Monday, February 26, 2007

For All the Marbles

Sometime around 2AM a couple of weeks ago, a woman came into the ER complaining of nausea and epigastric pain that went up into her left chest and shoulder. She was old enough to be in the prime age group for heart attacks, and she was having a couple of the symptoms that make us a little nervous. That was reason enough for us to suspect that she was having a heart attack.

Remember the ER chest pain creed, kids? Come on, say it with me... "Every human being who comes through the door is having a heart attack until proven otherwise."

Well, okay. Not every human being. I would exclude those who have not yet been born, and those who have already died. All others are suspect.

Well, guess what? The woman was having an antero-lateral wall ST-elevation myocardial infarct (STEMI). For the laypersons out there, that means the front/side part of the woman's heart muscle was dying because of lack of oxygen. When that happens, it friggin' hurts.
And after 3 spritzes of sublingual nitroglycerin, 325mg of aspirin, the start of a 10mcg/minute nitro drip, 12 mg of Morphine, and 5L/minute of oxygen, the woman was still having 10/10 crushing chest pain. Nothing was helping.

I was just getting ready to place a Foley catheter when I looked up at the patient's monitor and saw her go into what looked like ventricular tachycardia. The patient immediately lost consciousness.

At a loss for words, all I could do was slap the MD on the shoulder with the back of my hand and say "Hey!" as I directed his attention to the monitor.

Okay. I admit it isn't as sexy as saying, "Doctor, I believe our patient has gone into ventricular tachycardia," but it got the job done.

The MD said "Oh, crud," and stepped over to the patient as I moved over to the defibrillator, to which the patient had already been hooked up. After feeling for the patient's femoral pulse, he looked up at me and simply said, "shock her."

I hit the "charge" button on the machine and it made its usual bwooooooooop, rising in pitch until 200 joules (biphasic) was reached. Then it made an irritating warble that could have made Helen Keller wince. The machine was ready.

"Everybody clear!" I barked. Everyone jumped back from the patient and I hit the "shock" button.


The patient jumped, her arms and legs snapping outward. Her heart, having been dope-slapped, decided to get back with the program. That little rhythm strip at the top of this post shows what the defibrillator captured.

Turns out the rhythm was not V-tach, but Torsades de pointes. That's a lethal arrhythmia often talked about, but seen rarely. (Some medicos have never seen it in their entire careers, I am told.) The term is French, and it means "twisting of the points." Click on the picture. If you look closely, you will note that the points of the short, fast waves on the strip appear somewhat twisted around themselves- hence the name.

Be that as it may, the patient's heart found its way back into sinus rhythm, and the patient woke up within seconds afterward.

"How do you feel?" The MD asked.

The patient looked around foggily for a second or two, and finally said, "My chest pain is gone."

"Well, there you go," the MD said.

The patient was hastily packed up, shipped off to the cath lab, had her right coronary and left circumflex artery roto-rootered out, and made a quick recovery. She'll be fine.

That's what it boils down to, folks. Years of education, further years of experience, and hundreds of hours more of training are all packed into what totalled a mere ten seconds of time.

Yeah. It happens that fast. No Hollywood gomer can wrote this stuff. It just happens.

And you know what? I felt pretty damn good walking to my car after that.

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