7 AM and I walk in to the overhead page of “helicopter in route with tachycardia”. I get the scoop…tachycardia, possible pacemaker gone awry?
She arrives on the helicopter gurney, smelling like an odd morning mixture of jet fuel and fresh air. Her heart rate is 190, but she sits awake, talking to us. No pain, no problems breathing. Blood pressure, pulse ox and mentation adequate. I listen to her lungs and the first think I notice is how cold and wet her skin is.
She’s in her 70s, a rheumatic heart disease survivor and proud host of a pacemaker, clearly not needed right now. She’s been tach’ing away for about 3 and a half hours now, and it’s amazing her heart has not given up yet. The community hospital tried 2 different anti-arrhythmic agents without success, but her IV access has clotted.
We now have a technically unstable ventricular tachycardia with no IV access. My staff doc helps me set things into action. A colleague places a femoral venous line while the change of shift docs and nurses all watch and wait. We can’t do anything until he has access and we all hope that she doesn’t crump in the next 10 minutes. He’s successful, and I get the rest of things into action..code cart, sedation meds, informed consent. We sedate her, I charge up the paddles, placing them on apex and sternum. Here’s the part that everyone likes to hear. I announce to the 1,2,3,4, 5,6,7 maybe 8 doctors and nurses in the room…”CHARGING…EVERYONE CLEAR!” Nick walks right into the bed and someone shouts at him. I look around the room, leaning on the paddles enough to deform her chest and be sure I get a good current flow. I announce again, “SHOCKING ON THREE, EVERYONE CLEAR!” I look at the perimeter of the bed and make sure no one is touching. I look at my legs and make sure I’m not leaning on the bed. “ONE, TWO, THREE…” Just before I press the button, I notice that her pendulous left breast hangs over the paddle and is touching my right thumb. Shit. It’s too late and I hope for the best, wondering if a think latex glove will insulate me. I press the discharge buttons simultaneously. There is an eerie silence and pause while all eyes are on her bared chest. The machine is waiting for just the right time in her electrical heart storm to deliver the shock that I’m waiting for as well. An unsatisfying ‘click’ from the paddles is followed by the TV-like jolt to the patient’s chest as she breifly pops up off the bed and crashes back down.
We all turn back towards the monitor, fingers crossed, holding our breath…flat-line. Then one heart beat, followed by another and another, each with a nice healthy 1 second pause intbetween.
With a little electricity, I’ve converted this woman’s heart from a life threatening chaotic bag of congealing blood to an miracle of life…contracting in synchrony with itself, delivering red blood cells and oxygen to her brain.
She wakes up about 2 minutes later and doesn’t remember a thing. Her chest has been covered back up by now. We sit her up and she is smiling. The color returns to her face, her skin is warm and dry. I feel immensely satisified at my performance and her response. I look at her EKG tracing over and over as if I’m re-reading a blog post I’m especially proud of. With each slow beat of her heart, I can feel my own confidence building. I’ve just performed on a real patient the exact scenario i lectured our interns about last month in their first formative days of their residency.
I’m still insecure, but somehow, I know the intern thinks I’m a cool headed physician. The medical student summarizes the immense knowledge gap that has taken place over the past 2 years when she asks me, “What just happened?”