Posted on 01/21/2007 5:00:31 AM PST by 60Gunner
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 wierd 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 what wht 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.
Clunk!
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.
ER Nursing stories ping.
Sure beats babysitting drunks while you try to get their BAC below .30 We always got stuck with that job
When I had nerve surgery they gave me Versed. That's some weird stuff. Apparently you're conscious, but you don't remember a thing.
After getting hit with a nice shot of morphine and the Versed the next thing I remember is a young lady putting a hot dog down in front of me at the joint down the street from the surgeons office.
Modern medications are capable of some amazing stuff.
Nice work there 60gunner.
L
Thanks, Lurker. We have a saying in the ED: "Better living through chemistry" (or technology).
Oh, we still do. Had a 16 year old girl with a BAC of .269 tonight. And she was still breathing on her own. Can you say "tolerance?" I knew that you could.
My wife was prescribed Levaquin. One single dose put her into Atrial Fibrillation in a matter of hours. Some people cannot tolerate Fluoroquinolones.
It is not a pleasant way to find out...profound weakness, "Elephant sitting on chest", etc.
Avelox, Cipro, Cipro I.V., Floxin , Floxin I.V., Levaquin, Maxaquin, Noroxin, Tequin
A websearch may have saved her life, and got her to the ER in time. Otherwise, she just had wanted to sleep.
She was in the CICU for two days, and was released on the third day.
The effect is rare, but should be remembered.
Great team in this ER as well. They _listened_ when I told them of the literature regarding the fluoroquinolones, and jumped on it.
Wow. Is youe wife OK now?
I can't tell you how many patients I have had that convert on their own (from afib to sinus) as soon as we tell them they are scheduled to be cardioverted....
They especially love when I tell them "you've converted" and it always sounds like a religious experience (haha)
Technology is a wonderful thing...when it's working.... But great team work is priceless :)
Pretty good for 16. We always got the winos. "You two teen white boys go entertain the black wino in 203 so he doesn't pull out his IV's". I learned a LOT of new words like that.
I once got a terrible headache. I mean the worst one I've ever had. There was pain to the point of violent nausea. I went to the ED and as I'm sure you've already figured they suspected I was having a sub arachnoid bleed.
They needed to do a spinal tap.
The doctor never did get the needle past the cartilage in my lower spine although he did try four times. After the third shot of morphine he tried one last time and still couldn't get the needle to go where he needed it to go.
He finally gave up and told me that since I wasn't dead or in a coma I most likely didn't have a bleed. A quick cat scan confirmed there wasn't anything nasty going on in my head, well nothing nasty physically anyway.
The rookie doctor I wanted to do some serious damage to however.
Man those spinals are painful even when you're twanked up on morphine.
Thank God for opioides.
L
May explain some of the paroxymial afib we see from time to time...
Usually, the MD numbs the region with lidocaine before inserting that monstrous needle. Our lumbar puncture (spinal tap) kits have lidocaine in the package. That's our ER, at least.
One the count of three.
One
Two (riiiiiip!)
They looked at the monitor, and he had converted. They kept him for a few hours to make sure it was a good convert, and he left the hospital.
{grin}
Ouch.
L
Yes, thanks. She bounced right back in a week-She had no prior cardiovascular issues and passed a stress test on Day 3. But this is not the first time a Rx caused her trouble. They say "healing is an Art". Well, maybe so, but prescribing still needs peer review, or some kind of accountability. A doctor told me once that the reason for the Rx samples that began to get popular in the '80's was that the patient left with something of value in hand that would help. Add to that, hospital administrators demanding that doctors multi-schedule appointment slots, and there is great pressure to "Do something", write a script and get to the next patient.
I personally know three physicians who walked away from their practices, having become fed up with these demands as well as the malpractice premiums they generate.
One became a journal editor, one joined a subscription practice, and the other started a walk-in cash clinic.
May explain some of the paroxymial afib we see from time to time...
They are rare, remember, but the Cardiologist had heard of it and lit up when I told him there was abundant literature describing it. He recalled it instantly.
As soon as they saw the disrupted sinus rhythm on the EKG, in went the heparin.
Ok, as soon as started reading this, I recognized the style. When are you going to write a book? These stories are great!
interesting, perhaps dermal stimulation can pull off the
trick of sending enough current to the heart to cause
cardioversion....I wonder if anyone has researched that...
in the old days, the old pre-cordial thump was used in
unwitnessed collapses of patients...
Once we had a real snotty cardiologist, who after hearing
there was "code blue" in the ER, rushing in, saw a
comatose or very somnelent patient and administered the "precordial thump",...
I wasn't there to see it, but I would have loved to see
her face,when she was told that the "code blue" patient
was in another room....
16 year old girl with a BAC of .269 tonight.
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Wow! Is that the next story?
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