Before I get started, I would like to say a hello, to the not insignificant amount of new visitors I have had since Trauma Queens edition of ‘The Handover’
I hope you like what you have seen so far, and if so, I would like to think you may pop back and read some more. The more the merrier!
So, where were we……..
Last week, in my post ‘Sometimes’, I mentioned a couple of jobs which served the very important purpose of a swift reminder of not becoming complacent and tarring everyone with the same brush. Here’s the first one:
I was working on the RR car and was sent to a male with chest pain. No other details yet, but off I went ‘blues and twos’ to go and save another life!!
As I was weaving through the standstill traffic that is the signature of ‘rush hour’ where I work, I receive an update informing me that the patient is a 20yr old male.
Now, excuse me for being skeptical, but I would place money on virtually every paramedic reader of this blog, when receiving this update to think the same thing……..Yeah right!….another panic attack.
As I drive along, my mind set changes from swift action and transferral to a PPCI unit, to still a swift assessment, but more than likely a nice chat and a referral to their own GP the next day (If they settle well)
I arrive on scene and am met by a young lady standing at the door. I say a quick hello and tell her I will be “2 seconds!!” whilst I get my bags out of the back of the car.
I struggle to load up with my large first response bag, my oxygen bag, my patient report form holder, the lifepack 12 monitor/defibrillator whilst locking the car and heading towards the gate of the property, which remains closed!!
I gently knock into it and pray to the saint of over burdened rapid response paramedics, to give members of the public the common sense to think about opening a gate for a paramedic who has no spare hands to do it himself!!
I walk up the stairs and find our patient, Mark.
Mark looks well, he is a good colour, seems happy, alert and orientated. No signs of hyperventilation (actually hypoventilation, but that’s another story) or dyspnoea. All seems rosy!
M999: “Hi there, what can I do for you today?”
Mark: “Ive had this pain in my chest for the last hour, and my heart has been beating really fast”
M999: “Okay, have you been feeling short of breath at all, or breathing quickly?”
Mark: “Yeah, I used to get panic attacks, and this seems a bit like that, but my chest really hurts today”
As is the case whenever I get any patient, during the first couple of questions, I will ask for their hand, check their radial pulse, and feel the heat and moisture of the skin of their arm. It all helps with a rapid initial assessment.
I reach out for his hand and place my index and middle finger over his radial pulse………………….
Eh??…..Right, wasn’t expecting that!!…….Time to change gear!
As I feel for his radial pulse, I can barely feel the usual pounding of the artery against my finger tips. Its more like a rapid, week fluttering under his skin. I take a second to check that it isn’t some sort of muscular twitching over his artery, but instead trust my initial instincts. Its going so fast that I cant get a rate, but in all honesty I tend to go with a scale of 5 rates anyway:
- REALLY slow
- REALLY fast
Why make things more complicated than they need to be? Marks pulse definitely fell into the really fast band!
I take another look at him whilst calmly asking him if he has ever had a problem with his heart rate before? I cant help but wonder how he is tolerating it so well. His colour remains good, he show no signs or symptoms of being poorly perfused, the only symptom is this chest pain, which I can pretty much diagnose without the aid of an ECG. Its bound to be rate related ischaemia.
He tells me that he has had a number of episodes since he was 15 when he felt his heart was racing, but he had learned to stop it by putting his head between his legs and holding his breath (I guess he was doing his own valsalva manoeuvre) He had been to the doctors a number of times but he said they didn’t really believe him as it never happened when they were there.
I turn on the lifepack and start of by placing the limb leads which gives me:
This shows a fine example of an SVT (supra ventricular tachycardia) of 236 beats per minute, along with probable rate related ST depression which is the likely cause for his pain.
It was at this point that my back up crew arrived with the same presumptions that I had 10 minutes before hand. A quick look at the monitor, made them suddenly turn around and dash back to the ambulance to bring the carry chair.
On with the O2. In with the cannula (after telling him I was great at cannulas and it will only hurt for a second, as he has VERY reluctant to ‘have a needle’). Thank the lord I got it in straight away and swiftly!!
I got him to try the valsalva manoeuvre with no effect, then moved on to some carotid sinus massage prior to him getting packaged and onto the vehicle. Neither worked, and he stayed pounding along between the 230 and 250 mark throughout my time with him.
The crew left scene whilst I radioed ahead to pre-alert the hospital.
Once he had left and his friends had gone back into the house, I sat in the front seat of the car to complete my patient report form. Half way through I stopped for a second and said out loud to myself..
“Well, that will teach you!!”
Soon afterwards, I took another patient upto the hospital and called in to resus to check on him.
He looked fine (as before), but this time when I look at the monitor, his heart is going at a steady rate of 84 beats per minute.
I asked the doctor what happened with him, and she told me that he had required some Adenosine to slow his heart rate down, but it worked on the first dose. Aross the table in front of the doctor was a long rhythm strip which showed his SVT, then a mark when the Adenosine was given shortly followed by some PVCs (premature ventricular contractions), a run of VF (!!!!! for about 2 seconds), a couple more PVCs, then into sinus rhythm.
I look at the doctor and point at the VF section
M999: ” I bet that made you twitch a bit!”
Doc: “Your not wrong mate, not at all!!”