Skip to comments.For All the Marbles
Posted on 02/28/2007 12:26:43 AM PST by 60Gunner
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.
ER Nursing stories ping.
What an excellent story! Good Job!!
Was this because of the lack of Magnesium or the heart blockage ?
Thanks for the post. Interesting.
You know, I am really not certain. She was not my patient; another person was acting as primary nurse. I was just helping out. I honestly have not thought to ask him what the patient's CMP (comprehensive metabolic panel for the layperson) studies looked like.
The best book I have come across on trauma is called Waking the Tiger by author Peter Levine. I only started feeling better physiologically after reading it. I recommend it highly and it's unfortunately not an incredibly well-known text.
We sometimes forget that the body always remembers on a cellular level. Every physiological experience is recorded. If you experience something shocking enough, and it's not treated almost immediately, your body may ache and hurt indefinitely.
PTSD isn't even close to being well-understood by the medical community, let alone the layman, at this point in time.
Thanks again for the excellent post.
That's a crazy EKG. I cannot even see the QRS pattern. Still, I'd rather see cariac temponade.
Thank you, JDM, for your insight. I have not heard of this book, but I will certainly check it out.
Thank you for sharing this with us. You write very well.
Excellent, riveting post.
BTW- thank you so much for your service. God bless you.
I should say thank you for your service. Truth be told, unitl I was ten I wanted nothing more than to be an M-60 Gunner in a Huey, and I was so crushed when I found out the Army didn't really use those anymore. Medic is still a great alternative.
Interesting read for a former 11B and current epileptic. Thank you for putting things in layman's terms, otherwise, I'd have been totally lost. ;^)
This is a good mnemonic, but not always true. I had an MI patient whose only presentation was bilateral elbow pain.
The wierd ones happen just often enough to keep us on our toes.
That's the main idea behind my posts. I want to make sure that the layman understands what goes on in the ER. It isn't Hollywood.
I hear you. They have to pay me to be there. ;o)
The only highlight for me is if they have one or two really good looking nurses, which is rare for when I usually show up: in the middle of the night, strapped to a stretcher pulled out of an ambulance...
Thanks for the story. I am sitting here in my drawers after another horrendous shift in our Emergency Department trying to get sleepy so I can sleep a few hours before I have to go do it again. I was late getting out because I had to do the Blood Born Pathogen routine on a cop who got stuck with a dirty needle while searching a Crack Heads car. As I was leaving through the E.D. waiting area, I had to go around the fist fight in the middle of the triage area between the HIV positive guy who was stabbed and the guy who did the stabbing who had apparently come back to finish the job.The Police who were there with their buddy who got needle stuck decided to break the fight up, so I took advantage of the lull in the fight to get out the door. The friends of the Stabee and the Stabbor were fighting in the parking lot , but I managed to miss all of them as I zipped out of the lot. Just rereading this makes me tired so I am going to sit back and finish my can of Vienna Sausage and drink my diet soft drink before I go on to bed.... Gosh, sometimes I LOVE MY JOB....Keep up the good work...
They give us in the infantry(ex) the CIB if we fight in action. They need to give ER folks a medal for stuff like that...
I agree--- by the way, I was a door gunner then a flight engineer on a Chinook Helicopter in Viet Nam before I went into emergency Medicine... I call it my premed crash course.....LOL.. I feel right at home...
If you get enough narcotics, I can be pretty good-looking. (shudder).
LOL! Having seen the action at the ER at Charity in New Orleans, I'd consider Baghdad safer at some times...
They've pumped plenty of painkillers into me, in fact last month, during a seizure, my shoulder was knocked out of it's socket, and I didn't realize it till later that night, when the meds wore off. That got me another trip to the ER the next morning where the doctor, after taking X-Rays and keeping me in agony for an hour or so, pushed my shoulder back into the socket(on a scale of 1-10 as far as pain is concerned, this was 11).
But they've yet to pump enough stuff into me where I can't distinguish between a good-looking babe and a guy... ;^)
And I don't mean the Moe Jacket:)
Glad you enjoy your work. ER Docs, as my friend told me years ago, essetially are telling he whole world "I fear no disease". After a year moonligting as one I discovered ther were a whole lot of diseases I feared...
God Bless you.
Thanks for the ping 60Gunner
My worst pain ever, (and I have had some significant injuries) was when I had a blood clot, blocking my popiteal artery. No amount of morphine helped.
Thanks again 60Gunner for your excellent posts.
oops, I left the point out of my post. I'm with you ABG, they don't make enough drugs for that to happen.
Words fail me.
I have a cousin who has done ER work at BAMC. The stories he can tell, well....
You guys are awesome!
ER Nursing stories ping.
You gotta write that book!
These stories are too kewl. And I hate hospitals.
Nice job! The only Torsades I've seen are in a textbook.
It is rewarding to feel pretty damn good after a long nights work. Great job! Keep the stories coming
A little late to the party, but what a fantastic story!
May I please be added to the ping list? Thanks!
Theresa, you are on the list. Thank you for your encouraging words!
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