Saturday, January 20, 2007

Hey, We Can Fix That.

The ER is a complex and challenging environment where success is not always achieved, and where futility rears its ugly head far more frequently than we would wish. In such an environment, the quick successes can often have the effect of restoring confidence, especially after a long string of difficult cases where success has been elusive. The confidence factor is magnified when the case involves a scared patient with a heart that has decided to do its own thing.

I arrived for the beginning of my shift and received report from the offgoing RN about a patient who had just arrived in one of my treatment rooms. He was an otherwise healthy middle-aged male who came to us with a complaint of dizziness and a "really weird feeling in his chest." An EKG revealed atrial fibrillation, a condition in which the atria of the heart stop working in a organized fashion and simply begin quivering. The condition is dangerous because it can cause clots to form in the left atrium, which can be "sprayed" into the left ventricle and thus to the the rest of the body, leading to heart attack, stroke, pulmonary embolism, or kidney infarct- none of which are happy things. Both the patient and his wife were highly apprehensive, to say the least- and certainly appropriately so. In such a circumstance, it is important for us to establish the patient's and family's trust that we knew what to do, how to do it, and where to start.

I swept into the room with an ER Tech at my heels, exuding confidence and optimism. I wanted the patient and his wife to get the message: This guy knows what he's doing. I made a point of clearly explaining everything I was doing and why I was doing it. I have assisted with synchronized cardioversion many times, and I made sure that the patient and his wife were as comfortable with the process as possible. I made sure they had no doubts that this stuff is our bread and butter. The whole team was on the same page, and the MD running the procedure is top-notch. He's brilliant, he's personable, and he is a pure joy to work with.

I should mention here that when the members of a team are familiar with one another and they have a mutual high professional regard for each other, it is pure magic. It is simply thrilling. There is no easy way to describe it, and the word chemistry is overused in my opinion, but when that strong professional relationship exists, the patient notices. And the patient saw that the MD, the ER Tech, and I were completely "dialed in on each other" (his words).

That goes a long way toward alleviating some of the patient's apprehension, especially when his life is literally in our hands for a split second. During a synchronized cardioversion, the patient is literally one push of the button away from meeting his Maker. If the timing is wrong, we will stop his heart. Technology removes some of the dicey aspects of the procedure, but there is always that chance...

Synchronized cardioversion is a fancy way of describing shocking the heart into a normal rhythm. We don't smack the heart with alot of energy, but just enough to get its attention. But the tricky part is the timing. It has to be done exactly when the ventricles contract. Otherwise, we put the heart into ventricular fibrillation- that means death, which is what we euphemistacilly refer to as a "negative patient outcome." As I mentioned, our machine is able to hold off delivering the charge until it senses the ventricular contraction- that's the "synchronized" part of cardioversion. Better living through technology, eh?

Finally, the forces are gathered around the patient. He gives his wife a kiss. Respiratory therapy is present just in case we need to intubate or if the patient needs to have assistance with breathing. I drew up 15mg of Etomidate, a potent sedative agent with a very short half-life. The drug stays in the system for a mere 30 seconds. After that, the patient wakes up almost immediately. So I have to "slam" it, meaning I push it as fast as I can, but not too fast since it can burn like a mother.

The MD gives me the nod. I push the Etomidate. Ten seconds pass with no response. The patient says, "I'm still here, guys."

Then he is out. Just like flipping a switch. The MD makes sure the patient is unconscious, then he pushes the charge button and makes certain everyone is clear of the patient. The machine emits a beep that rises in pitch, and when fully charged and ready, it emits a noxious warble. The MD pushes the Shock button.


The patient's body jerks with the energy, then settles. All eyes are on the monitor. The patient's heart settles from its previous chaotic rhythm to a normal one. Twenty seconds have passed.

The patient's eyes begin to flutter open. As if on cue, he shakes his head and says, "I'm ready when you are, guys."

I tell him, "We're done."

"You're kidding," he said, incredulous.

"Nope. Take a look," I replied, directing his eyes to the monitor. "You're in sinus rhythm. Nice and normal."

He breathed a huge sigh of relief. His wife came to his side and kissed him on the cheek. They were both tearful with relief.

I finished charting my procedural assessments and asked if they needed anything else. They did not. I discontinued the monitor when appropriate to do so, cleared away the extra paper, and left the room.

It's nice to have one we can fix once in awhile.