ASEAN Journal on Science and Technology for Development, 32(2), 2015only characterized by a shallow understanding in the accident and emergency department,of actual events and conditions taking place decisions had to used all for three processes to(Dioso 2015). Figure 2 illustrates how to trust limit mistakes.an intuition. In this case, we can see that clinical That was why surgery was suggested to guidelines majorly influenced the decisionsbe done straight away, since by intuition, and by all healthcare professionals who wererecognizing patterns of previously encountered involved in treating and diagnosing the patient.cases, the author could trust this decision as an Likewise, the clinical guidelines affectedalternative option. This option (surgery without the patient’s right to decide what is best forX-ray) might be trusted that was the lesser evil herself. Patients themselves should be the keyas also one of the norms usually done in this decision makers (Quill & Holloway 2011).hospital. However, in this case, the orthopedic surgeons instigate a decision hence, in the end the patient DISCUSSION agreed because she was in the state of feeling intolerable pain.This section discusses the effectiveness ofclinical guidelines and the decision options that It is also a good decision from the physicianswere used in deciding for the best diagnostic to uphold their Hippocratic Oath that doctorstest to be used for the patient in a fast paced should do no harm for their patients (Osei &environment. Darko 2012), which is why sometimes, doctors in the hospital settings always decides on behalf One of the guidelines says that fracture of their patients in a fast paced environment.requires immediate surgical operation that The case presented a typical decision-makingcannot be delayed, and requires an X-ray result that was manipulated by physicians in an(Stiell et al. 1993). However, the decision emergency situation. Rushing a decision givesshould not be rushed and must be done with no avenues for the patients to think and decidegood clinical judgment. for themselves (Daniels & Nicoll 2011). It was expected that healthcare workers Lastly, physicians should use evidence-should not be overly prescriptive or descriptive based counseling to eliminate the perception ofin a fast paced environment. That was why the risk of unsound decision making (Pregnancy IntuitionsIntuitive hypothesis generation Intuitive perceptions Choosing a remedy Patient and therapeutic relationshipEarly stage of Late stage of consultation consultationReject Trust Figure 3. How to use an intuition (Dioso 2015). 130
S. Ismanto: Decision Making Processes for a Pregnant Woman2000), and not just mitigating patients to Solving problems using prescriptiveimmediately sign their consents. A clinical decision-making, in this case was somehowguideline (complications of fractures) in this better if it was not affected mainly by clinicalcase was used to mitigate the pregnant patient guidelines. Broadening perspectives usingto sign the consent for X-ray since the guideline decision trees to create a mental frameworkmentions about morbid outcomes if diagnostic must consider all options in order to turn awayprocedures are delayed. from frame blindness, especially in a fast-paced environment. There are recommendations for clinicaldecision makers which they might want to Decision-making should see all sides ofconsider in the future as they face the same or the problem before making a decision so thatsimilar cases. patients feel satisfied and still be safe both physiologically and psychologically. It was recommended that patients on privatehospitals in Indonesia who were not so much AcknowledgEmentcapable of paying their hospital bills must limitusage of technology such as X-ray machines. The valuable assistance of Regidor III is muchIntuitions were recommended especially if the appreciated for the supervision of this study.chief complaint was recognized to be similar topreviously encountered cases. In this way, the Date of submission: January 2016impact of decisions gave more benefits thanharm to the patient. Date of acceptance: March 2016 It was still however recommended in a REFERENCESfast paced environment that the use of clinical Bell, DE et al. 1988, Decision making: descriptive,guidelines should be considered as the safestdecision making process. Explaining to the normative, and prescriptive interactions,patient the advantages of each diagnostic Cambridge University Press.examination in order for her to understandclearly the options provided was the better Cousins, C 2008, ‘Medical radiation and pregnancy’,decision-making process. Health Physics, vol. 95, no. 5, pp. 551-553. CONCLUSION Damilakis, J et al. 2002, ‘Embryo/fetus radiation dose and risk from dual X-ray absorptiometryIt was therefore concluded that in this study, examinations’, Osteoporosis International, vol.IPT dominated the decision-making process; 13, no. 9, pp. 716-722.hence an X-ray examination was done thatwas safe for the fetus and the childbearing. Daniels, R & Nicoll, L 2011, Contemporary medical-Decision options were somehow incorrectly Surgical nursing, 2nd edn, Delmar Cengagepracticed since the patient was in pain, and Learning, New York.was not capable of understanding the optionspresented, that was why the doctors were the Dioso, R 2015, ‘Decision-making processes forones who decided on her behalf. Therefore, a do-not-resuscitate poisoned pediatric patientthe decision maker must always be in control admitted to the department of emergency andpsychologically and intellectually in order to medical services—a case study.’ ASEAN Journaldemonstrate a sound decision. on Science and Technology for Development, vol. 32, no. 1, pp. 31-51. Eskandar, O et al. 2010, ‘Safety of diagnostic imaging in pregnancy. Part 1: X-ray, nuclear medicine investigations, computed tomography and contrast media’, The Obstetrician & Gynaecologist, vol. 12, no. 2, pp. 71-78. 131
ASEAN Journal on Science and Technology for Development, 32(2), 2015Eskandar, O et al. 2010, ‘Safety of diagnostic Academy of Orthopaedic Surgeons, vol. 11, no. imaging in pregnancy, Part 2, Magnetic resonance 6, pp. 40–412. imaging, ultrasound scanning and Doppler assessment’, The Obstetrician & Gynaecologist, Offredy, M 1998, ‘The application of decision vol. 12, no. 3, pp. 171-177. making concepts by nurse practitioners in general practice’, Journal of Advanced Nursing, vol. 28,Hardy, M & Boynes, S 2008, Paediatric radiography, no. 5, pp. 988–1000. John Wiley & Sons. Osei, EK & Darko, J 2012, ‘Foetal radiation doseHarrison, EF 1996, ‘A process perspective on and risk from diagnostic radiology procedures: strategic decision making’, Management Decision, a multinational study’, in International Schoarly vol. 34, no. 1, pp. 46–53. Research Notices (ISRN) Radiology, vol. 2013.Hart, MA 2005, ‘Help! My orthopaedic patient is Quill, TE & Holloway, R 2011, ‘Time-limited trials pregnant!’, Orthopaedic Nursing, vol. 24, no. 2, near the end of life’, Journal of the American pp. 108-114. Medical Association, vol. 306, no. 13, pp. 1483–1484.Høiness, P & Strømsøe, K 1999, ‘The influence of the timing of surgery on soft tissue complications Say, RE & Thomson, R 2003, The importance and hospital stay. A review of 84 closed ankle of patient preferences in treatment decisions- fractures’, Annales Chirurgiae et Gynaecologiae, challenges for doctors, British Medical Journal, vol. 20, no. 11, pp. 687–694. vol. 327, vol. 7414, pp. 542–545.International Atomic Energy Agency Vienna 2014, Shaban, R 2012, ‘Theories of clinical judgment Radiation protection and safety of radiation and decision-making: a review of the theoretical sources: international basic safety standards, literature’, Australasian Journal of Paramedicine, International Atomic Energy Agency, Vienna. vol. 3, no. 1, pp. 8.International Commission on Radiological Protection Stiell, IG et al. 1993, ‘Decision rules for the use of 2000, ‘Medical radiation (ICRP publication 84)’, radiography in acute ankle injuries,” Health Care, Annals of ICRP, vol. 30, no. 1. vol. 13, pp. 15.Kim, H et al. 2012, ‘Evaluation of effectiveness of Thompson, C & Dowding, D 2002, ‘Decision making new design lead apron during pregnant X-ray and judgement in nursing―an introduction’’, in chest PA’, Journal of the Korean Society of Clinical Decision Making and Judgement in Radiology, vol. 6, no. 6, pp. 441–445. Nursing, Churchill Livingstone, Edinburgh.Michelson, JD 2003, ‘Ankle fractures resulting Whitley, AS, et al. 2005, Clark’s positioning in from rotational injuries’, Journal of the American radiography, 12th edn, CRC Press. 132
ASEAN J. Sci. Technol. Dev., 32(2): 133 – 144 Decision Making Processes for a Patient with Cardiac Pacemaker Admitted to the Accidentand Emergency Undergoing Magnetic Resonance Imaging – A Case Study F. P. RadityaThis case study aims to apply the processes of decision-making for magnetic resonance imaging(MRI) as a diagnostic examination for a patient with cardiac pacemaker admitted to a private hospitalin the capital of Indonesia. It also aims to examine and evaluate the case of a 53-year-old motherwho had a heart abnormality that has a pacemaker for one year and was diagnosed to do an MRIexamination because of a suspected tumor on the wrist area. The three basic models of decision-making — the descriptive, prescriptive and normative —were applied. The prescriptive used the information processing theory, while the normative useddecision trees as decision options and lastly, the descriptive used intuition and pattern recognition. Dominantly, the prescriptive model for decision-making is more appropriate for this case.The descriptive decision-making model, using intuition however, helped in supporting the intuitivehypothesis. Lastly, the normative model of decision-making played an important role but was notlikely effective.Key words: Decision-making processes; case study; MRI with pacemaker; A&EThis case study aims to apply the processes with computerized tomography scanning andof decision making for magnetic resonance