Temporary cardiac pacing.

Temporary cardiac pacing can be a life-saving manoeuvre. The indications and techniques are well established. 1 The procedure is one of the 'essential' components of the training programme in general internal medicine. This may be desirable, but is it wise nowadays? Is it achievable? The traditional indication for a temporary cardiac pacemaker is heart block; the usual venue for the procedure is a treatment room alongside a coronary care unit (CCU). Most patients have threatened or actual high-grade transient atrioventicular (AV) block in association with acute myocardial infarction. Some will have Stokes-Adams attacks or established AV block which is suYciently symptomatic to warrant urgent treatment pending the insertion of a permanent pacing system. For these patients, physicians with on-take responsibilities are required to learn the technique. Most physicians, however, lack the opportunity to maintain their skill. In Cambridge, for example, the number of temporary electrodes inserted in the CCU has dwindled year by year from 57 in 1994, to 29 in 1998; the numbers of procedures performed out of hours were, respectively, 29 and 10. Every hospital has seen a substantial increase in the number of senior medical staff. Many will admit that they have not inserted an electrode for a year or more, and would be nervous of doing so. Corridor conversations should not initiate policy changes, but they may prompt scrutiny of current practice. The reason for this decline is likely to be due in part to decreased need. The past decade has seen a huge change in the management of patients suVering from acute coronary syndromes. The introduction of thrombolytic treatment and the emphasis on rapid admission to hospital has meant that major infarcts are commonly aborted, and damage to the conduction system is rare. Supportive medical measures are more eVective, and in particular anti-arrhythmic drugs are generally avoided. Perhaps also, physicians who no longer feel comfortable with the technique will tend to postpone a decision until recovery or death occurs. There is nevertheless still a need for the skill. Patients with inferior myocardial infarcts who are expected to recover and victims of frequent Stokes-Adams attacks would be two such examples. The latter group are subsequently transferred to a specialist centre, often fearful of receiving a permanent system because the previous experience was so unpleasant. Multiple stab wounds, haematomata, and failure to pace are all too frequent complications. This was documented a decade ago in a study …