Think Before You Freak Out!

The other night I was getting report from the say nurse on a post-pacemaker placement patient (try saying that 5 times fast!) who was all in a tizzy.  Scattered and doing things that really didn’t make a whole lot of sense.  It had been a busy day, but it seemed like she was making more work for herself than she needed.  Almost like running in circles.  Not productive at all.

When the excreted fecal matter hits the proverbial air oscillator, I make sure I take a moment to assess the situation.  Following the Fat Man, I check my pulse and then begin to gather the situational information.  It seems that the ability to do this was lost upon my colleague and she went from zero to “Holy Shit!” in about 30 milliseconds.  Over what?  A simple 5 beat run of V-Tach.

Yes, V-Tach is bad.  We all know V-Tach is bad.  5 beats though?  Self-limiting in a patient who just come back from getting a pacemaker?  With a slightly low potassium?  Not all that surprising.  But no, flew off the handle she did. Called for labs, called the doc and worked herself into the fore-mentioned tizzy,  Through this the patient is fine.  Happily chatting with his wife about this or that.  He’s on the monitor, already has a K-rider infusing and is about as content as one can be in the hospital.  Why the drama?

Because all to often people don’t think before they act.  Had the nurse been thinking things through and not reacting several things should have gone through her mind.  First, the ventricular ectopy in the form of multiple PVCs and a single run of VT was caused by two different things, the hypokalemia – the patient was 3.6 on the AM labs and the fact that the cardiologist has just been poking and prodding and electrified piece of wire inside this dude’s right ventricle.  Or in other words they had been pissing it off.  Second, she already was correcting the hypokalemia with the running rider and if she really wanted a magnesium level, a quick add to blood still in lab would have sufficed.  Third, she needed to look at the patient.  Vitals OK?  Feeling OK?  No chest pain or discomfort?  Yes, yes and no were the answers.  Simple isn’t it?

I think why this got under my skin so badly was that the nurses isn’t exactly new.  She’s been a nurse far longer than I and has been in cardiology for nearly the entire time:  she should know better.  But it seems that my day shift has been functioning in the fight or flight mode for so long that any little issue, real or imagined, gets turned into a full-scale shit storm.  It’s like when the LOLs with delirium are extra hyper-alert that the slightest thing sets them off.  So it is with the day shift.  They forget to think.  Unfortunately many nurses are in the same boat, we’re running scared and rile ourselves up faster to make sure Bad Things© don’t happen.  So stop, think, then act.

As for the pacer dude, well, things worked out just fine.  All that drama for nothing.

hmmm…drama for nothing and chest pain free… h/t Dire Straits

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.