ultrasonography, only the modalities of animaging (MRI) as a diagnostic examination MRI is capable to show the soft tissues andfor a patient with cardiac pacemaker admitted joint fluids hence can easily see abnormalitiesto a private hospital in the capital of Indonesia. (Kartawiguna 2014). This is because MRIIt also aims to examine and evaluate the case images can capture process-based location andof a 53-year-old mother who has a heart the atomic number of cells (Kartawiguna 2014).abnormality with pacemaker for one year andshould be doing an MRI examination because Based on surveys which have been reported,of a suspected tumor on the wrist area. more than 650 000 patients every year are installing a new pacemaker implantation BACKGROUND OF THE STUDY worldwide (Figure 1). Where it contained 50% to 75% of these patients, it developedAn MRI is generally contraindicated for indications for MRI during their devices andpatients with pacemaker or implantable cardiac showed that every year, approximately 200 000defibrillator (ICD), because of the risk of patients with pacemakers or ICDs, MRI waslife-threatening interference with the device rejected (Roguin et al. 2008).(Bovenschulte et al. 2012). However, comparedAcademy Technical Radio-diagnostic and Radiotherapy Nusantara, Indonesia* Corresponding author (e-mail: [email protected])
ASEAN Journal on Science and Technology for Development, 32(2), 2015150 35 ICD 30 25 MRI 20100ICD (1000×) MRI (Millions) 1550 100 1998 1999 2000 2001 2002 2003 51997 0 2004Figure 1. Number of annual MRI scans and of newly implanted ICDs (Roguin et al. 2008). There are potential effects of MRI to without trauma cases. The author and the A&Ecardiac pacemakers and ICDs that were department physician-in-charge intuitivelyconsidered to be absolutely contraindicated suspected an abscess. Radiologic X-raydue to the following potential issues (Shellock examination of the wrist joint was conducted.et al. 1999): (1) Movement and/or vibration of However, the results were not clear showed inthe pulse generator or lead(s); (2) Temporary the X-ray. After analyzing the medical historyor permanent modification of the function of the patient, it was found that the patient had(i.e. damage) of the device; (3) Inappropriate installed a pacemaker in her heart because ofsensing, triggering, or activation of the device; an arrhythmia a year ago.(4) Excessive heating of the leads; (5) Inducedcurrents in the leads and (6) Electromagnetic Clinical specialists concerning heart andinterference. pacemakers say that MRI and other investigations for purposes of advanced diagnostic examina- In Indonesia, with the increasing prevalence tion might be contraindicated. However, A&Eof implantable devices and the increasing utility physician-in-charge instructed the author (asand availability of MRIs, there are many the radiologist), that soft tissues and joint fluidsoccasions where there is a great medical need from the patient’s wrist needed to be visualizedto perform MRI in patients with an ICD and using an MRI.pacemakers. As a result, these have led to thedevelopment of the guidelines for scanning The author identified possibilities ofpatients with cardiac pacemakers / ICDs (FDA giving options by looking at the history andRecommandation). the operation techniques done on the patient. The author also explained to the patient the The Case American Society for Testing and Materials International (ASTM) recommends groupingA 53-year-old mother admitted to the accident of pacemaker patients into three categories,and emergency (A&E) department with which are: Safe magnetic resonance (MR), thegreat pain and swelling in the wrist area 134
F.P. Raditya: Decision Making Processes for a Patient with Cardiac PacemakerMR compatible / MR and the MR conditional cardiac MR conditional devices would continueprohibited / MR unsafe (ASTM International to require the expertise and collaboration of2003). multiple disciplines and would need to prove safe, effective, and cost effective patient care. Having investigated by interview that thepatient was using Medtronic pacemaker with a Figure 3 explains the altered physiologynew generation of materials, the MR categorised of patients with pacemakers undergoing MRIsas ‘conditional’ was hence advised by the and analyzes the hidden effects after doing thehospital as a norm for doing an alternative to MRI examination.MRIs. Figure 2 shows the decision tree as thedecision option for the patient. These options A risk-benefit ratio must be establishedare used for patients with cardiac pacemaker before the MRI examination procedure iswho will undergo MRI (ASTM International carried out (University of California San2003). Francisco Guidelines 2015). The relatives’ decision (Say & Thomson Upon Entering the Radiology Unit2003) are also important to be considered, The author intuitively perceived the maintherefore the A&E physician-in-charge presents risks of MRIs that was conceived of a largeprobabilities shown in Figure 2, to the relatives magnetic force with