Um, You’re the Doctor, Right?

Back from a ID theft imposed digital holiday and stuck with a raging case of insomnia.  I mean, what did I do to sleep for 4 hours voluntarily?  I wanted to sleep, just couldn’t, so here I am.

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Nothing puts experience in perspective like having a doc ask you for advice.  It’s humbling and kind of scary all at the same time.  Really?  You’re the doc.  Y’know, medical school?  At least 1 year as a full fledged doc, writing orders, telling us lowly peons what to do?  Any of this ring a bell?

The conversation went along these lines…

“So I have a patient I want on tele, but they’re bradycardic.  I mean, you do that right?”  Dr. Obvious.

“Um, yeah.  We have brady folks all the time.  Not really a big deal.”  says perplexed charge nurse (PCN).

“OK, can you guys do pacing on the floor or do I need to send them to ICU?”  Dr. Obvious.

“Uh, if you’re thinking they need to be paced odds are pretty good they need to be in the Unit.”  PCN.

“Right.”  Obvious is thinking here.  “They’ve been brady and slightly hypotensive.  You guys can handle that right?”

“Uh-huh.”  starting to look around for Peter Funt and a camera crew.  “I mean, brady is fine.  If he drops too low we’ll just drop into ACLS and do our thing.  How low is he anyway?”

“He’s been holding steady in the 40’s.  Last BP was 100s over 60s”

face palm… “Look as long as he’s not doing any kind of funny block, I’m cool with them in the 30s with a pressure that good.  He’ll be fine.  If you want, you can write orders for atropine prn and we’ll put pacer pads on…”

I’m trying not to laugh here.  Really 40-50s with  pressures in the 100s?  I thought it was a real issue, like they’re runnning 30-40’s in a Mobitz II block or something funky.  Really?  Sure, I appreciate being asked what our comfort level was, but you’re the doc.  You get the special white coat and all that to make these hard decisions.  You want tele, fine.  We’ll deal with the the issues, and if the fecal matter hits the air oscillator, we know what to do.

Had a patient the other week that ran consistently in the low 30’s post-Sotalol.  I’m OK with that.  BP of 86/40 in a CHFer who’s talking to me coherently and making urine?  I’m good.  Now the guy who we were getting pressures of 70/palp with a heart rate in the 120’s and was minimally responsive, that made my sphincter pucker a little.  But that’s why I love telemetry, we take relatively unstable patients (even those that probably need to be in ICU) monitor them and do interventions to fix them.  Part of me appreciates the call, but part of me views it as an insult, in the implication we can’t take care of the (not)unstable patient.  Make your decision, you’re the doctor, right?

How to Scare a Tele Nurse

Or, “oh shit!  That VT isn’t stopping!”

I’m walking into the nurses station the other night when I hear the “oh shit!” alarm ringing in the tele cave.  Y’know the one, that incessant, high-pitched dinging that is saying “Pay attention!”  Reflexes trained by my years on a tele floor I look up expecting to see someone bradying down, or maybe some nasty artifact, but instead I see this starting – and it’s not stopping!

Do I…
A.) Start screaming like a little teeny-bopper freaking out and run in circles?
B.) Shit my pants?
C.) Drop what I’m doing and high-tail it to the room in question?

Believe it or not, C is the correct answer.  Sphincter slams shut as I haul ass down the hall.  I bust in the room expecting to find a dude laying there, unresponsive, not breathing or generally not doing well.  Instead I see dude and his nurse clamly chatting.  I breathlessly ask, “Were you shaking the leads?”

“No” she replies, “What’s up?

Dude looks up and says, “Is my heart racing again?”

“Uh, yeah, he’s in VT.”  I say, amazed that he’s sitting there calmly chatting.  “Do you feel funny or anything?”

“Yeah, my heart feels like it’s going pretty fast.  But I’m used to it, it’s happened many times before, no big thing.” he replies nonchalantly, basically amused with the gaping look on my face.

So we hook him up to the bedside monitor, and sure enough, there it is VT, rate in the 150’s, BP is 100/53, he’s pink (ok, kind of yellow), warm and dry.  No light-headedness, no dizziness, he does admit to a little bit of chest pain, but in reality he’s in better shape that half the floor, except that he’s in this particular rhythm.

Prehospital 12-Lead ECG has a great quote on their wide complex tachycardia page, “If it’s a wide complex rhythm (fast or slow) it’s ventricular until proven otherwise!”  And that’s how we were treating it.  So we grab some labs, call the ICU team to come assess him and a 12-lead EKG.  Should we have called a Rapid Response?  Maybe, but we felt we didn’t have to.  He was stable.  He has had this many times before.  And he was sitting there cracking jokes with us.

So here’s the 12-lead:

So what to do now?  The ACLS algorithm for tachycardia with pulses starts with determining if the patient is stable.  Check.  He’s cool.  Establish IV access.  PICC line left upper arm.  Check.  Wide or Narrow complex?  Duh.  Obtain 12-Lead EKG.  Check.  Expert consultation advised.  Check, ICU team is here now.  Amiodarone if ventricular tachycardia or unknown, adenosine if SVT with abberancy.  Oh, wait…he has a history of WPW and 3 failed ablations.  Now what?

This is where expert consultation is really a good idea.  In our case, he’s now cracking jokes with the ICU team as well.  He’s still rolling along between 145-160 BPM.  We grab some labs.  Turns out his potassium sucked, magnesium sucked and his calcium critically sucked.  The Team decides that amiodarone would be a good idea and getting his electrolytes sorted out might help as well.  So we’re hanging amio, mag and they’re calling cardiology.  Mind you this is 2130 on a Friday night.  Do you think a cardiologist is going to come in at that hour?  Nope.  She says, “Oh, just have one of the ED docs cardiovert him and call it good.”

He gets packaged and ready to roll to the ICU, ’cause by this time he was pretty much a 1:1 and the nurse had 3 other patients she was already neglecting.  Grab the defib off the code cart, because with our combined luck (this nurse and I have a history of codes/RRTs) dude will decide to stop having a pulse once we’re between floors in the elevator.

The rest is rather boring.  A little bolus of propofol (yeah, we MJ’d him good!) and the judicious application of 100 joules of DC electricity fixed him right good.  One shock and back into sinus.  But it was a good thing he was in the Unit as they spent all night getting his ‘lytes repleted.

What could have been a very bad thing ended up being a very, well, fun thing.  Too often on our floor a busy night consists of incontinence, wrangling demented patients back into bed 30 times an hour or chasing naked psych patients down the hall, so dealing with a true cardiac issue was a rather refreshing change of pace.