VOD stands for Vitals of the Day, and it is practice of less-than-scrupulous ambulance companies in which they don't bother taking the patient's vital signs, rather they just enter the mutually-agreed upon VOD on the patient trip report. This practice is especially prevalent on ambulances transferring elderly patients from nursing homes for seemingly non-emergent problems.

In one such instance, an ambulance company (whose name will be omitted to protect the guilty), transferred an elderly man from the nursing home across the street. He had fallen out of his wheelchair, and the patient really had no complaints… the nursing staff just wanted him "checked out." Upon arrival, the patient seemed stable, and the ambulance's report noted a blood pressure of 132/74 and a pulse of 84. (Both within normal limits.) However, it is policy of the ED where I work to get baseline vital signs on all patients when they come in. When I attached the pulse-ox probe to the patients finger (measures pulse and oxygen level in the blood), I was astounded to see the pulse barely get up to 30. (80 is normal, anything under 60 considered too slow.) A quickly obtained electrocardiogram revealed the following:

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What is this EKG rhythm? What are the rate(s)? Interventions? Click on "More" below to see the answer.

The patient was in third degree (complete) AV block, and this is the absence of conduction of atrial impulses to the ventricles. The site of block may be the AV node (as occurs in congenital heart block), or within the His-Purkinje system (typical for acquired heart block). In complete heart block, the atrial rate typically exceeds the ventricular rate, with no fixed relation between atrial and ventricular activity (AV dissociation), and the ventricular rate usually is regular, owing to the regularity of the escape rhythm focus. This patient had an atrial rate of 70 bpm and a ventricular rate of 30 bpm. Response to pharmacologic therapy is poor and often temporary. Persistent symptoms, transient episodes with an under-lying etiology likely to recur, or the failure to identify a reversible cause, necessitates pacemaker therapy. In this patient, we "floated a pacer" in the ER. (Passed a conducting wire into the heart, and then pulsed electrical current through it, in an attempt to make the patient's heart beat faster.)

Moral of the story: Do your job and take the patient's vitals…