A busy few days in Sorta Big City. The humidity and then lack of humidity was playing havoc with all of the Asthmatics in the city. Seems every other call was for some with some sort of respiratory issue. That included a couple of people who ended up on CPAP and one who ended up intubated at the hospital after our CPAP efforts untypically failed to reverse his decline. I’m still not sure what was going on with that, since he seemed to be getting better until after we got him to the hospital.
Then of course, it being a city and a weekend, we had a few shootings to relieve the boredom. Lucky people, if you get past the fact that they were shot. Minor wounds in the larger scheme of things.
Things just didn’t want to slow down. I though we were going to catch a break when one of the BLS trucks out in suburban land called for an intercept. Man, I hate intercepts. Generally because of the geography of Sorta Big City and where the hospitals are located intercepts just don’t work. Even if we do catch up with the BLS ambulance, mostly we just delay their getting to the hospital. Remember, most of EMS is temporizing, we rarely cure anything. In fact, all of medicine does more temporizing the actual curing. Even worse, in this case we were responding into another unit’s first due area because they were off
shirking taking care of some administrivia really important stuff.
Back to our story. I didn’t hear the initial dispatch because my internal filter was set to ignore anything that didn’t involve my unit number. Once they got to the scene and examined the patient they called for us, stating that they had a patient with “Bradycardia”. I think I read in a book once that Bradycardia can be a very bad thing. So, being the clsoest, but not close, ALS we were sent on our merry way. The address was a street I didn’t know, off of another street I didn’t know, which was of of a street that I did know, at least in theory. My partner was no better, so I looked it up. Oh, there it is. I probably had time for a short nap before we got there, but instead engaged in my co-pilot duties of making sure traffic to the right was clear as we approached each intersection.
When I wasn’t doing that I was reading the comments on the computer screen. Apparently this call had started out as a sub ALS diabetic emergency of some sort. While hypoglycemia in Type I diabetics can cause strange things, rarely does it cause cardiac problems. Can happen, I suppose, but I’ve never personally seen it.
The BLS crew described a man who was on death’s door. Which wouldn’t be all that surprising considering their initial report.
They had moved the patient out to the ambulance and had started to the nearest hospital, which essentially is a community hospital, sans cath lab or cardiology of any sort on weekends, nights, major holidays, etc. Not ideal, but if there is no ALS available, that’s what the BLS guys are supposed to do. Like Mr. Chekhov, I plotted a course to intercept, although we probably wouldn’t get to them before they were past that point. We got to the designated intersection ahead of them and a minute or so later they chugged in to view like a charging herd of turtles. What ever.
We grabbed our gear and went over to the BLS ambulance and climbed aboard. Imagine my surprise when I was met by a patient that was lying on the stretcher happy as the proverbial clam. His story was that he had woken up feeling kind of lousy, thought it was his blood glucose level, and had something to to eat. When that didn’t make him feel better, he decided to call 9-1-1. The EMTs arrived to find him a little hypotensive, a little sweaty, and surprise surprise, a very slow pulse. Having him lie down and giving him a bit of Oxygen seems to have fixed the hypotension and sweatiness, but his pulse was still slow. I placed my fingers on his wrist to see how slow and felt no pulse there. OK, no problem, I moved up to his elbow and felt a nice pulse. Nice, but very slow.
Time for the electronic marvel we call the cardiac monitor, although as I’ve said before it does so much more. In this case the first place to start was the monitor.
Yeah, that’s slow alright. In fact that’s very slow. We decided to explore the history of this a bit more while we put on the pacer pads, started an IV, and decided to which hospital we would transport. Which would NOT be community level hospital down the road. As it turns out, the patient had had a number of similar episodes, but had only been evaluated at a hospital for one of them. Not a local hospital, but one in a rural area of a neighboring state. Which, finding nothing wrong with his ECG at that particular point in time had discharged him without suggesting that he see his doctor for follow up. Sigh.
We also did a 12 Lead ECG which wasn’t very informative.
Proving the relative worthlessness of the computer based interpretations, our friendly monitor insisted that this was a “Marked Sinus Bradycardia with 1st degree AV Block”. Right, and the Flying Monkeys are doing a pre-flight in my colon. I’ve often found that the longer a description of a cardiac rhythm, the more your chances of being wrong. Not always, but it’s always something to think about when you are doing verbal contortions to describe a rhythm. In this case what the little computer brain in the monitor was calling “Marked Sinus Bradycardia with 1st degree AV Block”, was to my eye, and that of my partner, 3rd Degree AV Block or Complete Heart Block. As I described it to my patient who was puzzled at the concerned look on our faces, the top half of his heart wasn’t on speaking terms with the bottom half of his heart.
It’s something we don’t see all that often in the field and it’s something that when we do see it we usually have to treat. In this case, the patient was maintaining a good, in fact terrific, blood pressure. Something like 118/60, as long as we didn’t sit him completely upright. So, we decided that we would transport keeping an eye on the monitor and the patient.
My partner was watching the screen on the monitor like the guys at the all night coffee shop we go to watch the Keno machine as I dialed up the nearest hospital with a cath lab and gave them a heads up what we were coming in with.
My partners eagle eyed efforts paid off when he saw this on the screen and hit PRINT.
There was a bit of breath holding whilst waiting for that “escape” beat to show up. At this point we prepped some pain medication because it looked like the patient would need to be paced and pacing is a fairly painful procedure. Fortunately, the patient’s heart didn’t try that little trick again and we were able to avoid both the giving of drugs and the pacing of the heart.
After what seemed like an overly long time to get to the hospital we arrived and were promptly ushered into a room. We displayed out ECG strips, the very same ones you see here, to the doctor who ordered that the cath lab people be roused from their weekend slumber and dragged in because the patient needed an internal pacing wire placed. Which was followed, probably on the next regular OR day, buy a permanent pacemaker. His heart had been trying to warn him with his previous “similar episodes”, but he hadn’t taken the hint. Fortunately for him, his heart didn’t just up and quit.
Some people are just lucky that way.