Dispatched for a “Cardiac Disorder”. One of about 500 a week that we go to 495 of which turn out to be not cardiac disorders. Some aren’t even in parts of the body near the heart. It’s just easier for the dispatchers to do it that way, so that’s what they do. On the way to the call we look at the comments on the screen. 38 male, pacemaker firing.
“Uh, isn’t that what it’s supposed to do?”
“Well, maybe it’s a demand pacemaker.”
“But how would you know if that was kicking in?”
“Well, maybe it’s an overdrive pacemaker for SVT.”
“Or maybe the dispatcher doesn’t know the difference between a pacemaker and a defibrillator.”
“Um, could be.”
We arrive in due course to see one of the BLS guys coming out for the heavy duty stair chair. Uh-uh. That’s never a good sign.
We walk into a
well kept pretty messy apartment, which at least is on the first floor. We find our patient who is, uh, large. Very large. My guess is 400 pounds and I really should get a job guessing heights and weights at carnivals. I was about 10 pounds off, which isn’t bad.
“What’s happening this morning sir?”
“My defibrillator keeps firing.” To prove his point our patient let out a huge scream and levitated off the bed. Which to my amazement didn’t collapse into splinters.
“I was in for them to adjust it a couple of weeks ago and OWWWW – there’s something wrong with it.”
“I guess there is.”
The BLS guys had put the patient on O2, which wasn’t going to help but probably wasn’t going to hurt. Besides it looked like we were doing something while we got ready to do something. If you know what I mean and I think you do.
We also got a blood pressure, respiratory rate, and some history. The blood pressure was high, which was expected, the respiratory rate was a bit fast, but nothing worrisome. The history was as good as the patient could give, but wasn’t all that helpful. The list of meds contained no surprises. The medication surprises came later on, at the hospital.
While all that was going on I put the leads on and turned on the monitor, which showed us this,
At which point things went, as Law Dog says, “Sideways”. But just a bit.
Those jumpy bits in the strip are where the defibrillator fired. While the doctors will tell the patient that the might feel a bit of discomfort if the AICD discharges, the truth is it hurts like hell. At least every patient that I’ve ever transported who has had his or her AICD discharge tells me. I think in this case, the AICD fired about 10 times in all.
I should mention that there were some shocks in this sequences that were not recorded on paper. While continuously recording “Arrhythmia Andy’s” performance would have been educational, it would have killed many trees and spotted owls. Nor was I always quite fast enough on the Print button to get all of the interesting rhythms. At one point it seemed that the monitor was defibrillating Atrial Fibrillation, but I didn’t think that’s what it was doing. In fact I was pretty sure that machine was shocking sinus tachycardia some of the time. Which certainly was not the way it was supposed to be.
Here is an example of what seemed to be sinus tachycardia, but clearly wasn’t. In this case it wasn’t being shocked, but you get the point.
“What do you think we should do?”, I asked my partner.
“Versed.” was the answer. I was pretty sure he meant for the patient.
Good plan, and since it was slightly outside of our protocols, or so I thought, we got on the radio and consulted medical control. Who OKed the Versed mainly because the doctor on the radio had no idea what our protocols are. I think my partner could have asked to cut the patient in half to count the rings and the doctor would have said yes.
While my partner was on the radio, I started the IV. If you’re in EMS you know what happened. I penetrated the skin, got a nice flash as the stylet pierced the vein, and then the defibrillator discharged and the patient levitated off the bed. Fortunately the IV stayed in and I was able to advance the catheter and then secure everything in place. Then we gave the Versed. Which I think mostly made us feel better, because it didn’t seem to help the patient all that much.
Now came the hardest part of the call. Which was getting the patient out of the house and into the ambulance. Fortunately the four of us were able to get him into the chair and down the mercifully short front porch steps without difficulty. Well, without MUCH difficulty, because a 390 pound patient always presents some obstacles.
