Monday, 12 November 2007

It Is Impossible

Damn. I am still riding on adrenaline.

Just shy of midnight, 50 year-old Mr X walked in complaining of central burning chest pain for the past hour and a half rather than attend work as a taxi-driver on the night shift. I was at the fag end of seeing another patient documenting the notes and wanting some nourishment but had this chap’s ECG placed in front of my I-want-to-go-to-the-loo face for a quick opinion. The nurses are great at their job. Hmmmmm…1 mm ST elevation on V1 and an indeterminate rise on V2 with a very mild ST depression on the lateral leads. Riiiiiiight…I said he needed to be urgently seen next.

I rushed into the cubicle. He looked comfortable sitting on the trolley chatting away and his vital signs were all normal. I introduced myself. Tell me all about it I said. He had been on a proton pump inhibitor for years. He thought it was indigestion and had self-medicated with Rennies with some improvement in symptoms. The pain was almost completely gone. Well so far so good I thought. But closer probing with my rapid fire questioning in the next minute revealed that the pain had involved his left arm associated with very slight dyspnoea and brief sweatiness. Uh oh. That sounded cardiac rather than dyspepsia. And he was a known hypertensive. And a heavy smoker. And his father died in his 40s with a myocardial infarction. As far as I am concerned, that was good enough for me. We needed to get him out of the examination cubicle and move him to the resuscitation bay now.

Cardiac monitor lines were immediately unplugged. Trolley and patient rolled into Resus Bay 1. He looked absolutely fine, non-plussed and slightly amused at the fuss. Oxygen. IV access. Bloods. Sats monitor. Chests leads, BP, pulse, temp and BM. Aspirin and clopidrogrel stat. IV morphine and metoclopramide and GTN. The pain was completely gone now. Wahayy! Can we have a repeat ECG? Yes. It was completely normal. Straight-forward. So it was unstable angina +/- dyspepsia. Whatever. He needed to come in for a M.I. screen. I even weighed him myself to calculate the correct dalteparin dose. You MUST stop smoking I said. I’ve tried and I can’t – it’s impossible he said. Uhhhhhm, sure.

Instead of the regular on-call medical team, I instinctively called the on-call coronary care unit doc…that happened to be at another hospital. God knows why for it was purely a visceral instinct. They had one bed left in reserve only for a thrombolysable MI but another bed for assessment. Sure, he said, we can probably take him but could I fax the ECGs over first? He will call me back and let me know with a final answer. Sure. The ECGs were faxed over. Then the chest pain came back with a vengeance. I gave another IV bolus of morphine. The pain settled completely within minutes. Cool. Can we have another repeat ECG? Yes.

This time there was >2mm ST elevation on leads V1 and V2. Shite…this was a frank MI. I quickly checked that he had no contra-indication to thrombolysis. The call from CCU came back…I interrupted and said we now have a thrombolysable MI so you guys can actually take him. Despite being pain free, the morphine was likely masking the pain. We both agreed that he should be thrombolysed tout de suite.

And then he started gurgling and went into cardiac arrest right in front of me as I was on the phone.

“Uhmmmm…he’s just gone off so I’ll call you back okay?” I put the phone down. The crash team was called. Everyone and their dog ran to the resus bay. WTF. It was ventricular fibrillation. The first shock was delivered after I tried to hop, skip and untangle myself from all the bloody wires. His body convulsed violently with the shock. His face turned a ghastly blue. Chest compressions and bag mask ventilation was resumed. A second shock was delivered at the second cycle. Then the rhythm changed…yaaaaargh. Still no palpable cardiac output. Probable pulseless electrical activity or low cardiac output. Continue CPR and IV adrenaline. Then the rhythm changed to VF. Right…charge, clear, check and shock! Whump…his body convulsed violently. CPR was resumed and intubation attempted. And then a sinus rhythm appeared and he was self-ventilating. Bloody hell. Poised with the prepared tenecteplase in her hand the medical team member asked Was there a contra-indication to thrombolysis? No, I said. He had the green light for it. And the IV bolus was given.

And then he went into VF and a fourth shock was delivered. CPR was resumed. Then he suddenly struggled, sat bolt upright and spat out the Guedel airway. Everyone around him took a step back, with him and us looking at each other collectively with a massive WTF-is-going-on on all our faces.

He wondered out loud if someone could please contact his workplace.

Errrrrrrr. We all looked at each other and collectively spontaneously laughed as the intense tension of the last few minutes just vapourised. Phew.

Repeat ECG showed a massive antero-lateral MI across all chest leads. Arterial blood gas showed only a very mild acidosis. He needed a CCU but should he undertake the long journey to the regional specialist hospital where rescue angioplasty was available should the tenecteplase not achieve reperfusion? After a phone call with the cardiac specialist it was settled that the ECG should be repeated at 90 minutes post thrombolysis. If no improvement occurred by then, then IV tirofiban should be commenced and the patient transferred for emergency coronary angioplasty. Everyone and their dog dispersed to their usual work places.

Mr X was sat upright talking, comfortable, pain free and he was…alive. His concerned work mate came in to chat and joke with him. I went away and resumed whatever I was originally doing after the documentation was completed.

Then the crash team alarm bell was activated. Bloody hell. Whaaaaat now? Reperfusion arrhythmia?

Everyone and their dog ran to the resus bay. Mr. X looked fine and dandy. Mr. X’s concerned work mate lay collapsed on the floor like a star fish. Apparently he gurgled, went pale, unconscious and fell backwards off from the stool he was sitting on…but was now awake whilst a nurse held his legs up. It looked like a vasovagal syncope…a simple faint. A formal examination and check ECG supported that.

Mr. X’s family arrived and came round, chatted and joked with him. At 90 minutes the repeat ECG showed complete resolution of the MI for him. Absolutely amazing. I told him if he had originally chosen to go to work he would have definitely died tonight.

Transfer arrangements were formalized with the ambulance crew and receiving CCU. He thanked me as he realised how close to death he was.

"Look, you MUST stop smoking okay?"

“I already gave up an hour and a half ago!” he said.

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