magnetic attraction thatduring the discussion. was extremely large, in which attractive force is the potential to affect the projectile and change The patient was encouraged by the A&E the location of the patient’s pacemaker (Brownphysician-in-charge and clinical experts to take & Semelka 2003).the MRI conditionally. According to clinicalguidelines, there are altered physiologies to be The author adjusted the field strength toconsidered when patients are brought into the 1.5 tesla (Shellock et al. 2004).radiology departments that have pacemakersor ICDs. Primarily it may lead to radiation Figure 4 shows the resonant frequency infrequency (RF) interference, shifting location megahertz (MHz) as the formula that was usedof pacemakers, and thermal effect (Shellock by the author, referred to as Larmor Frequencyet al. 1999). (Kartawiguna 2015). However, in the category of the MRI If it uses magnetic field strength of 1.5 tesla,compatible/MR conditional pacemakers, these then the value of the RF must only be at 63.9could contain risks that could be fatal for the MHz (Kartawiguna 2015). The greater the RFpatient. The development and implementation ofMRI MR conditional Yes Regular MRI Another diagnostic support (CT Scan or USG) No Transfer to laboratory No treatment while confined in hospital Figure 2. The decision tree divided into probabilities. 135
ASEAN Journal on Science and Technology for Development, 32(2), 2015 Pacemaker (Mr conditional) RF signal Shifting location Thermal effectinterference of pacemaker Arythmia Reinstallation Scorch Arising artifacts the pacemaker on MRIBradiarythmia Takiarythmia MRI failedBradiarythmia Blood circulationUnconscious failure Stroke DeathFigure 3. Altered physiologies of patients with pacemakers undergoing conditional MRIs. ω0 = γ B0 ω0 is Larmor frequency (MHz tesla) γ is gyromagnetic constant (MHz tesla 1) B0 is magnetic field strength (Tesla) Figure 4. Larmor frequency.used will give a bad effect on the patient with would need to be scanned more than 30 minpacemaker (Götte et al. 2010). inside the MRI scanning device. However, by using a magnetic field that is The procedural management of MRI forless than 1.5 tesla, will require a longer scanning patients with pacemakers or ICDs is primarilytime (Roguin et al. 2004). This is because the divided into (1) protocols and examinationscanning time is inversely proportional to the procedure; (2) procedural management settingresonant frequency (Brown & Semelka 2003). and measures, and (3) planning and conduct ofThe author must explain to the patient that she procedures. 136
F.P. Raditya: Decision Making Processes for a Patient with Cardiac Pacemaker Performing these skills found on Table 1 a <2.0 kg to an average SAR of <3.2 kgwas important since the heating effect occured (Bovenschulte et al. 2012).during MRI. The energy heap the RF depositson body tissues (Bovenschulte et al. 2012). This The MRI scan was conducted by anresults in warming of the endo-/myocardium attending radiologist, and monitored by athat may lead to edema formation or even cardiologist and an electro-physiologist. Thescarring, which in turn can result in alteration patient was also monitored by the authorof the pacing thresholds (Bovenschulte et al. continuously during the MRI (e.g. blood2012). In addition, the Specific Absorption pressure, pulse rate, oxygen saturation, andRate (SAR) is a reference to the body’s ability ECG).to neutralize energy (Bovenschulte et al. 2012).The author was needed to measure the energy During the examination, the patient wasarising from the MRI, and on the type and monitored using electrocardiography and pulseposition of the electrode of the pacemaker. oximetry (Nazarian et al. 2011). The author also maintained visual and verbal contact on The increase in temperature approached the patient throughout the MRI procedure.those used in thermos-ablative procedures, so Figure 5 shows the electrocardiographic resultthe potential for harm was considerable; this with evidence of a captured pacemaker.can be expressed, for instance, in alterationsof the pacing threshold (Nazarian et al. The author also instructed the patient2011). The amount of the SAR recommended to verbally communicate in case of anyTable 1. Procedural management (The position paper of the European Society of Cardiology 2008)Procedural management of MRI in patient with a pacemakers or ICD MRI protocols and PM/ICD settings Planning and conductexamination procedure and measures of procedure• Restrict scanner field • Perform MRI no less than 4–8 • Perform the examination at strength to ≤ 1.5 t weeks after implantation a well equipped centre with experienced staff• Keep SAR of • Inspect device throroughly sequences used as low before and after MRI • Obtain cardiological as possible, no SAR > assessment of PM (non) 2 W/Kg • Continue monitoring after dependence, if patient is PM MRI until completion of dependent, consider re-• Plan examination reprogramming and testing evaluating the indications precisely in advances (threshold values of sensing as possible and pacing) • Radiologist and cardiologist should be present during the• If possible, do not use • Switch PM to “off” during MRI examination, with continuous surface coils (sensing only) or to “output” monitoring (ECG, blood below the pacing threshold pressure, pulse eximetry) • ICD treatment off • Programming of the PM/ICD in the MRI suite should be • Non-PM-dependent patients on possible asynchronous mode • A defibrillator with PM • Check ICD/PM parameters capability should be available (pacing threshold etc.) after 1 in the MRI suite month and 3 months 137
