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I was attending the ER yesterday. It had been a slow day, not many patients to see. That is usually a bad omen, since slow days tend to get shitty in any second with complicated patients.
I was having a coffee in a moment I had to spare when suddenly the speakers go off:
"Dr. Vargas, please call 1402. Dr Vargas, please call 1402."
So I call the ER. The EMTs were bringing in a 69 years-old female with a syncope (she had fainted at home while having dinner with her family, and she was being brought by ambulance.
When she arrived, she was awake and had no symptoms at all, but she had a long medical record:
- A stroke 1 year ago.
- A cerebral hemorrhage 2 years ago while under anticoagulant therapy
- A high frequency arrythmia (a paroxystical atrial fibrilation; the upper cavities of the heart, called the atriums or auriculae, start an unorganized beating not being in sync with the rest of the heart) in treatment
- A stage II breast cancer in treatment.
First thing I do when I get to her is take her by the wrist to get her pulse while I say:
"Hello, ma'am. How are you feeling?"
I instantly notice the extremely slow pulse. Maybe 30 beats per minute. The heart is supposed to beat at around 60 x minute...
"I feel a little dizzy but I'm ok. This happens to me all the time, I'm used to it but my daughter insisted to bring me in..."
The EMTs connect the heart monitors (which I don't know why wasn't connected en route to the hospital).
I see this:
![[image loading]](http://i.ytimg.com/vi/mVQzDsXKOSI/0.jpg) Oh, bollocks...
My face after reading up the heart monitor was something like this:
![[image loading]](http://1.bp.blogspot.com/_FmWfayiHQ98/SToyfo5GdWI/AAAAAAAAAUc/8ARGqhyoh24/s320/scrubs2-46.jpg) Yeah, I was not amused. It wasn't funny, like, at all.
Blood pressure: 80/40. Low.
Her slow heartbeat was compromising her blood pressure, and thus, the perfusion of her organs. She needed a pacemaker.
You see, the heart is a muscle. It beats because a pacemaker, located in the upper right portion of the heart, called the right atrium, has a bit of muscle tissue that has the ability to set off an electric discharge which propagates through the heart via the conduction system which consists, simply, of three "cables" or branches which derive from a common "cable" which comes from the heart's pacemaker.
![[image loading]](http://mdmedicine.files.wordpress.com/2011/04/cardiac-conduction-system.jpg) TL;DR: The electrical system of the heart, for dummies.
If that "common cable" isn't able to conduct the electrical impulse, the lower portion of the heart, called the ventricles, set off their own electrical discharge to keep the heart beating. The only problem is their discharge frequency is much, much lower than the atrial pacemaker. Rougly half of it, which isn't enough to supply the enough blood pressure to the body and brain. Hence, you pass out.
If all the atrial impulses are blocked, you get a 3rd degree AV block, or full heart AV block, a condition that requires the inmediate use of a pacemaker, either external or internal. If you fail to provide a pacemaker, the heart can stop beating alltogether, leading to an obvious conclusion:
![[image loading]](http://l.yimg.com/ck/image/A1386/138637/300_138637.jpg) Sup, bro...
And I didn't have one. And our low complexity hospital isn't prepared for such a thing.
So I had to somehow get an external pacemaker AND move my patient to a class A complexity center. I call the EMT dispatch, and their advanced medicalized ambulance wasn't available. They could send an external pacemaker and the equipment to operate it, but couldn't spare a medicalized ambulance.
I had to move my patient myself.
After a long 30 minutes, the pacemaker arrives to our hospital.
I knock my patient out with IV Midazolam and set the external pacemaker which starts stimulating.
We begin at 25 mA and rising.
Electrical capture at 40 mA.
Mechanical capture at 60 mA. Her heart was now beating at 70 beats per minute.
We get her into the hospital's ambulance, and rush to our reference center. There, a cardiologyst was waiting with an internal pacemaker equipment. The cardiologyst said "Since you stood up with your patient all the way from 50 miles out, you might as well stay with me and assist me in the placement of the pacemaker."
My patient got the pacemaker that same evening. And I assisted the procedure.
Today, after checking the correct functioning of the apparatus, she was discharged. She feels fine, and just came to the hospital to visit me. She brought me a large box of chocolates and a white rose, and said:
"I know this little present does not match your efforts, but I'd like to thank you for saving my life and being with me all the way."
She brought a smile on my face.
And reminded me again that I was born for this and how much I love what I do.
Thank you for reading.
 
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i feel kind of bad for this, but .. "sup bro" totally cracked me up >.>
oh well, happy end so good :')
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On August 03 2012 02:04 UmbraaeternuS wrote:
I had to move my patient myself.
So how did you get her to a hospital 50 miles from your with no specialized ambulance?
Great read as always, your blogs are probably some of the highest quality ones on TL ^_^
quick question though: what made you want to become a doctor in the 1st place?
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Another great read. Damn, sometimes I wish I would do something as great as you for a living. Never change, man.
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On August 03 2012 02:22 LazyFailKid wrote:
So how did you get her to a hospital 50 miles from your with no specialized ambulance?
