Shock me all you want, but save my shirt!
So the pace of my life has not let up at all, and just when I think it will settle out, the next challenge arises. I’d be lying if I said I didn’t love it, but I know the cup runneth over at this point and I find myself only able to stress a couple areas at a time, then leaving those areas alone for a while so I can go address another. Nothing new to many of you I know, but I fear I have left this blog for too long, and I am so happy to be back in front of a keyboard doing something other than emails, homework, or mindless arcade games to unstress. The weather has broken (for now), and it is in the 70’s here by day, and upper 50s at night. Everyone is coming out of their winter shells and it is good to see. I swear I have SAD and the boost that comes from the sunshine and warm weather is one I very much needed.
Last night the bay doors of the firehouse were open, a breeze passing through the firebay, and the old hands were at the bay table laughing and telling stories again. The stories were mostly of the youthful behavior of folks that are moved on, or life members. Some things never change, and kids in the firehouse are always that. No matter how old they get. I just sat by and listened and swore again that I’d get a blog out. The stories they told are theirs, not mine and I couldn’t do them justice here, but there is a run I have been meaning to post for some time, and now I finally will.
It was the tail end of last year, Cat was “riding the seat”, with Jenn driving. This was during the time that we knew they’d be together this year and so they were acclimating to each other ahead of time. Michelle was with us as a preceptee as well. We got punched for a chest pain call on the interstate in the late afternoon. I climb in the back and generally try to be there, but out of the way for this run. The response doesn’t take long and we pull up in front of a silver sedan on the side of the highway. The engine from one of our other stations is already there, and they have begun an assessment. The girls pile out to see what is happening, and hang back in the back of the unit to get ready for them. We normally have an IV line pre-hung in the back, but didn’t for some reason, so I was going to loiter back and get that set up for them when they arrived.
The back doors pop open as Michelle climbs out, and I sneak a peek out to the patient. He’s a fairly athletic guy in the early-40’s sort of way. Good shape, but not extraordinary, hair just starting to gray. I see out the unit, and through the windshield of the car that he is sweating badly, is pale and is clutching his chest. “OH, THAT sort of chest pain call”. Now, all chest pain calls are serious until proven to be muscle pulls, panic attacks etc, but there are the no-kidding, I’m having the BIG one and I’m doing it RIGHT NOW calls for ‘chest pain’ too. I know Cat had already run a ‘chest pain’ on the highway that turned into a code while she was on scene once this year and I’m not looking to repeat the performance. Though, just looking at the dude I have to admit I figured it was possible. I shift gears from “loitering” to “prepping” in the back and quickly have a line hung and the life pack set to go. I see that Cat and Michelle have come to the same conclusions as nobody is messing around out there. The guy is quickly loaded onto a cot, given O2 and is inbound to the unit as I’m heading to open the locker for the drug box.
The closer this guy gets, the worse he looks to me and I’m not really liking it. “Sure hope you got veins, man” I’m thinking as he is lifted into the back. “Lifepack is ready for a 12-lead” I’m saying as he is coming in, and Cat and the rest of the crew is piling on in rapid order.
“I’m not having a heart attack” the guy says. “Yeah, and I AM at my ideal weight” I think to myself…wow denial is a powerful thing. “Well, we will find out for sure in just a minute, sir, but I gotta tell ya, you sure look like you may be having one”. I say as I set about my work of getting vitals and generally mentally prepping for an ACS run. “No, No, I have SVT” he says, stopping my mental train dead…even if I do keep moving.
SVT…SupraVentricular Tachycardia. It means that some part of his upper heart goes haywire and keeps sending signals to beat to the rest of the heart. (there is a whole cardiology about automacity in the heart, but I’ll just add links to it here if you want to read about it later). Bottom line is that in SVT your heart beats fast, real fast, like more than 150 times a minute, though I’ve seen people tachy in the 200’s before. That’s bad. Not just because, damn, that’s real fast, but because your heart doesn’t refill with blood between beats, so your pressure drops all to hell (Firemen go ask a pump operator about cavitation, same thing) and your body and brain aren’t oxygenated and you can die. Now, that’s oversimplified, but the main points are valid…heart too fast, you die if it isn’t fixed.
Now, symptoms of bad SVT include: Chest pain, diaphoresis (Sweaty man), shortness of breath, pale color etc…you know, like exactly everything this guy has. The bad news is, that if random-dude off the highway knows how to use “SVT” in a sentence, he likely has it. Good news is, I can verify it with a 2-fingered ECG. So, as I’m pushing the BP cuff to start, I lay on the two fingers to his radial artery and hot-damn, he’s thundering right along. So there is that.
About this time the ECG is showing the same thing. My boy has SVT, with a pulse and heart rate about 180s as I recall. He’s obviously having increasing shortness of breath and is generally looking BAD. Now I’m on both ends of a related thought, “Sure hope this guy doesn’t die” and “WooHoo, I’m gonna stop this man’s heart”. I’ll explain later on here. As we get an IV established, we ask him about his history of SVT. Turns out that he hasn’t had an episode of it in 2 years, since a heart ablation surgery to stop it. No problem there. He was playing basketball when it started…that explains the sweats and tee-shirt and makes sense. Then he starts into telling us how hard it used to be to stop the SVT once it started. “Now don’t starting with the negative vibes” I think. I tell him to bear down like he’s taking a poo, but DON’T actually poo (Learned that last part the hard way on an 80 yr old once…GOTTA tell them not to actually crap their pants!) “I’ve already done all the vagal stuff” he says. Okay, so he knows what he has.
Cat is drawing up the adenosine now and I start to explain to him that we are going to give him a medication to fix his heart rate. (Truth is, it stops the heart completely for a few seconds, then hopefully the heart re-starts, and hopefully, it goes into a good rhythm after that…hence my thoughts above). I’m telling him that he is going to feel funny, and that it is described as a rushing or pressing down feeling. He knows the drug, and tells me that it usually doesn’t work for him. Great.