ASEAN Journal on Science and Technology for Development, 32(2), 2015complications that might arise such as headache, (3) The basic planning and execution of thenausea and/or vomiting or to alert the MR examination, taking all appropriatesystem’s “push-button” for any unusual heart (emergency) precautions to minimizesensations or palpitations. the risk for the patient. As a safety measure, the author also prepared Methodologyadvanced cardiopulmonary resuscitationequipment along the MRI hallway, along with This section examines and evaluates how thean external cardioverter or defibrillator and the three basic models of decision-making —programmer of the pacing device (Nazarian the descriptive, prescriptive and normativeet al. 2011). (Table 2) — were applied. After the scan, a systematic questionnaire Prescriptive Decision-making Modelwas provided to the patient to inquire regardingpain, sensation of movement of the pacemaker Information processing theory. Itsdevice, heat felt on the chest, or any other characteristic uses framework or informationdiscomfort. In addition, the duration of the MRI and facilitating more effective decision makingwas noted and the A&E physician-in-charge as its advantage (Bell et al. 1995; Harrisonassessed the patient of any untoward signs and 1996).symptoms. The information processing theory (IPT) After the examination an electro- that the author used was the proceduralphysiologists checked the pacemaker perfor- management of MRI in patient with a pace-mance. The result showed no changes on the makers found on Table 1. The proceduralpacemaker device, but the patient still must be management started with technical requirementsfollowed-up within 1 to 3 months. for the MR scanner, selection and planning of examination sequences and ended with The author however, was also aware technical handling of the pacemaker deviceabout the procedural management as a clinical before, during, and after examination.guideline for the patient undergoing MRIcomprising three basic components: Step One: Cue Acquisition(1) The technical requirements for the MR Upon admission to the A&E department, the scanner and the selection and planning patient was experiencing pain and swelling in of examination sequences; the wrist. These were the cues that led to the instigation of having a regular X-ray of the(2) The technical handling of the pacemaker wrist. However, another cue was found on the device before, during, and after X-ray results that the wrist did not have any examination; andFigure 5. Patient electrocardiographic result with evidence of a captured pacemaker. 138
F.P. Raditya: Decision Making Processes for a Patient with Cardiac PacemakerTable 2. Summary of three decision-making models (Shaban 2005; Thompson & Dowding 2002; Tanner et al. 1987; Offredy 1998; Dioso 2015) Normative modelCharacteristics Rational, logical, scientific, evidence-based decisions.Information sources Statistical analysis of large-scale experimental and survey research which isExamples representative of a target population where the findings can be applied.Advantages Decision trees as decision options.CharacteristicsInformation sources Enable decision-makers to predict and explain the outcomes of decisions.Examples Minimize judgment errors from “base rate neglect”.Advantage Prescriptive modelCharacteristicsInformation sources Frameworks or guidelines designed to enhance specific decision tasks.ExamplesAdvantage Principles and findings of previous scientific research (associated with normative models). Information Processing Theory. Facilitating more effective decision-making. Descriptive model Understanding how individuals make judgments and decisions focusing on the actual conditions, contexts, ecologies, and environments in which they are made. Observation, description and analysis of how decisions are made by managers and professionals in relation to their day-to-day responsibilities. Intuition. Adequacy in supporting assumptions made about decision-making processes with relevant examples from a suitable period of observation.fractures or dislocations. That was why an MRI MRI: non-pacemaker-dependent patients (lowwas hypothesized to be indicated. risk); ICD patients (high risk); and pacemaker- dependent patients (extremely high risk)Step Two: Hypothesis Generation (Table 3). The patient was classified as low risk.It was hypothesized that patients with pace- Therefore, it was hypothesized that in ordermakers