Tuesday, February 1, 2011

Broken hearts

Its been a hell of a week. Probably one of the most intense weeks I have ever had. I was working on writing you all a story about a stabbing, an ambulance crash and a 12 year old boy that was hit by a car and unfortunately died. Pronouncing him dead and telling his father was one of the hardest things we had to do in the past couple weeks. However as much as I love sharing with you the dark, depressing, and sad parts of the job, I had a lot of positive things happen this week. Things that made me proud to be Paramedic and people who ALS actually made a difference in. This is a short summery of my 2 Favorite cases from this weeks duty.

CASE 1: As we pulled up to the house I could I see we where alone. The ambulance had not yet arrived so I grabbed all our Advanced Life Support gear and had my partner grab the BLS gear as well. Our foot steps echoed as my team and I marched up the sidewalk with 50+ pounds of equipment. We where prepared for anything as I opened the front door. Upon entering the house I was led to a makeshift bed in the living room where I found an elderly women unconscious. Further assessment revealed that her airway was patent, respirations where clear, and pulse seemed to be slow. In fact her heart rate was 32. I hooked her up to our cardiac monitor to confirm she was in symptomatic bradycardia. Sometimes certain medications elderly people take such as beta blockers can cause this. Upon further investigation we found out the women did not take beta blockers or any other substances which would cause this. Time was ticking and her condition was getting worse. Her heart was not beating fast enough, which had lead to extremely poor perfusion and loss of consciousness. I had two choices to make. Option A. was to give her a drug called Atropine to try and raise her heart rate. Option B. was I cut her shirt off and placed the pacer/defib pads on her chest to start start pacing her with electricity. Due to the severity of her condition, lack of proper circulation, poor oxygenation to her tissue and the fact that she was unconscious I elected option B. After receiving permission from the family I cut her shirt down the middle and slapped the pads on her bare chest then began programing the monitor. While I worked on this I assigned the rest of the team to start oxygen and inter venous therapy. I adjusted the pacer settings (manually shocking her heart every couple seconds) I dialed the beats per minute to 80 and then started adjusting the mili amps (electricity) until I could see I was receiving capture on the monitor which was around 60 miliamps and began shocking. I could see her body twitch every couple seconds a shock was delivered. I confirmed that our electrical therapy was working by checking her pulse and making sure it matched the 80 beats per minute the monitor said, it did. I was now in control of when the womans heart beat. Our electrical Therapy was working and I continued pacing her until we could reach definitive care. Her skin color and condition improved en route and the receiving facility took over pacing on there machine upon arrival. The woman may need to get a permanent internal pace maker installed. She was lucky her family called 997 when they did and that an ALST crew responded.

CASE 2: The above case was still fresh in my mind when I got called at 3am for chest pain. I rubbed the crust from my blood shot eyes and reluctantly took my position in the camery. I was trying my best to start the report as we speed down the road towards the call. However I soon felt my stomach sink as I realized we had became airborne, we must have been going about 180 on a strait away when we encountered a small dip in the road. We simply flew over it and hit the ground fairly smoothly considering our speed. Only a few sparks could be seen behind us. I did my best to get back into writing the report which can often be a challenge traveling at these speeds and dealing with the insane driving in this country. Your nerves just become accustom it.

We finally reached our destination and after retrieving our gear we where lead to our patient. Upon reaching the patient she was siting upright on the sofa, covered by a vail, a concerned look could be seen in her eyes. I have seen the look before... A bittersweet combination of sincerity and fear. I find out shortly that her chief complaint is chest pain. It sounds as though the chest pain is cardiac and she had a heart attack 2 years ago. I quickly give her some chewable aspirin after confirming she has no allergy's to medication. I begin to prepare the cardiac monitor whilst ordering the crew to start an IV line, place high flow oxygen on the patient, and get vital signs. Suddenly one of my team mates who was acquiring vital signs says "Hey Mike, pulse is over 200" "What, double check that, the pulse oxcemitery unit is probably not reading properly." I replied. I finally get the monitor hooked up and find the heart rate to be only 110, which is slightly fast but normal for someone having pain."See, I told yo..... uh....." then I stair at the monitor in silence as I watch the heart rate quickly climb to 210 beats per minute. I recognized this picture perfect rythem on the monitor. We call this "Paroxysmal Supraventricular Tachycardia" or PSVT for short. Essentially what it means is that its like a car racing down the highway with no breaks. Her heart is beating 3 times as fast as it should, can not keep up at this rate forever and as a result is a less-effective pump, decreasing cardiac output and blood pressure also causing shortness of breathe.

With her cardiac history it can only work this hard for so long... I attempt whats called a vagul manuever on her. This is the least invasive procedure to try first and is easily done by instructing the patient to bare down and hold there breathe, like there having a hell of a bowel movement. Sometimes this can cause stimulation of the vagus nerve slowing down the heart rate. We tried a couple different methods of doing this over several minutes and nothing was working. She was becoming more symptomatic and her heart was now over 210 and climbing. My next step was to try and give her a drug called Adenosine. (Most paramedics have a favorite drug they carry, yeah were weird I know. Anyway just FYI my favorite is Adenosine) Adenosine is an ultra fast acting drug that expires and becomes ineffective just seconds after entering the blood stream. Therefor its imperative to push adenosine hard and fast followed by a large saline flush to shoot it up to the heart as quickly as possible. If done properly the desired effects are obvious. The patient will go flat line (asystole) on the monitor for a second or two. As you can imagine the feeling is pretty intense and this must be explained to the patient ahead of time. Like any drug there are serious risk, especially with those who have special conditions such as WPW.

As I prepare the adenosine I realize my crew is having a difficult time with the IV. There on there 2nd attempt and not sure if this attempt was successful either. I quickly look at the womens arms and can see she is a difficult stick. I continue preparing the adenosine but now I also must prepare my back up plan. If we are unable to achieve an adequate IV to push the medication quickly enough I have to try and move on to plan B. Plan B in this case is the most invasive procedure called synchronized cardoversion. It means I am going to have to deliver a large shock to the patient with the padals. I was really hoping we could avoid this.
The Adenosine was ready but the IV wasn't. Now I started staring at the defibrillator.... The woman and I gazed at the padals together as if she knew what I was thinking, and then... The IV was completed, and seemed to be running fine. We would soon find out. I grabbed the adenosine and saline that had been drawn up and connected it to her IV. We had one of the crew members explain to her that she was going to feel really bad for a few seconds and to just trust us. With one rapid motion I pushed the drug as hard and as fast as I could, quickly doing the same with the saline right afterworlds. It screamed through her vien on its way to  the heart like a runaway roller coaster. We all stood in silence and observed the cardiac monitor. What seemed like a lifetime went by, however in retrospect I am sure it was more like 10 seconds. Her heart rate maintained at 210 and no changes could be noted in her rythem. I was about to prepare a double dose and try again when suddenly the women let out a scream, followed by a moan as her face became extremely pale. I staired at the monitor in awe as I watched her heart stop beating, the heart rate went from 210 to 0 for about 1 second, followed by a large ectopic beat. Holy $%^#  I thought! I did this... and then..... a picture perfect Sinus Tach at a rate of 110. Soon afterwards the women no longer had chest pain or chest discomfort. We transported her to the hospital where several of the doctors shook our hands and gazed at the before and after ECG's we had printed off. They congratulated us on a job well done and had smiles on there faces. Many where surprised we converted her on only 6mg of the drug many people require a second double dose. The woman and her family thanked us and now we could go back to our station and await the next case.

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