Cat is ready to go, and we have a good IV, up in his bicept with a nice big catheter. We have a saline flush hooked into a second port on the line and we are all set. (The drug only lasts a few seconds in the body…thank god, did I mention it stops your heart? And so you have to get it in close to the heart and as fast as you can before it degrades). I push in the Adenosine, Cat slams in the saline behind it to flush it into his body and we have the ECG print a strip for all the promised coolness of his heart stopping and restarting and us saving the day. After the better part of a minute passes, and ECG tracing paper is pooling on the floor of the unit, we realize it is a bust. (looking back we found ONE beat that looked delayed on the strip). Well poo. We start transport in a quick way after this. The hospital is called and we tell them we are going to run this all the way down the line if need be, but he has a history of SVT that just won’t break.
Now our guy starts getting full on negative. He’s still talking, but looking worse and worse. How bad? Bad enough that I’m getting out the combipads to put on him. (The big sticky pads we use to shock you. I can use it for cardioversion, to shock the heart into behaving, or for defibrillation if the heart decides to give up…all in all, it is NEVER a good thing to have a medic put them on you!) He starts talking about how the last time he did this, the ER ‘screwed up’ when they shocked him and his heart stopped and he coded and they almost didn’t get him back, and it has caused all sorts of other problems, and they were incompetent etc etc. “Great, why not be a litigious ass on top of everything else?” I start to think. Cat and I share a brief look as he describes what sounds like a textbook cardioversion attempt that just didn’t work out good. (Side note: I put cardioversion into Google while writing this and the first Sponsored link up top was for a lawfirm under the title “Failed Cardioversion?”…sigh) This is concerning to us as we are about to embark down exactly that path if he doesn’t improve but soon. He briefly closes his eyes getting a “SIR!?” from me. He pops right up and responds. “Okay, here’s the deal, I don’t want to shock you, or jam a tube in your throat, but if you pass out, I promise I will do both and sleep fine after.” I tell him. He says that is a good deal, and promises to stay conscious for me. Michelle is looking to cut off his shirt to put on the pads, but he really adamant that we don’t do that. It is his new basketball team tee shirt yadda-yadda. She gives him a quick shave of the chest and on go the pads. The shirt remains but is pulled up. This whole time, Cat is drawing up a second round of Adenosine, double the amount from the first time (6,12,12 for you medic-folks), and I’m talking to him. He’s starting to give me things to tell his wife….NOT good and I’m generally just planning to have to electrocardiovert him (Shock him) and/or code him. By protocol, I could have blasted him right out of the chute, as he was clearly ‘unstable’, but the first pop of adenosine was preferred since he was still pretty much ‘with it’ and we just now got the pad to shock him with in place.
Cat is about ready to go for round two, and I’m double checking a pressure to see if I don’t just make a liar of myself and shock him anyway when Michelle has had enough fighting with the shirt and tells him we are just going to have to cut it off. “No, don’t do that!” he says, then he stops. “Hey….” He says. I notice his color start to pinken and I look at the monitor. He has self-converted…his pulse is now 110 and dropping fast. He takes a deep sigh and doesn’t move for a minute. We all just stare for a second that seemed like forever. At about 85 beats a minute, his heart settles in, and everything is fine. “It’s gone” he says and smiles. His color comes back fast as his pressure rises and his body gets back to normal. It is one of those really cool medic-moments when you realize how cool it is that our bodies work at all, and how resilient we are as humans. (Okay, what appears to have happened is that he got so stressed about his shirt getting cut that he tightened up…remember the ‘bear down but don’t poo’ thing?...this stimulated his Vagus nerve which results in slowing the heart. Again, overly simple, but true enough. This time though the stress of his shirt being cut worked where the bearing down, a vagal maneuver, did not.)
“I see that, how do you feel” I ask. He tells me he feels tired, but the pain is receding and he feels much better already. We chuckle and tell him it is no wonder that he’s tired, his heart just ran a marathon. We check vitals and reassess everything, and no kidding, we have a healthy 40-something male in the back of our unit now. I have Cat stand by with the adenosine that she drew up…just in case, but all in all, everything is looking great. Besides, we are at the hospital now anyway.
We arrive at the hospital to find the staff waiting outside one of the cardiac rooms in full combat mode. They are standing in that tense-ready position of a crew that knows bad things have just arrived. We come through the doors chuckling about some little comment and get puzzled looks. “All better” we say as we wheel him in. It takes a minute to explain what has happened, but the nurse even chuckles when I explain that Vagal maneuvers, Adenosine, and the threat of electrocardioversion did not stop the rate, but that the threat to cut his shirt did. The doctor actually didn’t believe us at first and thought we must have rubbed his carotid when going to cut the shirt. (Doing that also stimulates the Vagus nerve, but can result in a stroke in some patients, so we don’t do it.) I explain that she was going to cut bottom-up and that the carotid massage wasn’t a possibility. He just chuckles and shrugs as he signs off on the report.
We swing by to swing in to say hi after writing the report, and the guy’s wife is with him. He thanks us and smiles, but again makes some comment about the ‘idiots last time’, which makes us wince for the ER staff. “Yeah, he’s thanking you now, but wait until we have to rip off those pads you put on him!” the nurse says as we leave.
The patient was treated and released a few hours later with a referral to his Cardiologist for followup. He did not lapse back into SVT at any time. So three Medics, an EMT, front line cardiac drugs and thousands of dollars of equipment – Zero, a man’s concern over a $10 tee shirt – one. Whatever, I’m still taking credit on this one too!
posted by MedicChris @ 1:31 PM
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