would not survive computerized to survive the MRI, an external defibrillatortomography scanning; therefore, in order to should be available while conducting thevisualize the soft tissues on the tumor found procedure (Nazarian et al. 2011).in her arm, an MRI was more likely to beindicated. It was also hypothesized that the Another precaution was also hypothesizedpatient would survive the MRI if precautions that in order to survive an MRI an RFwould be done using clinical guidelines. wave exposure must be lesser than 1.5 tesla (Bovenschulte et al. 2012). This is because The clinical guideline of the European an RF takes place repeatedly during an MRISociety of Cardiology (2008), primarily examination that collects enough echo signalsproposes classification of pacemakers and to be processed into image data (BovenschulteICDs into three categories before conducting an et al. 2012). In accordance with the Larmor law, 139
ASEAN Journal on Science and Technology for Development, 32(2), 2015where Larmor frequency will be affected by the ICDs and their electrodes: the static magneticstrength of the static magnetic field, the greater field (mechanical effects), the transmittedthe strength of MRI is used, the greater the RF thermal effects, and the changing magneticwave is released therby cooking the pacemaker gradients in spatial encoding (inductionand its battery (Bovenschulte et al. 2012). In effects) (Henning et al. 2012). The proportionaddition, it was hypothesized that an RF waves of magnetic metals in devices and electrodeswere emitted that would interfere with the signal of pacemakers are limited, however, not greattransmission process of a pacemaker thus led to enough to cause displacement of either devicebradyarrhythmic or tachyarrhythmic. or electrode, that is why MRI is recommended (Roguin et al. 2004).Step Three: Interpretation of Cues The pacemaker electrode leads functionThe interpreted electrocardiographic result as an antenna, in which energy generated by(Figure 5) shows that the patient was positive variable magnetic fields is conducted to theto have a good functioning pacemaker and adjacent tissue in the form of heat (Henningwas recommended to have an MRI. It was also et al. 2012). This results in warming of theparticularly important for the author to ponder endo-/myocardium that may lead to edemahow urgently MRI was indicated and whether formation or even scarring, which in turn canthere were feasible diagnostic alternatives. result in alteration of the pacing thresholdsOther imaging procedures safer for patient (Sommer T, Naehle CP, Yang A, et al. 2006).with pacemaker such as ultrasonograms hasbeen considered, but only MRI is more specific The pacemaker device may be directlythat can show soft tissue abnormalities of the affected by electromagnetic interferencepatient’s wrist (Bushberg et al. 2002). (Shinbane et al. 2011). One factor is the activity of the reed switch. The standard parameters mayStep Four: Hypothesis Evaluation not always suffice for effective stimulation in patients who need high initial energy (ShinbaneIt was evaluated that there was a soft tissue et al. 2011). The main dangers are thus asystoletumor found on the wrist of the patient. In from inhibition of pacing and induction ofthis step, it was also evaluated that the patient tachycardia by inadequate asynchronous pacingwith cardiac pacemaker was made safe from (Gimbel 2009). Figure 6 shows the ECG resultmagnetism. There are three factors relevant for from patient after MRI examination.the problematic interactions with pacemakers/Table 3. Classification of patients according to the risk involved in performing MRI, when no other diagnostic procedure is indicated (The European Society of Cardiology 2008). Population risk groupsGroup 1 : Pacemaker-dependent Alternative means of cardiac stimulationExtremely High Risk patients (transcutaneous electrodes, temporary sensors) should be availableGroup 2 :High Risk ICD patients (non- External defibrillation apparatus should be pacemaker-dependent) available and emergency pacemaker operationGroup 3 : should be doneLow risk Non-pacemaker- External defibrillation apparatus should be dependent patients available 140
F.P. Raditya: Decision Making Processes for a Patient with Cardiac PacemakerNormative Decision-making Model this method of decision-making as a role of learning from experiences.Patients’ relatives were presented with optionsin a form of decision trees (Say & Thomson Intuitions are done descriptively according2003). The decision tree found in Figure 2 to Banning (2007) by starting with an intuitivewas used for this case based on the clinical hypothesis and perception. Thereby X-ray wasguidelines in outlining options. However, the chosen at an early stage of consultation but fromphysicians still instigated that MRI be advised the X-ray result it was not visible suspicionbecause the prescriptive decision-making disorders suffered by patients.process was the norm that is always done inthe A&E. It is usually during the late stage of consul- tation