With our own basic ambulance, an emergency medications portable kit, the defib, the external pacemaker and myself.
On August 03 2012 02:22 LazyFailKid wrote:
quick question though: what made you want to become a doctor in the 1st place?
I basically grew up in one. My mother is a nutritionist and used to work back in the 80's and 90's in the very same hospital I work now. Mom took me with her whenever she could and I wondered at how cool doctors were, saving lifes and making us feel better. They seemed so serious and wise man. I wanted to become one for as long as I can remember (except in junior high when I wanted to be an astronomer, ROFL).
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Umbraa saving lives all day ereday.
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I love your posts, they give incredible insight into a world that I know very little about. Thanks so much for sharing!
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Again, incredible, a great blog in a sea of mediocre ones. Thank you 
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Good thing they actually took her to consult. Sometimes patients like these can disregard a syncope as just a "faint" and not consult, she was very close to dying.
Pretty cool, I wonder if there's anything else you can do besides an external pacemaker while waiting for the real deal, particularly considering she also has AF, which can get pretty bad with any chronotropic drugs.
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I love reading these.
I gotta mention - I'm a physicist, not a biologist or doctor, so my scale could be off, but 60 mA seems like a lot amount to be putting into a person - I guess it's because you're using an external pacemaker, and an internal one would use much less current?
Anyway, great blog.
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On August 03 2012 05:53 mordk wrote:
Good thing they actually took her to consult. Sometimes patients like these can disregard a syncope as just a "faint" and not consult, she was very close to dying.
Pretty cool, I wonder if there's anything else you can do besides an external pacemaker while waiting for the real deal, particularly considering she also has AF, which can get pretty bad with any chronotropic drugs.
Not much. You can try atropine, but being a 3rd degree block, it's merely a diagnostical trial, not treatment. If it goes out of it, it was a blocked AF. If it doesn't, it's a pure 3rd degree block. In her particular case, it was a rare thing: She had a sick synus syndrome. Her syncope was a Stokes-Adams attack probably because of the low output. Go figure...
P.S: You're an intern, right?? If so, spoiler:
+ Show Spoiler +Animo wn, pongale huevos al asunto y aprovecha de preguntar y aprender todo lo que puedas, porque esto si no lo cachabas del internado, te piteabai a la paciente... Recuerda siempre la responsabilidad que llevamos con nosotros, porque en nuestro saber, que son nuestras manos, está la vida del paciente.
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Always great to read. A little motivation for the next 10 years can't hurt
You're a baller
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Your blog, as always, delivers in a big way. I got a rush of emotion out of the end of that. It's nice to be appreciated, it's nicer that people like you exist. It helps me validate all the faith I have in humanity and my belief that all the world needs is caring people.
Humanity is my religion. And individuals like you are the reason I believe so strongly in it. Keep doing what you're doing, and thanks for the story.
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On August 03 2012 06:29 UmbraaeternuS wrote:Show nested quote +On August 03 2012 05:53 mordk wrote:
Good thing they actually took her to consult. Sometimes patients like these can disregard a syncope as just a "faint" and not consult, she was very close to dying.
Pretty cool, I wonder if there's anything else you can do besides an external pacemaker while waiting for the real deal, particularly considering she also has AF, which can get pretty bad with any chronotropic drugs. Not much. You can try atropine, but being a 3rd degree block, it's merely a diagnostical trial, not treatment. If it goes out of it, it was a blocked AF. If it doesn't, it's a pure 3rd degree block. In her particular case, it was a rare thing: She had a sick synus syndrome. Her syncope was a Stokes-Adams attack probably because of the low output. Go figure... P.S: You're an intern, right?? If so, spoiler: + Show Spoiler +Animo wn, pongale huevos al asunto y aprovecha de preguntar y aprender todo lo que puedas, porque esto si no lo cachabas del internado, te piteabai a la paciente... Recuerda siempre la responsabilidad que llevamos con nosotros, porque en nuestro saber, que son nuestras manos, está la vida del paciente.
Yeah I'm almost there :D... And I'm trying to cover up most of what I don't know asking whatever comes up in my mind in my internships. I think pretty much anything they teach to me can be useful somewhere along the road. Emergency rotation was pretty good, but there's always SOMETHING left to study again
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thedeadhaji
39489 Posts
Assuming that you attended med school in South America, did you learn the medical terms in english as standard curriculum? O__O
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On August 03 2012 10:36 thedeadhaji wrote:
Assuming that you attended med school in South America, did you learn the medical terms in english as standard curriculum? O__O
Why? Did I fuck up writing something? o_o
No, it wasn't standard curriculum. I just read a lot on medschool and my main study sources were textbooks and papers written in english.
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Great read! Glad it turned out well.
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The pictures really don't add anything considering this is a serious blog and that women would have died if you hadn't done what you did. I guess you add them to break up the seriousness and make it seem less like bragging about being a hero.
(which you totally are)
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I've fallen in love with your blogs. I love listening to doctor stories, hehe
And the Scrubs picture was the cherry on top
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EPT