In the ambulance, we got everything sort of settled in and started off to the hospital. We gave more Versed, but things seemed to be getting worse, not better.
That doesn’t look very much like sinus tachycardia, does it? My thinking was that we were dealing with Atrial Fibrillation. Interestingly, defibrillators are placed for Atrial Fibrillation, they are placed for people with Ventricular Tachycardia. Which, as I mentioned, wasn’t what was going on here.
And the patient kept getting worse. By now we, or at least I, had decided that maybe it wasn’t a defibrillator problem. After all, even at 38 a patient with as many problems as this guy has is a ripe candidate for developing all sorts of bad conditions. And so I got a brilliant idea. He still had plenty of blood pressure, his rate was taking off, he was feeling worse, his rhythm was irregularly irregular. It had to be Atrial Fibrillation, right? Now what do we do?
My partner looked at me and I suggested “Diltiazem.”
He agreed and I mixed up and drew the correct dose for a patient this size. Which was at the maximum for a patient of his substantial size.
Have you ever watched The Three Stooges? I have. A lot.
In one short, Moe comes up with one of his typical brilliant ideas. Larry and Curly start to do whatever it is they have to do in order to get the plan off the ground. The camera closes in on Moe and he says,
“It was my idea, but I don’t think much of it.”
Which is how I felt about the Diltiazem. I just had the feeling that it wouldn’t help and might hurt. Which I mentioned to my partner. Who said that he thought we should give it. I said that we should give the hospital a call and see what they thought. One thing about this partner is that when he gets an idea in his head, it takes a crow bar and an act of Congress to get it out. So, back and forth we went. And forth and back for that matter.
At which point the patient decided to entertain us by throwing another rarely seen, at least by me, rhythm our way.
So the monitor/defibrillator/pacer/toaster oven shocked the patient out of Atrial Tac (and yes it is almost at 300 beats per minute) into something else. Only it wasn’t entirely clear what something else was. Damn. Now the patient was feeling worse, getting really diaphoretic, and looking like crap. I gave up the idea of giving the Diltiazem just as we backed into the hospital.
Where we were greeted by an empty triage area. Well, empty except for the two ambulance crews and the triage nurse.
“Uh, where’s the trauma team.”
“Oh, do you think we need them?”
“Yeah, we thought that was made clear on the radio.”
“You called on the radio?”
I looked and around and we were in the correct hospital. At least to the extent it was the hospital to which the patient had said he wanted to go. I don’t know if it was correct in that it would give the patient the best care, but that’s the patient’s decision in this case.
So, we proceeded into the resuscitation room and the trauma team kind of wandered in. We gave the story, I printed out a 15 foot long Code Summary, and then stood back to watch. At first the doctors wanted to give Diltiazem. Then they thought maybe Amiodarone because it had to be Ventricular Fibrillation. Then, they looked again and it wasn’t Ventricular Fibrillation. So, they decided to give more Versed. And Fentanyl. If nothing else, the patient would be sleepy. “Resting comfortably” as they say.
Then they brought up his old chart. History of Ventricular Tachycardia. Did have a defibrillator. Had been in recently for an “adjustment”. Meds included Metoprolol. Is known to be none compliant with medications.
Ding! You are now free to control your heart rate.
Yes sir, the medications work a lot better when you actually, you know, take them.
So, they gave him some Metoprolol IV and his heart rate dropped down to a reasonable rate.
It turns out that there was a problem with his AICD and he was non compliant with his medications. The combination meant that his AICD was seeing what was his normal underlying Atrial Fibrillation, interpreting it as Ventricular Tachycardia and shocking it. He was admitted so that cardiology could correct whatever was wrong with his AICD in the morning.
My life would be so much easier if patients would read the text books. Oh, and take their medications. It’s almost like medications are designed to fix specific problems and that taking them might make the patient better.
It probably wouldn’t hurt if he lost a couple of hundred pounds too.