where intuitive hypothesis generation isDescriptive Decision-making Model trusted (Dioso 2015). That is why the patient was decided to undergoing MRIs.Intuitively, as soon as the electrocardiographicresults were released, the collaborating health- Banning (2007) said that this process ofcare professionals descriptively decided that decision-making, as an intuitive perception isthe patient must require other investigations for also done by recognizing patterns from pastpurposes of advanced diagnostics. Physicians experiences. Figure 7 illustrates the process ofare required to see and analyze the picture of trusting an intuition.the soft tissue and joint fluid from the patient’swrist. In a descriptive decision-making, intuition DISCUSSION(Offredy & Meerabeau 2005) enumeratesprobabilities during a discussion. Probabilities The prescriptive decision-making model wasare easier to use when collaborating with other dominantly used in this case. The patientexperts to intuitively enumerate tasks to measure acquired the cues but the intuition also supportedclinical reasoning (McAllister et al. 2009). In the IPT that the patient could be safe before,addition to Brien et al. (2011) and Benner during and after an MRI. However, normativeand Tanner’s (1987) study on how to trust an decision-making model was not completelyintuition, Hams (2000) also said that during used autonomously by the patient.discussions with the relatives and the clinicalexperts, patterns of previously experienced The patients are the key decision-makersevents must be intuitively considered in order to (Lomas et al. 1989). However, if the patientvalidate an intuition. Banning (2007) supported was not completely knowledgeable of the possible disadvantages of an intervention, thenFigure 6. The ECG Result from the patient shows a regular rhythmic capture of the pacemaker. 141
ASEAN Journal on Science and Technology for Development, 32(2), 2015it is justified that the patient takes advices from non-ferromagnetic or weakly ferromagnetichealthcare experts (Lomas et al. 1989; Offredy (most are) because it is the lowest field strength& Meerabeau 2005). available to minimize ferromagnetic risk (Roguin et al. 2004). In this case study, the patient had chancesto choose but it was also seen that there was Recommendations based on material, non-no other radiologic diagnostic examination ferromagnetic ‘passive’ implant (e.g. titanium,that might visualize the abscess intuitively titanium alloy, nitinol) MRI should be usedhypothesized that it was found on the wrist of immediately after implantation or six weeksthe patient. after implantation (Nazarian et al. 2011). RECOMMENDATIONS Recommendation based of the procedural management as a clinical guideline for patientMRI of PM/ICD places high demands on undergoing MRI comprises: (1) The technicalboth personnel and apparatus, and should requirements for the MR scanner and the selectionthus preferably be performed at well- and planning of examination sequences; (2) Theequipped centres with experienced staff (FDA technical handling of the pacemaker before,Recomandation 2015). during, and after examination, and (3) The basic planning and execution of the examination, It is recommended that the patient with taking all appropriate (emergency) precautionsa pacemaker or ICDs should be subjected to to minimize the risk for patient safety.MRI only when there is no alternative accurateradiologic diagnostic examination (UCSF CONCLUSIONGuideline 2015). It is therefore concluded, that IPT used clinical Recommendations for static magnetic field guidelines in order to decide that MRI was thedevices however must use the static magnetic best option for the patient. Dominantly, thefield 1.5 to 3 tesla, which corresponds to 30 000 prescriptive model for decision-making was– 60 000 times the strength of earth’s magnetic more appropriate for this case. The descriptivefield (Shinbane et al. 2011). MRI scanners are decision-making model however, helped intypically superconducting, thus, they were supporting the intuitive hypothesis that therealways attracting ferromagnetic object into was an abscess in the patient’s wrist. Therefore,the scanner. That is why the devices should be intuition made the decision-making easier. IntuitionsIntuitive hypothesis generation Intuitive perceptions Choosing a remedy Patient and therapeutic relationshipEarly stage of Late stage of consultation consultationReject Trust Figure 7. How to use an intuition (Dioso 2015). 142
