“Umm, can I have a doc in this room? ”
The nurse was casual and collected. But anytime a nurse asks, “Can I have a doc in here?” you can be pretty certain there is some excitment in your near future.
She & I alternated glances between the patient and the monitor.
Patient: awake but confused. Monitor: Rapid heart rate, undetermined rhythm.
The nurse said, “I thought she may have been in vfib for a second, but she looks OK now.” For a brief moment I felt all knowledge leave my brain. I was unable to neatly categorize this patient into a diagnostic box. We knew nothing about her. The paramedics brought her in on a stretcher, provided no history and said, “She’s fine,” then they left.
As I ran out of the room to pull up an old EKG looking for a similar tachycardic rhythm the nurse rapidly stuck leads to the patients chest to run a 12 lead. I scanned through her old EKG images as if I were playing a game of concentration with a deck of children’s playing cards…no 2 EKG images looked alike. Fast, slow, narrow complex, wide complex…did this woman have any EKGs that looked “normal”?
The new EKG looked nearly identical to one I pulled up from a few months ago. Rapid Atrial Fibrillation. I was relived. Her blood pressure was in the 160s…plenty of room for some calcium channel blockers to slow her heart rate down. The only thing I didn’t have an explanation for was …
Massive Confusion. Suddenly her eyes got as wide as dinner plates as she gripped both bedrails with either hand. Her mouth gaped open as if she was trying to communicate…something…anything to us.
The nurse and I looked back at the monitor. Her heart rate had gone up to 200 and her blood pressure dropped to 70.
“Let’s shock her,” I quietly said to my reliable team of two nurses.
I felt myself getting hot as if a warm bucket of surreal had been poured over me. I asked for some ativan to be given before syncrhonizing her cardioversion, but I couldn’t wait any longer. In the old days, this is where I would have turned to the life pac monitor, grabbed the paddles from their holsters and had a nurse squirt conductive gel on the metal surfaces. I would have rubbed them together, placed then on the patient’s chest while I leaned in with my body weight yet avoiding all contact with the bed and any random patient body parts like wandering hands or floppy arms, shouting “SHOCKING ON THREE”. Cardiac resuscitation used to be so much more dramatic…TV show dramatic.
Instead, we gently placed adhesive pads to the patients chest & back. I turned to the crash cart and rotated the knob from “monitor” to “defibrillate” while the nurse pressed “synchronize”. After I saw the reasurring punctuation of the course LCD monitor identifying each QRS complex I checked the patient one more time. Heart rate 200, in a sine wave shape. She still had dinner plate eyes and her pressure continued to drop.
I hated to do it but I had to. “Shocking on three,” I quietly said to my team. One, two, three...I pressed the button and the unnerving pause that accompanies a synchronized cardioversion made my heart skip a few beats. After what seemed like an eternity, but was probably a fraction of a second, there was a click, followed by a shriek. Her body briefly convulsed but her eyes remained open. After a moment, she’d forgotten what happened entirely, but her heart had fallen into line in a rate controlled atrial fibrillation.
It’s not often we see someone’s rhythm convert right in front of us, and even less often that a single shock does what we are told it should do. Most often we see patients when they are far beyond reasonable methods of resuscitation, but today was different. Thanks to the nurse who was not too timid to ask for another set of eyeballs on her patient we were prepared to do what we are trained to do best…shocking on three, one, two three…