, and of my recent ablation. A more recent note, post ablation, would have been instructive, and probably have saved everyone about three hours of gurney time.