F.P. Raditya: Decision Making Processes for a Patient with Cardiac PacemakerLastly, the normative model of decision-making Gimbel, JR, Bailey, SM, Tchou, PJ, Ruggieri, PMplayed an important role but was not likely & Wilkoff, BL 2005, ‘Strategies for the safeeffective since the patient was still relying on magnetic resonance imaging of pacemaker-the physician’s advice. dependent patients’, Pacing Clin Electrophysiol, vol. 28, pp. 1041–1046. Acknowledgement Gimbel, JR, Johnson, D, Levine, PA & Wilkoff, BLThe valuable assistance of Regidor III for the 1996, ‘Safe performance of magnetic resonancesupervision of this study is much appreciated imaging on five patients with permanent cardiac pacemakers’, Pacing Clin Electrophysiol, vol. 19, Date of submission: January 2016 no. 6, pp. 913–919. Date of acceptance: February 2016 Götte, MJ, Rüssel, IK, de Roest, GJ, Germans, T, Veldkamp, RF & Knaapen, P et al. 2010, References ‘Magnetic resonance imaging, pacemakers and implantable cardioverter-defibrillators: currentAmerican Society for Testing and Materials 2003, situation and clinical perspective’, Neth. Heart ‘Standard practice for marking medical devices J., vol. 18, no. 1, pp. 31–37. and other items for safety in the magnetic resonance environment’, ASTM International, Henning, B, Schlüter-Brust, K & Liebig, T et al. F2503-05 (West Conshohocken, PA). 2012, ‘Deutsches Ärzteblatt International MRI in Patient with Pacemaker’, Dutsch Arztebl. Int.,Banning, M 2007, ‘A review of clinical decision vol. 109, no. 15, pp. 270–275. making: models and current research’, Journal of Clinical Nursing, vol. 17, no. 2, pp. 187–195. Joint Commission on Accreditation of Healthcare Organizations 2007, ‘Working together toBell, DE, Raiffa, H & Tversky, A 1995, ‘Descriptive, improve MRI safety’, The Joint Commission normative and prescriptive interactions in decision Perspectives on Patient Safety, vol. 7, no. 2, pp. making’, in Decision-making, eds DE Bell, H 1–4; 8–12. Raiffa & A Tversky, Cambridge University Press, Cambridge. Kanal, E & Gimbel JR 2009, ‘MR-conditional pacemakers (letter)’, AJR Am. J. Roentgenol., vol.Bovenschulte, H, Schlüter-Brust, K & Liebig T, et al. 198, no. 5, pp. W502–503. 2012, ‘MRI in patients with pacemakers: overview and procedural management’, Dtsch. Arztebl. Int., Kartawiguna D 2015, Tomografi resonansi magnetik vol. 109. No. 15, pp. 270–275. inti; teori dasar, pembentukkan gambar dan instrumentasi perangkat kerasnya, Graha Ilmu,Brown, MA & Semelka, RC 2003, MRI Basic Yogyakarta. Principles and Applications, 3rd edn, New York: Wiley-Liss Publication. Lomas, J, Anderson, GM, Domnick-Pierre, K, Vayda, E, Enkin, MW & Hannah, WJ 1989, Do PracticeBushberg, JT, Selbert, JA, Leidholdt, JE & Boone, JM Guidelines Guide Practice?, New England Journal 2002, The essential physics of medical imaging, of Medicine, vol. 321, pp. 1306–1311. Lippincott Williams & Wilkins, Philadelphia. Martin, ET, Coman, JA, Shellock, FG, Pulling,Dioso, R III 2015, ‘Decision-making processes for CC, Fair, R, Jenkins, K 2004, ‘Magnetic a do-not-resuscitate poisoned pediatric patient resonance imaging and cardiac pacemaker safety admitted to the department of emergency and at 1.5-tesla’, J. Am. Coll. Cardiol., vol. 43, medical services. ASEAN Journal for Science pp. 1315–1324. and Technology for Development, vol. 15, no. 2, pp. 15–21. Nazarian, S, Hansford, R & Roguin, A et al. 2011, ‘A prospective evaluation of a protocol for magneticFood and Drug Administration 2015, ‘Manufacturer resonance imaging of patients with implanted and user facility device experience database cardiac devices’, Ann. Intern. Med., vol. 155, (MAUDE)’, viewed 15 October 2015 <http:// no. 7, pp. 415–424. www.fda.gov/cdrh/maude.html>. Naehle, CP, Zeijlemaker, V & Thomas, D et al. 2009, ‘Evaluation of cumulative effects of MR imaging 143
ASEAN Journal on Science and Technology for Development, 32(2), 2015 on pacemaker systems at 1.5 tesla’, Pacing Clin. by operation of an extremity MR system’, AJR Electrophysiol., vol. 32, pp. 1526–1535. Am. J. Roentgenol., vol. 72, pp. 165–170.Roguin, A, Schwitter, J & Vahlhaus, C et al. 2008, Shinbane, JS, Colletti, PM & Shellock, FG 2007, ‘Magnetic resonance imaging in individuals with ‘MR in patients with pacemakers and ICDs: cardiovascular implantable electronic devices’, Defining the issues’, J. Cardiovasc. Magn. Reson., Europace, vol. 10, pp. 336–346. vol. 9, no. 1, pp. 5–13.Roguin, A, Zviman, MM, Meininger, GR, Rodrigues, Sommer, T, Nachle, CP, Yang, A et al. 2006, ER, Dickfield, TM, Bluemke, DA et al. 2004, ‘Strategy for safe performanceof extrathoracic ‘Modern pacemaker and implantable cardioverter/ magnetic resonance imaging at 1.5 tesla in defibrillator systems can be magnetic resonance the presence of cardiac pacemakers in non- imaging safe. In vitro and invivo assessment of pacemaker-dependent patiens : a prospective safety and function at 1.5 t’, Circulation, vol. 110, study with 115 examinations’, Circulation, vol. pp. 475–482. 114, no.12, pp. 1285–1292.Shaban, R 2005, ‘Theories of clinical judgment UCSF Department of Radiology & Biomedical and decision-making: a review of the theoretical Imaging 2015, ‘MRI safety policy of UCSF: MRI literature’, Journal of Emergency Primary Health imaging of patients pacemakers and implantable Care, vol. 3, no. 1–2, pp. 1–10. cardioverter-defibrillator’, viewed 15 October 2015, <http://www.radiology.ucsf.edu/patient-Shellock, FG et al. 1999, ‘Cardiac pacemakers and care>. implantable cardiac defibrillators are unaffected 144
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