New Puzzler Answer

[Guest guest]

KUDOS AND CONGRATULATIONS to the many folks who got this right.

Some of you didn't know the name for it, but that's OK. You figured out

what had happened.

Some of you are destined to leave EMS for a career in comedy, well, maybe,

Tim. Don't quit your day job just yet, but don't hang up on Letterman either.

The situation is known as " Twiddler's Syndrome " and it gets that name because

people " twiddle " with their pacer by feeling of it over and over with their

fingers and in the process cause it to turn around in its little pocket,

winding the lead around it like fishing line on a reel. As this happens,

little by

little, the lead gets pulled up and out of position. If it's a ventricular

lead it can get up into the atrium and start pacing there, or it can go back

up into the superior vena cava and start pacing whatever nerve is close to it.

In this case, it was the phrenic nerve, but it can be the brachial complex

and cause the right arm to twitch, and so forth.

It usually happens in older ladies, because the connective tissue around the

" pocket " is loose, allowing the pacer device to turn. The remedy is to

tighten up the pouch, tack the lead to connective tissue, and so forth, so it

won't

move again.

The condition can cause plenty of problems, not the least of which is failure

to pace and drop in cardiac output and PEA, et cetera.

It's great to know that so many of you are so sharp. Thanks for playing.

Gene

In the case I presented, the patient was actually a man whose swimming caused

the lead wire to pull upward with his forward stroke, and it eventually

pulled out of position and started pacing his phrenic nerve.

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