Indian Guy

They had given us box lunches so I ate mine at the nursing station in between patients. Our first was a forty three year old Indian man complaining of chest pain. His EKG was all but non diagnostic but his symptoms were dramatically similar to an ST elevation MI. The doc and I stood there and puzzled over his EKG, me saying. "Looks fine but look at him." Her saying. "Where are the elevations, his presentation mirrors a STEMI."
Amed, the man sits up on th bed, clearly uncomfortable. "My wife will need to know." He says in perfectly Oxford clipped English. "May I please use my celluar telephone to ring her about this development?"
"Yeah, go ahead." I tell him as I'm slapping two sets of monitor leads on him. The room monitor to record all of the goings on in his heart and a Lifepack 12 for the inevitable trip to the cath lab.
"Ganesh? Hello darling, its me. Yes I know its odd of me to call you at this hour, but I have to let you know something. I needed to call an ambulance at work because of chest pains. They drove me to St. Vincent's Hospital in Worcester. I'm not sure, please hold my dear." He looks up at me. "Sir are we across from the Centrum?"
I shake my head. "Nah, DCU center. Tell her exit 16 off of 290, its got a sign."
"The gentleman says we are across from the DCU Center. Exit 16 off of 290 he has told me."
The doctor had been on the phone with the cath lab and she whilred around. "Let's get him upstairs."
"Darling, I must be going. Yes, I am quite sure I will not be home for dinner. Okay, I would like that but please drive carefully. I love you too."
The elevator ride upstairs is uneventful. He sits calmly asking questions about the procedure and how long recovery will be. Can we give him a note for work? Will he need specialized recovery classes? When can he see his wife?
Once in the Cath Lab suite we roll through the recovery room. The nurse at the foot of the bed looks up into the office and then back at the patient. "Sir how do you feel?" She asks.
I glance monitor as I hear him say. "I am not feeling so very we...." His EKG rthym collapses into asystole. Muttering an obscenity I push him the bed into the cath lab in order to give us more room to work. A nurse starts compressions while I cut off his pants with my trauma shears.
The man's whole body lurches, his hands grabbing the wrists of the nurse doing compressions.
"Who shocked him?" She's pissed.
"No one, theres no pads on him."
"Felt like he was shocked, does he have an eternal defib?"
"No." He is shaking and the monitor shows a sinus brady with a weird complex.
"What happened please?" Small and childlike his voice shows his fear.
"Just relax, let them do their thing. Good luck, bro." I tell him as I hustle our stuff out of the room in order to give them space for the procedure.
Two hours later a phone call from the cath lab tells us that the catherization was totally clean, no clots to be found.

Tunnel Vision

ACLS protocols are the product of thousands of man hours on the part of cardiologists, physians, paramedics, nurses and other medical professionals. They represent the thoughts, ideas and the decisions of the best and brightest of the medical field. As such, they are seen as the Bible for paramedics, offering algorithms and standards of care for a good deal of common, lethal, acute heart conditions.
On Monday I watched a woman in V Tach, an arrhythmia that when not treated in the aggressive style advocated by Advanced Cardiac Life Support guidelines, often progresses to V Fib (a previsouly mentioned death rhtyhm that does not circulate blood or do pretty much anything but look really nasty on the monitor) receive care that flew dirrectly in the face of ACLS guidelines. Unstable patients are supposed to be cardioverted immediately, a syncronized burst of electricity is passed through the body and breaks the arrthymia, allowing the heart to resume a normal healthy beat. Stable patients are usually treated with a concoction of drugs and chemicals in order to produce the same effects as the shock. But unstable patients need to be treated as aggressively as possible.
A woman was brought in by AMR for not feeling well. I had seen her before, a morbidly obesse but usually very friendly, animated woman who gave me awarm feeling just to be around. On Monday she was nearly unresponsive, skin graying and clearly miserable from the pain. Tombstones of V Tach were arching in creepy progressions across the monitor. She'd go through a ten to fifteen second run of V Tach followed by bijeminy, pairs of PVCs kicking off as the heart is basically dying. Her blood pressure was just barely palpable at around 80ish. Thinking that it was obvious I had already slapped pads on the woman and called everyone clear. She needed to be whacked, hit her with a syncronized blast that AMR didn't bother with because her apartment was within sight of the hospital. Load and screw in the shortest order possible.
"Let's hold off on the cardioversion for now, I think this is electrolyte related." The doctor tells me as I watch the patient kick off another run of V Tach. V Fib certainly isn't far away now.
So at the doctor's orders, we run K wide open through a central line (aparently two patent 14s weren't good enough). All the K suceeds in doing is lowering her pulse to around 30. I call to the other nurses on my team. "We need a code room, like now, shes shittin' out here. And can we please cardiovert?"
The doc comes back, telling us to run Amiodarone. Another non agressive treatment that should be saved for stable patients or those refractory to shock. We run it, despite telling her that the patient is low, circling the train.
Once in the code room I watch the monitor and see our patient fall into V Fib. "V Fib, " I call out calmly as I feel her carotid for a pulse. She snaps herself from it and into the V Tach once more. I'm pissed now and I turn to the doctor one more time, barely controlling my anger. "She needs to be whacked here. Please, can we shock her? Its what she needs." Again, refusal. No, let's run some calicum. Her electrolytes are off.
Calcium does nothing. She bounces in and out of V Tach for a while. I call her son and her husband from their jobs telling them it might be a good idea to get down to the hospital. Theres a flurry of activity and I run into the room to see a cardiologist bitching that the nurse hung up on him. More V Tach.
"Cardioversion? Anyone? Bueler?" My pleas fall on deaf ears as the woman continues to decline. For a horrifying moment I see her kick a really nasty form of V Fib known as Torsades des Pointes. It's a sure harbinger of death that means the electrical tissues located in different areas of her heart are firing, trying to regain some sort of order.
The doc watches her crash back into a perfusing, though poorly, V Tach and orders Mag Sulfate in order to prevent further Torsades. Another run of V Fib, this one a bit longer around 30 seconds. Still no shock.
Finally the cardiology department has me and a crash team rush her upstairs. As soon as she is switched to their bed the lead doc says. "Was she ever cardioverted?"
The ED doc tells him that she thought it was all electrolyte based and that she was treating that avenue. Without hesitation the cardiologist turns, juices her at 200 joules and she flops into a normal sinus rythym for the first time in the two hours she has been in the hospitals care.
"'Bout fucking time." I snarl miserably and take the stairs back to the ED.
Despite years of training, or maybe because of it, some doctors like to think they know better than the knowledge contained in medical protocols, they think they can make deceisions and follow their own path even when its clearly not the right one. Blinders go on and they refuse to accept other views. Its not just docotors, nurse, EMTs, medics, anyone can fall into the trap of thinking their treatment plan is the one true path. Unfournately keeping one's pride intact and being the one who came up with the life saving treatment plan often shortchanges the only person who really matters.....the patient.
I hope that if I fuck up, if I come up with a sour treatment plan that my partner or someone else on my team will point out that mistake. I hope that I will be coherent enough to push aside my convictions about what I think the problem is and take the in put of my fellow providers. I've worked EMS for a while and I know I don't know everything. I can't stand people that have more letters after their name that don't know that basic rule of medicine. You can miss things, you can have a bad day but you always have a team to bounce ideas off of. I hope that I will be enough of a medic to be able to take into account other people's ideas on treatment and combine them with mine (or throw mine out completely) in order to provide optimum care for my patient. Because in the end, after all is said and done, after the truck is cleaned and restocked it doesn't matter who said. "Hey, shock 'em." Just that it gets done.