AED Refusal, Wet Chest, and a Pacemaker: Decision Points at the Pool Deck
A 65-year-old man collapses on a wet pool deck. Bystanders have pulled him clear of the water; his chest and swimsuit are soaked. He is unresponsive and not breathing normally. An AED arrives, but a bystander insists you must not use it because 'he has a pacemaker - it's in his left chest - the shock will stop his heart.' A second bystander says the wet skin will 'short out' the AED and wants to dry him with a towel first. You have scissors, a towel, and razor in the AED kit.
1. Resolve the pacemaker objection and the wet-skin objection, and state the correct sequence for applying the AED.
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Pacemaker objection: An implanted pacemaker is not a contraindication to defibrillation. The precaution is to avoid placing a pad directly over the device - place the pad at least ~8 cm (a hand's width) away from the generator, and use the standard anterolateral or anteroposterior placement otherwise. The shock will not 'stop his heart'; withholding defibrillation for a shockable rhythm is what kills him. Wet-skin objection: Water on the skin can cause arcing between pads and reduce effective energy delivery, but the fix is quick drying, not skipping the AED. Move him from standing water, briskly wipe the chest, and apply pads to dry skin. This takes seconds. Sequence: dry the chest → apply pads avoiding the device (and avoiding the sternum if a patch is present) → clear everyone, including oxygen sources → analyze → shock if advised → resume compressions immediately. Judgment point: neither a pacemaker nor wet skin is a reason to withhold defibrillation; both are handling adjustments.
2. The AED prompts 'shock advised.' Walk through the shock delivery and the immediate post-shock actions, including how you handle the wet deck and bystanders.
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- Clear the patient loudly and visually - "I'm clear, you're clear, everybody clear" - ensure no one is touching him or the wet deck in contact with him, and that no one is on the stretcher/board. Wet surroundings raise the risk of a bystander contacting water during discharge.
- Deliver the shock per the device prompt.
- Resume chest compressions immediately - do not pause to check a pulse or rhythm after the shock. Post-shock pause is a major determinant of survival; compressions restart within seconds.
- Continue 2-minute cycles, reanalyze when prompted, and swap compressors at rhythm checks. Judgment point: the shock itself is a 1-second event; the quality of the resuscitation is determined by how fast compressions resume and how short the pre-shock pause was. Bystanders must be physically clear, but do not spend extra time 'double-checking' at the cost of compression time.
3. After one shock and two cycles, the man begins breathing. The AED remains attached. What do you do with the device and the patient, and what is the most common error here?
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Leave the AED attached and powered on, with pads in place, so it can reanalyze immediately if he rearrests. Place him in a recovery position if breathing is adequate and a pulse is present, monitor breathing continuously, keep him warm and dry (wet swimsuit on a pool deck promotes hypothermia), and keep EMS access clear. Do not remove the pads or turn off the device. Most common error: removing the pads or powering down the AED because the patient 'looks fine,' leaving no immediate readiness if he rearrests - which is common in the minutes after ROSC. A second error is leaving him supine and unmonitored with a full stomach and no airway protection. Judgment point: post-ROSC care in BLS is 'keep the device on, keep watching, keep the airway protected.'